A Reference Handbook OF THE MEDICAL SCIENCES EMBRACING THE ENTIRE RANGE OF SCIENTIFIC AND PRACTICAL MEDICINE AND ALLIED SCIENCE VARIOUS WB ITBBS ILLUSTRATED BY CHROMOLITHOGRAPHS AND FINE WOOD ENGRAVINGS Edited by ALBERT H. BUCK, M.D. New York City VOLUME TH NEW YORK WILLIAM WOOD A COMPANY 56 & 58 Lafayette Place 1886 Copybight, 1886. By WILLIAM WOOD & COMPANY TROW'S PRINTING AND BOOKBINDING COMPANY, NEW YORK. LIST OF CONTRIBUTORS TO VOLUME III. ADOLF ALT, M.D St. Louis, Mo. EDMUND ANDREWS, M.D Chicago, III. Professor of Clinical Surgery in the Chicago Medical College ; Surgeon to Mercy Hospital. SAMUEL ASHHURST, M.D Philadelphia, Pa. One of the Surgeons to the Children's Hospital, Phila- delphia. JAMES B. BAIRD, M.D Atlanta, Ga. FRANK BAKER, M.D Washington, I). C. Professor of Anatomy, Medical Department of George- town University. F. E. BECKWITH, M.D New Haven, Conn. Professor of Obstetrics and the Diseases of Women and Children, Yale College. ALEXANDER D. BLACKADER, M.D.. .Montreal, Canada. Instructor in Diseases of Children, McGill University. W. P. BOLLES, M.D Boston, Mass. Professor of Materia Mcdica and Botany, Emeritus, at the Massachusetts College of Pharmacy ; Visiting Surgeon to the Boston City Hospital. NORMAN BRIDGE, M.D Chicago, III. Professor of Hygiene and Adjunct Professor of Prin- ciples and Practice of Medicine, Rush Medical Col- lege. LUCIUS D. BULKLEY, M.D New York, N. Y. Surgeon to the New York Hospital, Out-Patient De- partment, Section of Skin Diseases. WILLIAM N. BULLARD, M.D Boston, Mass. Physician to the Nervous Department, Boston Dis- pensary ; Visiting Physician to the Carney Hospital. FRANK WOODRUFF CHAPIN, M.D.. .New York, N. Y. Late Resident Physician, Riverside Hospital, Black- well's Island, N. Y. WILLIAM S. CHEESMAN, Jr., M.D. .Auburn, N. Y. SAMUEL C. CHEW, M.D Baltimore, Md. Professor of Principles and Practice of Medicine in the University of Maryland, Baltimore RUSSELL 11. CHITTENDEN, Ph.D...New Haven, Conn. Professor of Physiological Chemistry, Yale College. T. M. CLARK Boston, Mass. Professor of Architecture, Massachusetts Institute of Technology. HENRY C. COE, M.D New York, N. Y. Pathologist and Surgeon to Out-Patients, Woman's Hospital; Assistant Surgeon to the New York Can- cer Hospital; Instructor in Gymecology, New York Polyclinic. W. T. COUNCILMAN, M.D Baltimore, Md. Associate Professor of Pathological Anatomy, Johns Hopkins University. EDWARD COWLES, M.D Somerville, Mass. Superintendent of the McLean Asylum ; late Superin- tendent of the Boston City Hospital. ANDREW F. CURRIER, MD....New York, N. Y. EDWARD CURTIS, M.D New York, N.Y. Professor Emeritus of Materia Medica and Thera- peutics, College of Physicians and Surgeons, New York. CHARLES L. DANA, M.D New York, N. Y. Professor of Diseases of the Mind and Nervous Sys- tem, and of Medical Electricity, New York Post- Graduate Medical School and Hospital; Visiting Physician to the Bellevue Hospital, and to the North- western Dispensary, Nervous Department. N. P. DANDRIDGE, M.D Cincinnati, O. Professor of Genito-Urinary and Venereal Diseases, Miami Medical College. ROBERT II. M. DAWBARN, M.D. .New York, N. Y. Examiner in Surgery, and Instructor in Minor Surgery, College of Physicians and Surgeons ; Visiting Phy- sician to the Northwestern Dispensary, Department of Diseases of Children. D. BRYSON DELAVAN, M.D New York, N. Y. Surgeon to Department of the Throat, Dcmilt Dis- pensary. HENRY HERBERT DONALDSON, A.B... .Balti- more, Md. Johns Hopkins University. WILLIAM II. FLINT, M.D New York, N. Y. Attending Physician, Presbyterian Hospital; Assistant to the Chair of Principles and Practice of Medicine, Bellevue Hospital Medical College. GEORGE B. FOWLER, M.D New York, N. Y. Professor of Physiological Chemistry, New York Poly- clinic ; Physician to the New York Infant Asylum. GEORGE R. FOWLER, M.D Brooklyn, N. Y. Surgeon, St. Mary's Hospital. GEORGE C. FREEBORN, M.D... .New York, N. Y. Instructor in Histological Technique, College of Phy- sicians and Surgeons. JAMES M. FRENCH, M.D Cincinnati, O. Assistant Demonstrator of Pathology and Instructor in Physical Diagnosis, Medical College of Ohio ; Microscopist and Pathologist to St. Mary's Hospital. ALBERT L. GIHON, M.D Washington, D. C. Medical Director, United States Navy. II. GRADLE, M.D Chicago, III. Professor of Physiology, Chicago Medical College. JOHN GREEN, M.D St. Louis, Mo. Professor of Ophthalmology, St. Louis Medical Col- lege. CHARLES E. HACKLEY, M.D...New York, N. Y. Attending Physician, New York Hospital. ALLAN McLANE HAMILTON, M.D...New York, N. Y. Professor of Diseases of the Mind and Nervous Sys- tem, New York Polyclinic. JOHN B. HAMILTON, M.D.... Washington, D. C. Surgeon-General, United States Marine Hospital Ser- vice ; Professor of Surgery, Medical Department of the University of Georgetown, Washington, D. C. III LIST OF CONTRIBUTORS TO VOLUME III HENRY N HEINEMAN, M.D... .New York, N. Y. Attending Physician, Mount Sinai Hospital; Surgeon to the New York Hospital, Out-Patient Department, Section of Diseases of Children. FREDERICK P. HENRY, M.D. .Philadelphia, Pa. Professor of Pathology and Microscopy, Philadelphia Polyclinic and College for Graduates in Medicine ; Physician to the Hospital of the Protestant Episco- pal Church. S. S. HERRICK, M.D New Orleans, La. Late Secretary of the State Board of Health, Louisiana. WILLIAM B. HILLS, M.D Boston, Mass. Assistant Professor of Chemistry, Harvard University. LAURENCE JOHNSON, M.D....New York, N. Y. Professor of Medical Botany, Medical Department of the University of the City of New York; Visiting Physician to Randall's Island Hospital. W. W. KEEN, M.D Philadelphia, Pa. Professor of Surgery, Woman's Medical College, of Pennsylvania ; Surgeon to St. Mary's and the Wom- an's Hospitals. ALFRED L. LOOMIS, M.D New York, N. Y. Professor of Pathology and Practice of Medicine, Uni- versity of the City of New York ; Physician to Bel- levue Hospital. R. L. MacDONNELL, M.D Montreal, Canada. Demonstrator of Anatomy and Lecturer on Hygiene, McGill University. WALTER MENDELSON, M.D... .New York, N. Y Instructor in Clinical Microscopy in the Physiological and Pathological Laboratory of the Alumni Associa- tion of the College of Physicians and Surgeons ; Attending Physician to the Roosevelt Hospital, Out- Patient Department. MIDDLETON MICHEL, M.D... .Charleston, S. C. Professor of Physiology and Histology in the Medical College of the State of South Carolina ; one of the Surgeons to the City Hospital, Charleston. T. WESLEY MILLS, M.D Montreal, Canada. Lecturer on Physiology, McGill University. CHARLES SEDGWICK MINOT, M.D. .Boston, Mass. Instructor in Histology and Lecturer on Embryology, Harvard University. WILLIAM OLIVER MOORE, M.D. .New York, N. Y. Professor of Diseases of the Eye and Ear, New York Post-Graduate Medical School; Assistant Surgeon, New York Eye and Ear Infirmary. 11. H. MUDD, M.D St. Louis, Mo. Professor of Surgical Anatomy and Clinical Surgery, St. Louis Medical College. WILLIAM II. MURRAY. M.D... .New York, N. Y. Late House Surgeon, New York Hospital House of Relief. JOHN II. MUSSER, M.D Philadelphia, Pa. Attending Physician to the Philadelphia Hospital; Chief of the Medical Dispensary of the Hospital of the University of Pennsylvania ; Pathologist to the Presbyterian Hospital. CHARLES B. NANCREDE, M.D. .Philadelphia, Pa. Professor of General and Orthopaedic Surgery in the Philadelphia Polyclinic ; Surgeon to the Episcopal Hospital and to St. Christopher's Hospital. SAMUEL NICKLES, M.D Cincinnati, O. Professor of Materia Medica, Medical College of Ohio. ROSWELL PARK, M.D Buffalo, N. Y. Professor of the Principles and Practice of Surgery, University of Buffalo, N. Y. THEOPHILUS PARVIN, M.D.. .Philadelphia, Pa. Professor of Obstetrics and Diseases of Women and Children, Jefferson Medical College. F. PEYRE PORCHER. M.D Charleston, S. C. Professor of Materia Medica and Therapeutics, Medical College of the State of South Carolina; one of the Physicians to the City Hospital, Charleston. ABNER POST, M.D Boston, Mass. Visiting Surgeon to the Boston City Hospital; Clinical Instructor in Syphilis, Harvard University. T. MITCHELL PRUDDEN, M.D..New York, N. Y. Lecturer on Normal Histology, Yale College ; Director of the Physiological and Pathological Laboratory of the Alumni Association, College of Physicians and Surgeons,' New York City. J. PICKERING PUTNAM Boston, Mass. Architect. MARY PUTNAM-JACOBI, M.D.. .New York, N. Y. Professor of Materia Medica and Therapeutics in the Women's Medical College, New York. LEOPOLD PUTZEL, M.D New York, N. Y. Visiting Physician to Randall's Island Hospital. HUNTINGTON RICHARDS, M.D. .New York,N. Y. Assistant Aural Surgeon, New York Eye and Ear Infirmary. HENRY A. RILEY New York, N. Y. Attorney and Counsellor at Law. IRVING C. ROSSE, M.D Washington, I). C. THOMAS E. SATTERTHWAITE, M.D..New York, N. Y. Professor of Pathology and General Medicine, New York Post-Graduate Medical School ; Pathologist to the Presbyterian Hospital. EDWARD W. SCHAUFFLER, M.D...Kansas City, Mo. Professor of Physiology, Kansas City Medical College. WILLIAM T. SEDGWICK, Ph.D Boston, Mass. Assistant Professor of Biology, Massachusetts Institute of Technology. N. SENN, M.D Milwaukee, Wis. FREDERICK C. SHATTUCK, M. D.. .Boston, Mass. Instructor in the Theory and Practice of Medicine, Har- vard Medical School; Attending Physician, Massa- chusetts General Hospital. GEORGE B. SHATTUCK, M.D Boston, Mass. Visiting Physician, Boston City Hospital. JOSEPH R. SMITH, M.D New York, N. Y. Surgeon, United States Army. M. ALLEN STARR, M.D New York, N. Y. Professor of Diseases of the Mind and Nervous System, New York Polyclinic ; Attending Physician, Depart- ment of Nervous Diseases, Demilt Dispensary. THOMAS L. STEDMAN, M.D. .. .New York, N. Y. Attending Surgeon, New York Orthopaedic Dispensary and Hospital. GEORGE M. STERNBERG, M.D. .Washington, D. C. Surgeon, United States Army. JAMES STEWART, M.D Montreal, Canada. Professor of Materia Medica and Therapeutics, McGill University. LEWIS A. STIMSON, M.D New York, N. Y. Professor of Physiology, University of the City of New York ; Visiting Surgeon, Bellevue and Presbyterian Hospitals. MORSE K. TAYLOR, M.D. .Fort Sill, Indian Ter- ritory. Surgeon, United States Army. IV LIST OF CONTRIBUTORS TO VOLUME III. WILLIAM GILMAN THOMPSON, M.D. .New York, N.Y. Lecturer on Physiology, New York University Medi- cal College ; Physician to Roosevelt Hospital, Out- Patient Department. ALBERT VANDER VEER, M.D Albany, N. Y. Professor of the Principlesand Practice of Surgery and Clinical Surgery, Albany Medical College; Attend- ing Surgeon, Albany Hospital. ARTHUR VAN HARLINGEN, M.D. .Philadelphia, Pa. Professor of Diseases of the Skin in the Philadelphia Polyclinic and College for Graduates in Medicine ; Consulting Physician to the Dispensary for Skin Diseases. GEORGE L. WALTON, M.D Boston, Mass. Clinical Instructor in Diseases of the Nervous System, Harvard University; Assistant in Out-Patient De- partment for Diseases of the Nervous System, Mas- sachusetts General Hospital. WILLIAM L. WARD WELL, M. D. .New York, N.Y. EDMUND C. WENDT, M.D New York, N. Y. Curator and Pathologist to the St. Francis Hospital and the New York Infant Asylum. CHARLES FRANCIS WITHINGTON, M.D....Bos- ton, Mass. RUDOLPH A. WITTHAUS, M.D. .New York, N. Y Professor of Chemistry, Medical Department of the University of New York. JOHN McG. WOODBURY, M.D. .New York, N. Y. Assistant Demonstrator of Anatomy, Bellevue Medical College. ALFRED A. WOODHULL, M.D... .David's Island, N. Y. Surgeon, United States Army. W. GILL WYLIE, M.D New York, N. Y. Professor of Gynaecology, New York Polyclinic; Gynae- cologist to Bellevue Hospital; Surgeon to St. Eliza- beth's Hospital. PHILIP ZENNER, M.D Cincinnati, 0. Clinical Lecturer on Diseases of the Nervous System, Medical College of Ohio, Cincinnati. V A REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. FACE. The face is, of. all the topographical regions of the body, the one which, if not the most important sur- gically, at least excites the most interest. Situated at the cephalic pole of the body it is for that reason intimate- ly connected with the brain and the more important organs of special sense, those for seeing, smelling, and tasting being situated in cavities formed by it-even the ears being popularly reckoned as belonging to it, although more properly considered as related to the skull. The respiratory and digestive tubes have their principal exter- nal communications through it. Because of these various circumstances there has developed, from the originally simple muscular layer covering that end of the body, a great variety of small and highly differentiated muscles, which subserve the various acts of prehension of food, mastication, and protection of tlie various orifices. This has resulted in a corresponding variety of surface-form, and character, so much so that the face has become the special and significant index of individuality, two so nearly alike as to create confusion being very rare indeed, and the first step toward concealment of identity being to hide the face. Secondarily to its special functions, the varied muscular play of the face has come to express the emotions of the mind through all the varied gamut from the basest, merely animal appetites, rage, fear, hatred, and lust, to the opposite extremes of quiet and subdued emotion and self-control. It is probably this physiogno- mical character which has caused the face to be held in far higher honor than the other portions of the body. To disfigure or befoul it is the greatest possible indignity, and in all nations, at all times, the treatment of the face has held a peculiar place in fashion and social usages. In popular language the face is considered to be limited By the line of the hair, but anatomically considered this is not exact, as all parts above the brows properly belong to the brain case or cranium. Topographically, therefore, we speak of the face as limited above by the brows and a line connecting them along the bridge of the nose, and laterally by a line running along the upper edge of the malar bone and the zygoma to the ear, thence down along in front of the ear to the mastoid process. Below it is limited by a line from the mastoid process along the lower edge of the jaw to the chin. It is not, however, conven- ient or usual to adhere too closely to these limits. The forehead, may, for certain purposes, be considered a part of the face, and in so far as its muscles and other anatom- ical features are directly connected with it, it is proper to consider it as facial. In the same manner many feat- ures of the external ear are undoubtedly facial, as are its nerve and vascular supply, and physiognomically speak- ing, it is subsidiary to the face-although, as the external apparatus of an organ situated within the temporal bone, it is proper to place it in the cranial region. Marked off in the manner indicated, the face presents, in solid contents, a shape which has been frequently com- pared to a wedge, the base of which is applied to the base of the skull. It is not the purpose of this article to treat of all the regions which might be contained within such a wedge, but to examine only the external superficies, leav- ing the orbital, nasal, buccal, and pharyngeal cavities to be treated elsewhere. Viewed from the front the face, in connection with the forehead, presents an irregular oval outline, with the broad end uppermost. The irreg- ularities of the oval are occasioned by the greater or less prominence of the external angular processes, of the malar bones, and of the lower jaw. Merkel1 has taken these as a means for establishing race distinctions of facial form, dividing all possible faces into some four or perhaps live types. The first of these is that characteristic of the Indo- Germanic races, and is shown in Fig. 1091. In this the Fig. 1091.-Face from a Roman Antique Bust. (From Merkel.1) oval is greatly wider above, the angular processes of the frontal being wide apart, while the malar bones and the inferior maxillary region are less developed. It may be noted that this type is a necessary consequence of what may be called cephalic preponderance, in which the size and capacity of the brain case are the most important struc- tural features. Further on will be shown that this pecu- liarity has a very important influence in modifying the physiognomy, and may be said to be the principal leading feature which distinguishes the human face from that of the brute. The second type is found more especially in the East- ern or Mongolian races (see Fig. 1092). Here the oval is more regularly formed, there being a wide base to the brow, a strong development of the cheek bones, and a small lower jaw. A third type, with a squarish physiognomy, is found in 1 Face- Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the Eskimos, the Lapps, and the Finns, where there is little difference in the development of the three regions-the brow base, the malar region, and inferior maxillary re- gion being about equal (see Fig. 1093). North African races show a fourth variety, the brow pends largely upon the stress put upon it by the muscles of mastication, and if these are strong, causing an enlarge- ment below, it must follow as a matter of course that their upper attachment upon the malar bone must also be of considerable size. Without doubt, there is an endless variety of faces Fig. 1092.-Japanese, from a photograph. (Merkel.1) Fig. 1094.-Turco, North Africa, from a photograph. (Merkel.1) being small, the other two regions large (see Fig. 1094); while South African races have a rhomboidal physi- ognomy, the malar region being wide, while those above and below are comparatively deficient (see Fig. 1095). It will be noticed that, as regards the relative promi- nence of the three regions mentioned, these five types ex- tending to connect these typical ones, and it would be very hazardous to decide by these data alone upon the race of tin individual. The same difficulties would be found here as in craniology, the race differences not being sufficiently accentuated to be entirely reliable, and there will be found in any country faces which would Fig. 1095.-Hottentot. (Merkel,1 after Fritsch.) Fig. 1093.-Kamschatdale, from a photograph. (Merkel.1) fall in with types varying from that of the general form of face belonging to that particular locality. The characteristics of outline are far from being the only ones of a racial character. The nose, in particular, is of great importance. Its length affects the length of the haust the possible combinations, with the exception of a case where the malar region is small, while those above and below are large. It is unlikely that such a type could be found, as the prominence of the malar bone de- 2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. upper lip, and the shape of its bridge and of the nostrils greatly alter the general appearance of the other portions. The size and shape of the lower jaw has much to do with the character of the face, and is closely connected with the nose. Finally, the shape of the forehead, which usually corresponds in some degree to the variations of the lower jaw, occasions varieties of physiognomy. There appears to be a functional reason for the correla- tion between them, as in lower types the jaw is an in- strument of prehension and a tool for tearing and cutting, while in the higher, the gradual development of the fore- limbs into arms with hands has rendered this unnecessary; and at the same time a corresponding increase of the size of the brain has made support below essential, and the whole substructure of the face has retreated in order to effect this. These facts were pointed out by a Dutch artist, named Camper,2 in the middle of the last century. He proposed to measure the projection of the face, which he termed the facial angle, by the angular distance be- tween two lines, one of which, horizontal or nearly so, he drew through the centre of the external auditory meatus and the inferior border of the anterior nares, the other, representing the plane of the face, he drew tangent to the most prominent points, viz., the glabella (above the root of the nose), and the anterior surface of the incisor teeth below. Three other facial angles have also been pro- posed : that of Cuvier and Geoffroy St. Hilaire, with a base line from the auditory opening to the lower border of the upper incisors, the facial line being the same as Camper's ; that of Cloquet, with a base line from the au- ditory opening to the alveolar border of the superior 103, prognathous. The following gnathic indices were found by him as an average of a considerable number of measurements • English, 96 ; Chinese, 99 ; Eskimo, 101 ; Fijian, 103 ; Australian, 104. In the Indo-European races, when the face is held with the eyes directed forward, a line drawn from the lower edge of the orbit to the upper edge of the auditory canal is horizontal, and runs along the upper border of the zy- gomatic process. This was accordingly adopted by the Frankfort Anthropological Congress of 1882, as a stand- ard for obtaining the position of the skull. The history of the early formation of the face is of considerable importance, as many of the malformations and deformities found in adult life result from retarded or arrested development, and are easily explained by reference to the embryological history. It also explains the occurrence of certain areas in the face which are of a lower grade of activity, and somewhat less likely to re- sist the attacks of disease ; and further, the reasons for the anatomical situation and relations of certain cavities which would otherwise be very puzzling. It should be remembered that the face is a secondary formation, not belonging to the original plan of the body, which is that of two closed tubes lying one above the other, a neural or dorsal, and a visceral or ventral one. Between the two tubes lies the primitive vertebral column, corresponding to the bodies of the vertebrae in the adult. The neural tube bends forward over the ventral at the ante- rior extremity of the embryo, because of the rapidly in- creasing volume of the brain, and thus forms the cra- nium or brain-case, including the forehead. The anterior Fig. 1096.-Showing the gradual retreat of the jaws in passing from lower to higher types of face. (From Rimmer. 3) maxillary, the facial line being drawn from the glabella to the same point; and that of Jacquart, with a base line from the auditory opening to the inferior border of the nares, the facial line from the glabella to that point. None of these angles should be considered as giving any- thing more than approximate results as to the grade of intelligence of the individual, as they do not take into ac- count the greater or less prominence of the frontal sinuses, or the more or less thickness of the bones. It may be said, however, that on observing a series of outlines like those shown in Fig. 1096, drawn successively from the lower apes, the anthropoids, and man, there is seen a gradual in- crease in the. facial angle as the scale ascends, and it is impossible to accurately define the limit between the brute and human qualities of face. Camper's angle averages eighty degrees in the Indo-Germanic races, seventy-five degrees in the Mongolian, sixty to seventy degrees in the Negro. In the gorilla it is about thirty- one degrees, and less in the mammalia generally. The sculptors of Greece were acquainted with the ar- tistic effect gained by increasing the angle, and in their statues carried it to 95 degrees (Apollo Belvidere), or even to 100 degrees (Zeus of Otriculi), giving thereby an added power and majesty to the countenance. As the facial angle is found to be too inexact for accu- rate scientific use, Flower has proposed to substitute for it what he calls the gnathic index, that is to say, the ratio which exists between the length of lines drawn from the middle of the anterior margin of the foramen magnum, and from the middle of the naso-frontal suture to the cen- tre of the anterior margin of the alveolar arch of the upper jaw. Skulls in which this index is below 98 are or- thognathous, from 98 to 103, mesognathous, and above end of the visceral tube, where the face is to be, is at first quite smooth, and the complicated structures which con- stitute the completed face are all made in a quite simple way, by the increase of some parts and the retardation of others, causing on the one hand a growth of bud-like pro- cesses, which fold over to make new shapes, while on the other, portions of the primitive tube-wall thin away and disappear. First, there forms, on the anterior end of the tube, a trans- verse fold, which deepens and widens, and is known then as the facial fossa, or, in the language of comparative anato- mists, the stomodseum. It will be seen as a widely gaping cavity in Fig. 1098. .This is originally entirely independent of the alimentary canal, being first merely a small depres- sion, then deepening by the growth of the surrounding edges, until it constitutes an invagination of the ectoderm or outer embryonic covering, extending down to form what is the primitive mouth cavity and pharynx. This origination of the lining of the mouth and pharynx from the outer layer is of some importance, as indicating the es- sential nature of its epithelial lining and its liability to cer- tain disorders, as, for instance, epithelioma, which is never known to occur upon tissue not of ectodermic origin. The facial fossa extends as far back as the primitive spine, and from its lower part is formed a secondary cul- de-sac which is to develop into the respiratory apparatus, trachea, bronchi, and lungs. The pharyngeal sac is in close contiguity to the cavity of the ventral tube, the lin- ing membranes of the two being closely applied to each other, and forming a partition. Little by little this par- tition thins away, and an antero-posterior slit is at last formed, which enlarges and establishes a communication between the pharynx and the stomach. As the body in- 3 Face. Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. creases in growth, and the neck and vertebral column lengthen out, this passage, which is at first very short, becomes elongated to form the oesophagus. In animals that have the neck and thorax slightly developed, the original simple condition remains and the oesophagus is consequently very short. In the meantime other changes have been going on around the margins of the facial fossa. On each side, near the part which corresponds to the anterior portion of the body of the sphenoid bone (presphenoid), small ex- crescences occur, which increase in size and extend down- ward and forward in the shape of transversely arched bars, until they meet and unite on the middle line. These are called the branchial or visceral arches, from the fact that they are exactly similar in formation to the arches from which are formed two incisor teeth on each side, and the middle part of the upper lip. The lateral nasal processes, which do not descend so low, form the several turbinated bones, the nasal, the lachrymal, and the sides of the nose. The remainder of the face is formed by secondary pro- cesses, which bud out from the mandibular arch. There are two sets of these : 1st. The su- perior maxillary processes, which arise very near the origin of the mandibular arches, and extend up- ward and forward, resembling in this respect the primitive branchial arches, but differing in that they never meet on the median line (see Figs. 1097 and 109$), but join with the frontal process. From this are developed the malar bone and the principal part of the external sur- face of the superior maxillary. From the inner surface of the su- perior maxillary processes on either side grow little secondary processes, which join in the middle line and form the palatal process of the su- perior maxillary bone, shutting off the nasal cavity from the mouth. 2d. The pterygo - palatine pro- cesses. These bud from the man- dibular arch, a little posterior to the superior maxillary processes, pass downward and forward behind them, and meet on the middle line. They are the basis for the ex- ternal pterygoid plate of the sphenoid and the palate bone. They close in the roof of the mouth behind, forming the soft palate with the uvula and the remainder of the hard palate. Within the various arches and processes which have been mentioned, cartilaginous matrices form which are later replaced more or less completely by bones. A curi- ous exception to this is in the lower jaw, where the carti- laginous matrix, known as the cartilage of Meckel, Fourth and fifth cerebral vesicles. Ear. Third cerebral vesicle. Eye. Second vesicle. Olfactory organ- Fig. 1099.-Front View of the Head of an Embryo of Eight Weeks, show- ing the arches and pro- cesses closed in to form the face. (From His.4) First vesicle. Mandibular arch. Second branchial arch. Third branchial arch. Fig. 1097.-Side View of the Head of an Embryo of Four Weeks. (From His.4) Superior maxiliary process. which support the bianchite in water-breathing verte- brates, and are believed to be vestiges of that state, re- peated, as so many such structures are, in the foetal con- dition only. Three-of them are shown in Fig. 1097, the fourth being concealed behind the third. It will be no- ticed that the first is larger and extends farther forward than the others. This is called the mandibular arch, and is the only one immediately connected with the formation of the face. It is the basis in which the inferior maxil- lary bone is laid down, and is shown completely in Fig. 1098. In the spaces between the branchial arches the tis- sue thins away until fissures are formed in the primi- tive tube. These are then called the branchial or visce- ral clefts. They all close up during foetal life, except a portion of the first, which remains as the Eustachian tube within, and the auditory canal without. At the upper part of the facial fossa another significant change has taken place, beginning, in fact, earlier than the formation of the visceral arches. This is the extension for- ward in the median line of a growth very much like the bran- chial arches, except that it is single. This is called the fronto- nasal process, and in its end there are hol- lowed out two pits, the primitive nasal fossae, afterward con- nected with the olfac- torynerve. These pits deepen and furrows form uniting them with the facial fossa. (See Fig. 1098.) These grooves separate the frontal process into two por- tions, an inner, called the internal nasal process, and an outer, the external nasal process. The internal forms the perpendicular plate of the ethmoid, the vomer, the septum between the nasal cavities, and the inter-maxillary bone which afterward unites with the upper jaw, and Eye . Superior maxillary process. Ear. Mandi- bular arch. Fig. 1098.-Front View of the Head of an Embryo of Five Weeks. The gaping cleft is the facial fossa ; above it is the fronto-nasal process with the olfactory fossa'; below the mandibular arch is completed; on the sides the superior maxillary processes are seen. (From His.4) Fig. 1100.-Showing the Situation and Direction of the Branchial Clefts. A, Orbital cleft; B, naso-maxillary cleft; C. buccal cleft; D, first branchial cleft; E, second branchial cleft; F, third branchial cleft; G, fourth branchial cleft. (From Cusset.6) almost entirely disappears, being represented in the adult only by the internal lateral ligament of the lower jaw and by the malleus bone of the middle ear. The inferior max- illary bone is developed from membrane external to the cartilage. The various coverings and organs of the face are out- 4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. growths from the framework. The tongue arises mainly from two little growths from the anterior part of the mandibular arch, that unite in the median line and be- come connected with the two arches below. The eyelids are formed from the superior maxillary processes. By gradual extension of growth the clefts which exist be- tween the various processes become more or less oblit- erated. Fig. 1099 shows the foetal head when this is com- pleted, and Fig. 1100 the head of the adult, with lines indicating where the fissures would be found had they re- mained unclosed. The order of their obliteration is as follows: First. The intermandibular suture, where the mandibu- lar processes unite on the me- dian line ; completely closes. Second. The inter - ptery- goid cleft, where the pterygo- palatine unites with the in- ternal pterygoid process of the sphenoid ; completely closes. Third. The buccal cleft, between the mandibular arch below and the superior max- illary and internal nasal pro- cesses above (C, Fig. 1100). Superficially this is closed, except that portion forming the aperture of the mouth; while deeply it is almost entirely open, forming the wide gap between the upper and lower jaws. Fourth. The orbital, where the superior maxillary pro- cess unites with the frontal and with the lateral nasal (A, Fig. 1100). The external portion of this closes; the middle remains permanently open as the orbit to receive the ocular vesicle, an extension from the brain forming the optic nerve and retina ; the inner part closes super- ficially, but deeply remains open as the nasal duct. Fifth. The naso-maxillary cleft (B, Fig. 1100), between the superior maxillary and internal nasal processes. Su- perficially this is closed, except so far as it forms the ex- ternal apertures of the nose. Deeply it is obliterated, ex- cept the small naso-palatine canal. Sixth. The palatine cleft, between the palatal processes on the middle line. The posterior palatine canal remains as a relic of this. Congenital deformities and defects of the face can, as before stated, usually be explained by reference to the development. Frequently these are caused by failure of the clefts to properly close. Those which close later are the ones more frequently defective. If only a small por- tion remains patent a fistula or a cyst may form, and the lines on Fig. 1100 show where this is most likely to occur. In cases where the whole cleft remains open the deform- ity may be very great. Hare- lip is a,defect of this sort re- lating to the naso-maxillary cleft. It may exist on one or both sides ; in the latter case the intermaxillary bone with its attached incisors is seen de- pendent from the septum of the nose. Cleft palate is also frequent, and a slight trace of it, in the division of the uvula into two bilateral portions, is probably more common than is usually supposed. Fig. 1101 shows a case of a lack of union in the orbital and naso-maxillary fissures. Occasionally the buccal cleft is not closed in, and the mouth extends back to the ear without the aid of the comprachicos of Victor Hugo. One or more of the arches may fail to develop. Fig. 1102 shows a case of the defective development of the mandibular arch on one side, possibly due to a failure of Meckel's cartilage. Defects of this kind are not infrequently connected with a deformity of the external ear, which grows from the sides of the first branchial cleft. Figs. 1103 and 1104 show a very curious deformity, which results from the failure of the frontal process to develop properly. In that case the other processes pass over and grow together at their touching edges just the same, but the fronto-nasal processes being absent or rudimentary, there is no nose, and the two orbits are thrown into one, a single eye appearing in the middle of the face. From Fig. 1101.-Orbito-nasal Fissure. (From Mason.6) Fig. 11C3.-Head of a Cyclops. (From a specimen in the Army Medical Museum, Washington, D. C.) this peculiarity the monstrosity is called a Cyclops. It is accompanied with defective development of the olfactory lobes. At birth, the face of the child still shows some peculiar- ities which resemble those of intra-uterine life. The most significant of these is the situation of the different or- gans of special sense. By following up the situation of ear, eye, and nose, in Figures 1097, 1098, and 1099, it will be seen that the ear has very greatly ascended and the nose somewhat descended in the course of development. At birth the ear is still much lower than in the adult, the external opening being but little above the mouth, and the nose relatively much higher. The brain and organs of special sense have developed much more rapidly than Flo. 1102.-Want of Develop- ment of Mandibular Arch, with Defect in Ear. (From Mason.6) Fig. 1104.-Skull of the same Specimen. (Army Medical Museum.) the face, and are proportionately larger. The muscular portions of the face are yet rudimentary, while a con- siderable amount of fat tills out all interstices. At this period racial distinctions are not pronounced, children of even the most strongly marked races showing great similarity, according to the law that the farther back we go in development the more generalized are all the features. The eruption of the teeth, the gradual mod- 5 Face. Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. elling of the bones by growth, and the development of muscular prominences and depressions gradually change the infantile character of the physiognomy. The face be- comes longer in proportion to its width, and the jaws are shaped with reference to their use in mastication. The frontal sinuses are not fully developed until puberty is reached. In old age special alterations in the face occur from the loss of the subcutaneous fat and the less tonicity of the skin, which causes it to lie in folds and wrinkles. The teeth fail out, and the alveolar processes being con- skull gains on the face. This is owing to the increase in the occipital bone which occurs with the development of the posterior neck muscles. The general law that can be deduced from the table is that the base of the skull, to- gether with the face, increases relatively in size from birth onward, the skull as a whole, relative to the face, de- creasing. This will be quite apparent on an inspection of Fig. 1105, which shows that the line dividing the head and face into two equal portions is higher in the child and in the female than in the male adult. As the face is of more'recent formation than the rest of Fig. 1105.-Relative Size of the Face to the Head in the Child, the Adult Female, and the Adult Male. The dotted line divides the vertical length of the head into two portions. (From Rimmer.3) sequently absorbed, the height of the face is considerably lessened. The other bones are also thinned by absorp- tion. The following table from Froriep1 gives a resume of the changes which occur, in the relations of the face to the skull, at different periods of life and in the different sexes. the head, its structures show much less diversity of origin, although they have undergone a higher degree of differen- tiation. It is impossible here to separate the soft parts into distinct layers, the skin, subcutaneous fat, and most of the muscles, all belonging to a single sheet in which the structures are interwoven with great complication. The Table of the Relative Dimensions of the Skull and Face at Different Ages. At birth (boy) Two years (girl)... Five years (boy)... Ten years (boy)... Adult (woman).... Adult (man) Old man Ago. 1 : 0.408 1 : 0.468 1 : 0.547 1 : 0.560 1 : 0.627 1 : 0.703 l^1 Antero-posterior diameter of the skull is to the vertical diameter of the lace as 1 : 2.081 1 : 2.033 1 : 1.872 1 : 1.833 1 : 1.720 1 : 1.683 1 : 1.976 Vertical diameter of the face is to the vertical diameter of the skull as i Facial basis (from root of nose to ar- ticulation of lower jaw) is to antero- posterior diameter of the skull as a : 2.222 • 2*206 : 2.085 : 1.971 : 1.818 : 1.760 : 1.717 1 : 1.529 1 : 1.636 1 : 1.435 1 : 1.450 1 : 1.550 1 : 1.320 1 : 1.333 Anterior transverse diameter of facial basis (through the external angular processes of the frontal bone) is to transverse diameter of the skull as 1 : 1.529 1 : 2.068 1 : 1.500 1 : 2.133 1 : 1.244 1 : 2.212 1 : 1.260 1 : 1.962 1 : 1.254 1 : 2.051 1 : 1.118 1 : 2.012 1 : 1.142 1 : 1.975 Posterior transverse diameter of the facial basis (through zygomatic pro- cesses) is to transverse diameter of the skull as M Antero-posterior diameter of the facial basis is to an tero-posterior diameter of the basis of the skull as By columns A and B it will be seen that the vertical diameter increases with age, the loss of teeth accounting for the change in old age. This element does not enter into account in column C, in which a tolerably regular increase is seen. D and E show also that the facial basis continually gains on the skull. In F, it is seen that up to the fifth year the posterior part of the basis of the Fig. 1106.-Distribution of the Trigeminus Nerve. arterial blood is mainly from a single source, the facial artery ; the distribution of small infra-orbital and mental branches being inconsiderable. The venous discharge is equally simple, being confined to the facial vein. While 6 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fate. Face. for the cranium there are several sets of lymphatics each of which has its appropriate set of glands, those of the face all discharge into a single group, the submaxillary glands. To one nerve, the facial, is confided the motion of all the essential muscles of the face, excluding those of mastica- tion, while sensation is supplied almost entirely by the trigeminus, the distribution of its chief branches bear ing a striking resemblance to the arrangement of the embryonic processes which fold over to form the face. Thus, the ophthalmic division supplies mainly the parts derived from the fronto-nasal process ; the superior max- illary quite closely confines itself to the superior maxil- lary process ; while the mandibular arch is supplied by the inferior maxillary (see Fig. 1106). Notwithstanding this simplicity of origin, the special- ization of parts is carried to a higher degree than in any other portion of the body, a fact which makes the study of this region, by dissection, particularly difficult. The layer of muscular fibres which may be found, on micro- scopic examination of other parts of the body, scantily scattered through the subcutaneous connective tissue, is in the face and neck enormously developed, forming below a broad sheet known as the platysma myoides (Fig. 1107), and above a series of small bundles which have, it is true, been named as separate muscles, but w'liich have not the same value as muscular units elsewhere in .the abundance of the sebaceous and sudoriparous glands, which are found here. The great vascularity of the skin produces certain appearances of color, characteristic of health and important aids to diagnosis, and it is only upon the face and neck that blushing usually occurs. The subcutaneous connective tissue is very loose, and easily infiltrated. Abscesses usually point with great quickness, because they are not confined by an unyield- ing layer of fascia. The activity of nutrition renders the tissue particularly liable to destruction in cases where the nutrition is seri- ously impaired, as in cancrum oris. Cicatricial tissue formed here is apt to cause very strong contraction. In almost all regions of the face the meshes of the subcu- taneous tissue are tilled with fat, the greater or less pre- dominance of which gives character to the physiognomy, being less in adult males than in children or females, disappearing to a considerable extent in the emaciation of disease, and when remarkably absent in health, giving to the face a "lantern-jawed" expression often associated with irritable, nervous temperament, and morose disposi- tion. Shakespeare makes Caesar distrust Cassius, because of his " lean and hungry look," and desire " sleek-headed men, and such as sleep o' nights." The muscles of the face (Fig. 1108) are divided into two grand divisions, the masticatory and the mimetic. The first group resembles in structure and arrangement the muscles of other regions, and'is separated from the second by appropriate fascia-the parotideo-masseteric and the bucco-pharyngeal. The mimetic set is distrib- uted in very varying degrees throughout the subcutane- ous tissue, attached by one extremity to the skin, by the other to bone. In some persons there is an almost con- tinuous sheet, in which it is not possible to distinctly mark off all the muscles usually described ; in others there are very perceptible intervals between the several groups. In many dissections of faces of negroes which the author has made, the mimetic muscles appear on the whole to be considerably less developed, while the masticatory group is in excess. The greater roundness of outline is due al- together to the excessive development of fat. It is only with the greatest care, the aid of a strong light, and occa- sional assistance of a glass, that the entire sheet of mimetic muscles can be detached from the surrounding fatty tis- sues and satisfactorily shown. When a dissection of this sort is carefully performed, it is clearly demonstrated that the appearance represented in anatomical text-books of certain well-defined and separate muscles is, in some de- gree, illusory. The degree of differentiation is far greater than usually shown, small bundles constantly detaching themselves from the main mass, and being inserted into separate points of the skin. If any one will watch the play of features which marks the usual expression of any ordinarily intelligent person, he will see this indepen- dence very clearly. While these muscles are of the striated variety, they yet are very pale and not entirely subject to the will. Certain emotions are invariably ac- companied by muscular play of the countenance, and it is also impossible to set in motion one group of muscles without associating others more or less prominently with them. There thus come to be certain general and asso- ciated changes of physiognomy, corresponding to the dif- ferent emotions or mental states. Complex as this system is, it can be shown that the whole set of mimetic muscles may be reduced to two general categories, which have relation to the orifices of the face and head, and the primitive necessity which ex- ists of opening and closing each of them. They can be divided into dilators and sphincters, the former ar ranged in a radial manner about the orifices, the lat- ter encircling them. This is particularly apparent about the mouth, where the sphincter is the orbicularis oris, the dilators on each side, the levatores labii superioris, the levator anguli oris, the zygomatici, the risorius, the depressor anguli oris, and the depressor labii inferioris. The nose has for constrictors the compressores naris, and for dilators the depressores ala? nasi, the anterior dilata tores and the posterior dilatatores. The eye is closed by the orbicularis palpebrarum, its dilators are absent (ex Fig. 1107.-View of the Face with the Skin Removed and the Superficial Fascia left in Place. The platysma myoides is seen to be continuous with the superficial fascia. The risorius, here represented by a few crossing fibres, is sometimes sufficiently distinct to form a separate layer. (Taken from Weisse's Practical Human Anatomy, with per- mission of the author.8) body, for separate bundles of fibrils in each muscle may have independent actions, and this independence may vary in different individuals in a marked degree, giving rise to all the different grades of mimetic power and mo- bility of countenance. The skin, therefore, differs somewhat from that of other portions of the body, owing to its intimate union with the underlying muscles and connective tissue. This will be seen when an attempt is made to take up a fold of it with the hand ; it is not lax and separable as is the case elsewhere, but there is lifted with it the underlying tis- sues. When cut the same cause makes it strongly re- tract. It is thin and delicate, easily lacerated, and when injured easily repaired, owing to its extreme vascu- larization. Indeed, wounds of the face are among the easiest to heal of any in the body, union being usu- ally by first intention. This same activity makes the skin much more liable to eruptions than in any other por- tion of the body. In the eruptive fevers, small-pox, scar- latina, measles, chicken-pox, erysipelas, the face is usu- ally much more extensively affected than other parts. It is also the special seat of acne, owing to the great 7 Face. Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cept the so-called fibres of Muller, which will be men- tioned further on), the upper lid being moved by a special ocular muscle not belonging to the mimetic set, and the lower lid being pushed downward by the motion of the globe. Even the ear has traces of a sphincter in the tra- gicus and antitragicus, and of dilators in the rudimen- tary helicine muscles, all being vestiges of a previous state when the organ was more actively used than at present. To be exact, there should be added those mus- cles which are remnants of the undifferentiated muscular sheet, and have a general effect of sliding the general sur- faces of skin over the bones, such as the occipito-frontalis layer of inert fatty tissue, the result of nutritive forces which have only a secondary effect on character. Im- bedded in this are the real agents which cause expression, the muscles and nerves, which, by their action on the skin, afford us the proper data for our judgment. Even allowing, as seems probable, that the action of a single group of brain-cells causes a definite and similar result in every case, it would still be necessary to note that the ac- tion is usually very complex, and that the muscles of the face are frequently in conflict, one set struggling to dis- play emotions, another to conceal them. Besides this, the results of the action of muscle nerve-force are twofold, and it is necessary to dis- tinguish the evanescent surface play of the mo- ment from the effects of previous oft-repeated ac- tion which has left its marks in lines and con- figurations which are of a higher physiognomical value. Any attempt to establish arbitrary rules has invariably failed, and most of Lavater's dicta seem now absurd. An empirical compari- son of the human feat- ures with those of ani- mals has been a favorite method of pursuing this study, and seems to be a late survival of the doc- trine of signatures which was in vogue up to the seventeenth century. A well - known American publication of this sort compares Germans to lions and Englishmen to oxen, gravely deducing thence considerations as to national characteris- tics. A curious book by Sue, published at the end of the last century, com- pared human physiog- nomy with that of fishes, serpents, grasshoppers, etc. " Many fishes," he says, " are wanting in that which gives a char- acter of amenity, kind- ness, and tenderness." " Intestinal worms have a very decided physiognomy. . . . The character of their physiognomy inspires in man sorrow and awe." Even this is no more signal example of the lengths to which imagination will go in this regard than the picture of the ghost of a flea," by the poet artist Blake, which has a weird physiognomy of superhuman ferocity. Fig. 1108.-The Muscles cf the Face as they Appear after the Removal of the Platysma Myoides and the Super- ficial Fascia with its Subcutaneous Fat. Those here shown all belong to the mimetic set, except the masseter and the buccinator, which are masticatory. (Taken from Weisse's Practical Human Anatomy, with the permission of the author.8) and its derivatives, the platysma myoides and the riso- rius. The study of the expression of the face has been ar- dently pursued for many ages, with a singular barrenness of fruitful results-so much so that many have been in- clined to deny that any value whatever can be assigned to it as a determination of character. That this is going too far must, however, be conceded by any one who will reflect how very largely our ideas of men are influenced by their physiognomy and that, notwithstanding con- spicuous failures and mistakes, we tacitly rely upon our own judgment of faces, with results which are, on the whole, satisfactory. Unfortunately the subject has been usually approached in an unscientific spirit, degraded by much false sentiment, and obscured by conclusions de- rived from insufficient data. When we consider the difficulties in the way, this is not surprising. There is first the skeleton of the face, a fixed frame, established by hereditary conditions, and but little variable within the period of a single life. These hered- itary conditions may but imperfectly correspond with the fully developed character, and data derived from the bony framework may lead to totally erroneous conclu- sions. Upon this framework is superposed an irregular Calmness. Sadness. Gaiety. Fig. 1109.-The Three Figures of Humbert de Superville. Among a mass of trivialities and absurdities it is true that we occasionally find something which is of value. Lavater's observations have, some of them, been amply verified by modern investigation. Humbert de Super- 8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. ville, in a work which appeared in 1827, published the pre- ceding diagrams (Fig. 1109), W'hich, though seemingly absurd and even laughable, are in general borne out by the observations of modern physiologists. The lines repre- sent an outline of the face, the eyes, the low'er border of the nose, and the lips, and may be considered as a statement in the simplest form that, starting from an expression of repose; in which the lines above mentioned have a horizon- tal tendency, the mimetic muscles about the facial orifices tend to draw the ends of those orifices upward and out- ward in an expression of gaiety, and downward in an expression of sadness. Meynert9 divides all possible movements of the face into two categories, those of aggres- sion and those of repulsion. The first relate to the ap- propriation of external resources, air, food, etc., and es- sentially depend upon a dilatation of the body orificesand cavities. Pleasurable emotions receive their expression from these-the raised corners of the mouth and nostrils are dilatory acts. In laughter the nostrils bulge, the lips separate, and the teeth show. This is clearly seen in the face of a laughing child (Fig. 1110). Painful emotions are indicated by a narrowing of the cavities and of the face ; when not too intense the head is bowed, the arms lax, the eyeball retreats, and the eyelids are drooping or closed, and there is a general tendency toward the obliteration of personality. The " long face" cies rather than exact areas, and have not, therefore, a precise scientific value. Cautioning thus the reader, that he may avoid the error which has destroyed phrenology as a science, the results arrived at by Duchenne may be briefly stated, illustrating the most important of them, after the man- ner of Humbert de Superville, by diagrams taken from Duval.12 The occipito-frontalis muscle (Figs. 1108 and 1112), which raises the eyebrows and corrugates hori- zontally the skin of the brow', ex- presses, when slightly contracted, attention ; when the action is great- er, astonishment. In a young per- son the forehead does not wrinkle, but the open and bright expression of the eyes produces the effect. In trying to awaken a slumbering memory the brows are often raised in an apparent effort to concentrate the gaze. In many other ways the face shows that allied associations may produce similar results. The orbicularis palpebrarum (Fig. 1109) is really a com- pound muscle, the different parts of which are capable of separate action. Besides the closing of the lids, which is ^specially the function of that portion which is upon the lid it- self, the orbital portion may, by its lower half, assist in laughter, and the upper half is con- cerned in that knitting of the brows that comes from slight perplexity or reflection (Fig. 1113). The eyebrows are thrown forward and the eyes retreat. " Deep- browed reflection " is not merely a poetic fancy. The pyramidalis nasi produces by its contrac- tion short horizontal folds between the brows, and slightly depresses their inner ends. Its action gives an air of harshness and menace to the face, the poets' " shadow on the brow." The corrugator supercilii, called by the French the "muscle de douleur," draws the eyebrow inward and upward, and wrinkles the brow concentrically over it. (Fig. 1114.) The expression is one characteristic of suffering, particu- larly of mental agony. Darwin carefully studied the muscle and found that in but few persons was it voluntary, only acting when the cortical centres became strongly ex- cited. Some actors have it under control. In children it does not produce folds, but a peculiar mod- elling of the forehead over the in- ner end of the brow (see Fig. 1111). The zygomaticus major draw's the angles of the mouth upward and outward, carrying also out- ward the lower extremity of the naso-labial line, the fold which is directed obliquely downward and outw'ard from the ake of the nose. It widens the mouth, and is essentially the muscle of laughter (see Figs. 1110 and 1115), and, according to its action, may produce either a " broad smile," or a " grin Fig. 1112.-Diagram Show- ing the Action of the Oc- cipito - frontalis Muscle. (Duval.) Fig. 1110.-Laughing Child. From a photograph. Fig. 1111. The Same, Crying. From a photograph. of the sorrowful is more than a figure of speech. If the emotion becomes more intense, other brain centres are excited, and a series of secondary acts ensues in which, by cries or moans, the person makes known his condition. Fig. 1111, in contrast with Fig. 1110, shows the expres- sion then produced. The proper method of studying the expression of the emo- tions was first shown by Duchenne10 in his work on the "Mecanisme de la Physionomie Humaine," and was fol- lowed by Darwin in his " Expression of the Emotions." 11 Duchenne confined himself to an examination of the action of the different mimetic muscles and muscle-groups, excit- ing them by means of electricity, using for his experiments an old paralytic whose facial muscles were in such a state that he could not interfere by voluntary acts with the ex- periments. By an analysis of this kind it is possible to settle the approximate value of each muscle in the pro- duction of expression. It would, of course, be quite im- possible to map out the face with precision and say that each separate area had assigned to it a separate emotion. Most mental states are extremely complex, and undoubt- edly involve widely separated cortical areas of the brain, and it must accordingly be expected that the external ex- pression of them is equally complex. There is also want- ing a sufficiently definite nomenclature of emotions to en- able us to know exactly what is meant by such terms as joy, sorrow, happiness, sadness. They indicate tenden- Fig. 1113.-Diagram Rep- resenting the Action of the Orbicularis Palpebra- rum Muscle. (Duval.) 9 Face. Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from ear to ear." Little wrinkles are formed at the outer curves of the eyes, which make the eyelids seem to be raised at the outer angles. Some women of great per- sonal vanity abstain from laugh- ter because of the wrinkles thus caused. The zygomaticus minor and the levator labii superioris carry out- ward the middle portion of the naso labial line, and curve upward the upper lip, producing an ex- pression of pouting, discontent, grief (Figs. 1111 and 1116). The changes are nearly the reverse of that produced by the great zygo- matic. As Duval remarks, it is astonishing that these muscles, so closely related anatomically and by their nerve-supply, should express such opposite emotions, and we are strongly reminded that certain moods of laughter are akin to tears. The internal elevator of the lip (levator labii superioris alaeque nasi) carries the emotion still further, producing an effect of narrowing the face by raising the centre of the lip, nearly straightening the naso-labial line, making of it a gutter for tears, and folding the skin at the outer angle of the eyelids. (Figs. 1111 and 1117.) The muscles about the nose were believed by Duchenne to give, while in action, an expression of lewdness to the physiognomy. It is very difficult to detine what such an expression may be, but observa- tions of the natural habits of the lower animals lead us to suppose that there may be some ground for this idea arrived at by an indepen- dent method. Undoubtedly the sense of smell is an important guide in determining the rutting state, and it is well known that many animals have a special apparatus intended to excite this sense under such conditions. The orbicularis oris closes the lips, and by a continuation of its action causes them to protrude, as in pouting. The depressor anguli oris (Fig. 1118) pulls down the angle of the lips, and draws inward the lower end of the naso-labial line. The emotion expressed is, when little marked, that of sadness ; when more so, contempt. It is frequently associated in movement with the muscles of the upper lip, and there is occasionally a separate action of a slip of the internal ele- vator, which raises a little corner over the canine tooth of one side. Darwin notes one case where this was habitual and voluntary, and the author has also seen one very well- marked case. This appears to be a reminiscence of the snarling ex pression which many lower animals assume, the showing of the teeth being for the purpose of intimida- tion. The depressor of the lower lip also turns it outward, and indicates an act of ejecting something un- pleasant from the mouth. The pre- dominant emotion is therefore dis- gust and disdain. The platysma (Fig. 1107), by drawing down the lower jaw and wrinkling tire side of the neck, assists in the ex- pression of terror. Space does not permit of a further discussion here of the remarkable work of Darwin,11 in which he has shown that the complicated feature-play of man has been de- rived from comparatively simple acts performed by the lower animals for attracting agreeable objects, or for re- pelling those which are disagreeable. As mentioned be- fore, it is usually the case that the action of several mus- cles combines. In laughing, for instance (Fig. 1110), the action of the lower portion of the orbicularis palpebrarum is combined with that of the zygomaticus, and in crying (Fig. 1111) the whole orbicularis is put into strong ac- tion, tightly compressing the eyeballs for the purpose of guarding, as Darwin believed, against an over-disten tion of the ocular blood-vessels. Several years ago the author sug gested that the reason for the asso ciated action of certain muscles was found in the association of nerve-centres in the cortical area of the brain. " It is now known that the cere- bral centres which control the sepa- rate muscles put in action are closely contiguous in the brain, and that they probably intercommuni cate and excite each other in a defi- nite manner, predetermined by habit and heredity. The conscious mind has only to set in motion the subor- dinate apparatus, when it goes on, and works out the problem with matchless skill, like the system of cogs and eccentrics that produces the intricate pattern in an engrav- er's lathe. All have noticed the uncouth manner in which children and untrained persons follow with lips and tongue the motions of their hands when using a tool of any kind. . . . The facial muscles are actuated from a cerebral centre in close proximity to those which move the arms and hands. In the lower animals this is necessary, for the mouth is an organ of prehension, used in strict association with the fore-limbs in seizing prey, and in other acts. As this associated movement became strongly fixed by long habit, it survives with great ob- stinacy, and though it has not been useful to the race since the historical period, we have yet to caution our children not to put their tongues out when they write."12 Since this was written, Meynert9 has advanced similar views as to the action of the cortical centres, and has ex- panded the subject with characteristic force. He calls the phenomenon by which an excited cortical area tends to propagate its excitement into contiguous portions " ir- radiation," and concludes that the fine fibrillary plexus connecting the brain-cells is the agent concerned in this propagation. This is the most primitive and slowest form of the transmission of nervous impulses, the higher and more rapid form, such as those for inhibition or con- scious volition, being conveyed by the medullated fibres possessing an axis cylinder and a sheath of Schwann. Flechsig has shown that different bundles of fibres de- rive their medullary sheath at very varying periods, according to their necessity in connection with vital processes. Those which refer to respiration and the movements of the mouth are among the first to get their sheath, being medullated in foetal life. Because of irradia- tion and the impossibility of corti- cal inhibition, the control of a child over its facial expression is far less than that of the adult. It is this irradiation which causes the phenomena of the successive gradations of expression. In merriment there may first be a smile, then a broader one, then a hearty laugh with action of the thoracic muscles, finally even tears and perhaps inhibition of respiration, should the ex Fig. 1114.-Diagramshow- ing the Action of the Cor- rugator Supercilii Mus- cle. (Duval.) Fig. 1117. - Diagram showing the Action of the Levator Labii Supe- rioris Akeque Nasi Mus- cle. (Duval.) Fig. 1115.-Diagram show- ing the Action of the Zy- gomaticus Major Muscle. (Duval.) Fig. 1116.-Diagram showing the Action of the Zygomaticus Minor and the Levator Labii Superioris Proprius Muscle. (Duval.) Fig. 1118.-Diagram show- ing the Action of the De- pressor Anguli Oris Mus- cle. (Duval.) 10 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. citement be great. It is not unusual to hear that one " laughed till his sides ached." There is for each of these phases a somewhat separate action of different muscles, the area of cortical excitement and of corresponding mus- cular action con- tinually extending. The same principle may be applied to other emotions; the varying phases of rage are still more marked. It may be said generally that un- derlying all the muscular play of the face there is some simple princi- ple relating to prim- itive needs. The arching of the lips, as in sucking, remains throughout life an expression of approval and contentment. In all expressions of passions there are distinct reminiscences of the strictly animal use of the jaws and teeth as weapons of defence. This is so marked that it makes the predominance of the masticatory set of muscles a very marked feat- ure in brutal countenances. Fig. 1119 shows what brutality large masseters with prominent teeth may give to the face. Piderit13 thinks that all idealized forms of expression are derived from simple ones. The emotions excited by any mental conception must of necessity correspond to some previous experience of the senses, and their expression will be the same as that attending such previous experience. Therefore we term certain expres- sions of the countenance indicative of mental states, bitter,'sour, sweet, because we recognize the same feature-play which attends the actual experience of the sense of taste. The muscular movements caused by agreeable or disagreeable ideas act in accordance with harmonic (agree- able) or discordant (disagreeable) sense-impres- sions. The arteries of the face are shown in Fig. 1120. The simplicity of their origin has been al- ready mentioned. But very little trace of any segmental character can be found, as might be expected from what has been said of the devel- opment of the face. The transverse facial (Figs. 1120 and 1102) is believed to represent a superficial trunk intended for the superior max- illary process, the internal maxillary represent- ing a deep trunk of the same general nature.14 They do not, as in other regions of the body, confine themselves to definite layers, but weave in and out, now superficially to the muscles, now dipping down under them. The mobility of the face being great, involves with it corre- sponding variations of volume, and the course of the arteries must necessarily be very tortuous to accommodate themselves to changes without being occluded by stretching. The arterial network is very rich-so much so that in a fully injected specimen the meshes left between them are not more than three-eighths of an inch in diameter. The Figure gives rather an in- adequate idea of this, only the main trunks being shown. In no superficial part of the body is the union of arteries across the median line so general and free as in the face. From this it results that it is necessary, in all cases of face- wounds, to tie both ends of the severed vessel, as bleeding will almost invariably occur from.the opposite side. In the tongue, however, there is a tolerably complete separa- tion by the median raphe. The extreme vascularization of the face makes it, above all other regions, the most adapted to plastic operations. Surgeons can replace here consid erable losses of substance, either by the turning of a flap taken from contiguous parts, or from some remote part of the body. Notwithstanding its vascularity, haemorrhage is not very profuse in wounds of the face, as the insertion of the muscles into the skin causes a strong retraction which arrests it. A curious phenomenon connected with the finer vessels of the skin is their injected appearance in those addicted to the use of alcohol in excess, or those who are much exposed to the cold. The veins are somewhat fewer than the arteries. The general course of the facial vein is not, as in other re- gions, parallel to that of the artery (see Fig. 1121). It takes a more direct course across the face, and is so united with the circumjacent connective tissue that it gapes somewhat when cut. It has no valves. It com- municates freely with the sinuses of the dura mater in the cranial cavity, both by means of its anastomosis with Fig. 1119.-Showing the Effect of Large Masti- catory Muscles on the Expression. (Rimmer.) Fig. 1120.-The Arteries of the Face and Neck. 1, Common carotid ; 2, external caro- tid ; 3. internal carotid; 4, superior thyroid: 5, lingual ; 6. facial ; 7, submental; 8, occipital at its origin: 9, where it becomes superficial; 10. posterior auricular; 11, superficial temporal; 12, transverse facial; 13, coronary of the lips ; 14, lateralis nasi; 15, angular. (Beaunis and Bouchard.) the ophthalmic vein and by a branch from the pterygoid plexus, and thence through the foramen ovale. Its ten- dency to remain open makes it liable to some affections, like septic absorption. Carbuncle of the face has caused thrombosis of the sinuses, and the injection of naevi has sometimes been fatal (Treves). The vein in the face proper is not very prominent, but upon the forehead, as frontal vein (vena praeparata), it often swells out in a striking manner when the circulation is even slightly impeded, as by laughter or any strong emotion, as that of anger, which interrupts the respiration. 11 Face. Face. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The lymphatics of the face arise from the numerous lacunae which are left by the peculiar structure of the sub- cutaneous tissue. The trunks, however, are not as nu- merous as in some other portions of the body. They all discharge into the submaxillary glands, a chaplet of bead- like bodies twelve to fifteen in number, situated along the under border of the lower jaw. Those below the angle of the jaw correspond to the distribution of the facial artery and vein. The nerves (Fig. 1122) have a very peculiar arrange ment, which depends upon the history of the muscles. The original simple, single muscular sheet, the pla- tysma, has become broken up into many small bundles, which have, to a certain extent, changed the original di- rection of their fibres, some bundles being turned in one direction, some in another. A similar modification has taken place in the nerve which supplies them, the separate fibres first turning upward, then again downward, uniting early physiologists, and they considered the facial to be a nerve of mixed function. A knowledge of the bony framework of the face is very important surgically. The thirteen bones ■which com- pose it are of very different value, structurally speaking. While the lower jaw is so hard and dense that it is diffi- cult to cut even with the best instruments, the lachrymal bone and the bones of the orbit are so thin that they may be injured by a very slight thrust. These differences of strength depend mostly upon reasons which are, so to speak, architectural, being an arrangement of materials to resist stress and shock. The two grand divisions of the skeleton here are the upper jaw, fixed and immov- able, offering a surface for impact in acts of shearing, tearing, and grinding; and the lower jaw, which may, as combined with the upper, be compared to a nippers, shears, and pestle, and which must be, as the active mem- ber of the combination, necessarily very compact and firm. At the points of greatest stress, the superior maxillary bone becomes thickened, in order to form a buttress against the shock. Accordingly, we have all around the lower edge a thick and strong alveolar process, which receives the roots of the teeth. As the strongest pressure in biting is exercised by the second molars, they are accordingly the largest, and have deeply-set fangs. The alveolar process is thickened for their insertion, and a strengthening ridge ex- tends from it up to the malar bone, which articu- lates obliquely in such a way as to transmit all shocks directly to the frontal and the temporal bones. In any strong effort of the jaws, like cracking a nut, we place the object under this ridge. Another strengthening process, the ca- nine eminence, is found above the canine teeth, which also have long roots. These are, in ani- mals, instruments of great importance, serving both as weapons and for the tearing and firm holding of prey. A trace of this use remains in man, and is exhibited when a seamstress bites her thread, which she usually does with the sharply pointed eye-teeth, instinctively using that part of the jaw which is the best protected. It may be remarked that the eye-teeth are al- ways placed at the angles of the mouth, where they can be used to the best advantage without the necessity of widening that aperture. The width of the mouth, therefore, depends upon the situation of these teeth, and it is not without reason that a small mouth is considered a mark of refinement, as it indicates a departure from animal characteristics. The thrust upon the eye-tooth is con- veyed upward through the nasal process of the superior maxillary to the frontal bone. Another set of strengthening processes is intended to guard the face against any laterally directed force. Blows of this kind are usually received on the prominence of the cheek over the malar bone, and are carried along the zygoma and the lower border of the orbit. The hori- zontal plate of the hard palate also affords efficient sup- port. Force applied directly in front is delivered by means of this and the internal border of the orbit back upon the palate bones and the pterygoid processes of the sphe- noid. At other points than those mentioned the skeleton of the upper face is very thin, and internally it is hollowed out by the large cavity known as the maxillary sinus, or antrum of Highmore. When fractures occur, they usu- ally, according to a general law of distribution of force, are most frequent at those points where the thicker and thinner portions of the bone unite, following along the edges of the bars which have been described, separating the alveolar process from the rest of the bone, or run ning vertically upward from the bicuspid teeth to the orbit. They are not limited to single bones, but pass directly across without regard to sutures. The infra- orbital canal for the infra-orbital nerve and artery falls in the weaker part of the bone, and is believed to rep- resent an interval between portions which ossify sepa- rately in the foetus. The history of the ossification of Fig. 1121.-Superficial Veins of the Face and Neck. 1, External jugu- lar ; 2, internal jugular : 3, facial; 4, angular ; 5, its anastomosis with the ophthalmic ; 6, frontal; 7. temporal; 8, posterior auricular ; 9, oc- cipital. (Beaunis and Bouchard.) and reuniting with those on either side to form a compli- cated plexus. This takes place mainly in the facial nerve, and forms what is known as the pes anserinus. The trigeminus also has a similar arrangement, where its infra-orbital branch appears on the face, but to a much less degree. This is sometimes called the pes anserinus minor. It is quite impossible to localize with any precision the differ- ent twigs of the facial nerve for electrical treatment, and it is best to place one pole at the exit of the nerve near the stylo-mastoid foramen, and the other near its entrance to the affected muscle. Another peculiarity of the two great nerves that sup- ply the face is that they unite with each other very soon after their exit (see 6, 12, 13, 14, and 16, of Fig. 1122), so that when a branch upon the face is severed it is always a mixed nerve that is cut. This fact quite misled the 12 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Face. the superior maxillary bone seems, however, to need re- investigation. There is but very little diploic tissue found in the skeleton of the face, the rule being thin layers of com- pact tissue only. When there is considerable thickness, as in the malar bone, the alveolar processes, and the lower jaw, there is a scanty diploe. The result of this is that while necrosis of the superior maxillary is rare, and only affects the alveolar processes, that of the lower jaw is more common. There is but little callus formed when repair is necessary. The periosteum is usually thin and closely adherent, not favoring resections. A few words must be added on the anatomy of sepa- rate regions of the face. Orbital Region.-The external portion only will be considered. The skin around the edges of the orbit is exceedingly thin and movable, not liable to be wrinkled early except at the outer corners, where radiating folds (crow's-feet), due to the action of the zygomatici, are the first to appear with advancing age. Above, the eyebrows form a marked feature, which lends particular force to the physiognomy, differing considerably in different races, and being generally less prominent and thinner in blondes than in those of dark hair. At the inner portion the hairs are nearly straight, and occasionally a stray tuft is seen, here, which reminds one of the vibrissae of lower animals. This comes directly at the point where the corrugator supercilii exerts its most marked action, and considerably accentuates the expression both of this muscle (Fig. 1113) and of the upper portion of the orbicularis pal- pebrarum (Fig. 1114). Very shaggy brows are thought by some to indicate strong perceptive faculties, but it is not apparent that there is any scientific basis for the supposition. The brows correspond to the upper edge of the or- bit, and incisions for operations about the up- per part of the eye may very conveniently be made along the middle of the eyebrow, as the hair tends to hide the scar. The supra-orbital foramen (see Fig. 1123, a), where the supra- orbital nerve becomes superficial, is at the junction of the inner and middle third of the supra-orbital line. Frequently only a notch is found, in that case very easily felt. In neu- ralgia of the first division of the fifth nerve, pain is usually elicited on pressure here, and the nerve may be excised by an operation. It is not infrequent to find the skin here sharply cut, almost as with a knife, by contu- sions. In such cases the retraction is not great, and the haemorrhage slight; but by rea- son of the concussion the deeper organs may be affected, blindness having been known to ensue, apparently from the infiltration of the sheath of the optic nerve. The subcutaneous tissue is here lax and sub- ject to infiltration, especially at the lower edge of the or- bit, and it is here that we get the first signs upon the face of any general dropsical infiltration, as from renal dis- ease, or chronic arsenic poisoning. The general shape of the edge of the orbit (Fig. 1123) is quadrangular, with a somewhat obliquely directed di- ameter, the lower outer edge being the least prominent, reminding one of the fact that this is the latest portion acquired-there being, in fact, no outer edge in many ani- mals, the orbit in that case being continuous with the temporal fossa. In a Maori skull in the author's posses- sion there is a decided thinning of the frontal process of the malar bone. The eyelids, when closed, show a curved slit, whose di- rection is obliquely downward and outward, and there may be seen through them, when they are thin, the shape of the cornea, which in sleep is directed upward, but when awake directly forward. The skin over the lids is ex- tremely loose, and through it may usually be seen a rich network of vessels which contribute to the success of plastic operations in this region. Cicatrices on the cheek are apt to draw away the lower lid, and so occasion ec- tropion. It is the laxity of the connective tissue here that makes a "black eye" so common after contusions, and is the reason that a slight inflammation causes a con- siderable oedema, sufficient, indeed, to close the eye en- tirely. Emphysema of this tissue has been known to fol- low a fracture involving the air-cells of the ethmoid bone. There is a total absence of fat here, the tissue re- sembling that of the scrotum in that respect. When the sphincter of the eyelids is rendered inactive, as from paralysis of the facial nerve, the eye falls forward con- siderably, and this is also the case when the sphincter is widely dilated, as in fright. Muller has demonstrated in both eyelids longitudinal unstriped fibres, which are un- der the control of the sympathetic and draw the lids open, and Wagner has shown that an irritation of the sympathetic in the neck causes these fibres to contract. Within the body of the lid certain semilunar bodies are Fig. 1122.-The Superficial Nerves of the Face. 1, Trunk of the facial; 2, temporo-facial division : 3, cervico-facial division ; 4, posterior auric- ular ; 5, auriculo-temporal branch of the fifth ; 6, union of this nerve with the facial; 7, great occipital, from the cervical plexus ; 8, union of this nerve with the posterior auricular ; 9, superficial cervical, from the cervical plexus: 10, its union with the facial; 11, mental nerve from the fifth; 12, its union with the facial: 13, buccal nerve from the fifth, joining with the facial; 14, infra-orbital nerve from the fifth, joining with the facial; 15, frontal nerves (fifth); 16, union of the ex- ternal frontal with the facial. (Beaunis and Bouchard.) found which go by the name of the tarsal cartilages, al- though they are not properly cartilages, being merely condensed white fibrous tissue with some elastic ele- ments. That of the upper lid is larger and more mova- ble than the lower. The under surface of these con- nective-tissue bodies is liable to become thickened in spots, forming the so-called granulated lids. At the orbital edges these bodies thin out and then receive the name of the tarsal ligaments. They offer a resistance to the out break of abscesses of the orbit. At the angles or canthi 13 Face. Facliingen. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the eye little bridge-like ligaments attach this appa- ratus to the contiguous bones. That on the inner side may easily be seen. The whole system is probably of use in preventing the orbicularis from throwing the in- tegument into folds. At the edges of the lids are the orifices of the meibomian or tarsal glands, which secrete a fatty matter. They lie in the substance of the tarsal cartilages, and may be seen under the conjunctiva, when the lid is everted, as a collection of yellowish-look- ing granules. The deepest layer of the eyelids repre- sents, embryologically speaking, the enfolded integu- ment. It is a very fine and thin epithelial layer called the conjunctiva, and is reflected from the lids upon the eyeball, and therefore divided into a palpebral and an ocular portion. It is so thin that any effusion of blood under it is readily seen, and the color is usually a very striking scarlet, as oxygen passes quite freely through the membrane and arterializes it. One of the diagnostic symptoms of a fracture of the base of the skull is a sub- conjunctival clot. At the inner canthus of the eye the conjunctiva forms a small reddish, crescentic fold, the plica semilunaris, a relic of the third eyelid or nictitating membrane of birds. A collection of a few sebaceous glands and hair-follicles on the nasal side of this is called the caruncle. Directly above and below the outer edge of this, on either lid, are the puncta lachrymalia, minute orifices which open into the canaliculi of the nasal duct. These canaliculi pass toward the nose for a short distance and then join the duct at nearly right angles. The orifices and the whole apparatus is for the purpose of properly carrying off the secretion of the lachrymal gland. In affections of the eye, the puncta may be so turned outward that they cannot collect the ordinary secre- tion, and there is a constant flow upon the face. The upper part of the nasal duct, which ends in a blind pouch, is called the nasal sac ; the lower discharges into the nasal fossae. It is sometimes neces- sary to operate upon the sac for fistula lachrymalis. The point where the incision should be made is shown at b, Fig. 1123. Allen15 gives as a rule for finding the lach- rymal sac, in conditions when the face is disfigured by swelling, the following: ' ' Draw a line from the wing of the nose to the outer border of the supra-orbital arch. Then bisect this line by a second, which will, when produced upward, cross the root of the nose. The second line will exactly cross the position of the lachrymal sac. " A very curious apparatus for drawing off the tears by the lachrymal sac is found in that portion of the orbicu- laris palpebrarum known as Horner's muscle, which passes directly over the sac to be inserted upon the edge of the nasal groove of the lachrymal bone. Whenever the orbicularis acts, as in winking, the sac is compressed, and in expanding again by its own elasticity sucks in fluid through the puncta and the canaliculi. The eyes, popularly spoken of as " the windows of the soul," are dependent almost entirely upon the surround- ing parts for their expression. That this is the case is apparent when we recollect how completely a mask ob- literates the expression. Nasal Region.-The nose is one of the most significant marks of the individuality of the face. On this account it has been used by artists as a measure of the head, and, in- deed, of the whole body, the rule being that the head is four noses high, while the whole body is about eight heads in height. Exact researches have shown that there is no such thing as any absolute relation of this sort, and every modulus that has ever been invented has been found faulty. The nose of the higher races of man differs much from that of any of the animals, even the anthro- poid apes. A glance at Fig. 1096 will show that there is a gradual ascension from a snout-like form to the fully completed Roman or Grecian organ. The loss of the nose is a more significant mark of de- formity of the face than any other. During the middle ages the mutilation of the face was used as a barbarous punishment in Italy, and the practice still survives in Eastern countries. It is therefore from these regions that we get the principal methods for repair of the de- formity. Tagliacozzi, the Italian surgeon who invented the operation bearing his name, was known in his day as Nasifex. The shape of the nose is due, in considerable degree, to the development of the fronto-nasal process, the central portion of which forms the cartilage of the septum, the lateral portion the lateral cartilages. It is the incomplete development of the first which produces the nez retrous- se ; of the latter, the outwardly directed nostrils of the negro. The police department of Paris has found that an exact description of the nose is one of the best methods of iden- tifying suspected persons, and has published elaborate directions for the use of its agents. Since they have adopted this system, the number of recognitions of sus- pects has risen from eight in the first six months to two hundred in the six months ending June 30, 1885. The. skin is quite adherent, especially toward the point and wings, and here contains many sebaceous glands. It is very likely to be affected by eruptions and syphilitic ulcerations. It may attain enormous size by the increase of its subcutaneous tissue. The muscles of the nose are not very active in ordinary conditions, but the dilators become prominent in cases of dyspnoea. It was because of the innervation of these muscles by the facial nerve that Sir Charles Bell called it a nerve of respiration. The skeleton of the nose is both cartilaginous and bony, and in introducing a dilating instrument it should not be carried beyond the lower cartilaginous part. The limits will be seen on comparing the two sides of Fig. 1123. The bones are sometimes fractured or displaced by a di- rect blow upon the bridge, but this must be of consider- able force. Union is very rapid, but a restoration to place is not always easy, and it may be necessary to insert plugs in the upper nares. Buccal Region.-The mouth is the facial orifice pos- sessing the greatest variety of movements, and here are concentrated the numerous muscles which are shown in Fig. 1108. In consequence of the necessity for these movements they have been fixed in the animal race for a longer period than others, and are more likely to be au- tomatic. The control over the mouth is a measure, to a certain extent, of the mental power, and in imbeciles and idiots the mouth is more likely to show the mental con- dition than any other feature. There is but little that need be said as to the topography of the lips, there being merely the external skin, closely adherent and covered, in the male, with thick hair, the various layers of the orbicularis muscle, and the mucous membrane. The subcutaneous fat is rather interspersed between the muscle-fibres than forming a layer bv itself. The lips do not, therefore, grow fat with the rest of the face. The skin and mucous membrane are frequently affected with scrofulous and syphilitic ulceration. In- cisions in the lips should preferably be horizontal, both with regard to the course of the muscle-fibres, and be- cause the vessels run in that direction (see Figs. 1120 and 1121). The nerves of the lips have special end organs, which probably give them an unusual degree of sensibility. Facial paralysis of one side only causes the unaffected Fig. 1123.-The Relation of the Soft Parts of the Face to the Skeleton, a, Supra-orbital notch, or foramen ; b, point of incision for lachrymal fistula ; c, infra-orbital notch ; d, line of incision for excision of the su- perior maxillary bone by external flap ; e, line of incision for operating by superior flap; /, mental foramen. 14 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Face. Fachingen. muscles to draw the mouth to their side. It is probable that the simplest and earliest forms of speech are the labials, pronounced by placing the lips together. The words papa and mamma are instances of this, and similar forms are very widely spread, even among savages; too widely to be accounted for by transmission. Region of the Cheek.-The subcutaneous fat here forms a rounded mass lying deep down in the substance of the cheek upon the buccinator muscle, and never entirely lost even during extreme emaciation. This is called by French authors the "boule graisseuse de Bichat." It affords an excellent support for the action of the muscles which pass from the oilier surface to the corners of the mouth. The posterior part of the cheek, which is more properly the jaw, is occupied by the masseter muscle and the paro- tid gland. The gland will form the subject of a special article. The situation and the direction of its duct of discharge may be seen in Fig. 1108. All incisions in the cheek should have reference to this duct and to the direc- tion of the branches of the facial nerve. The incisions for removing the superior maxillary bone fall within this region. In Fig. 1123 the line marked d running along the lower border of the orbit and the side of the nose shows the method by external Hap, which is preferable where only a portion of the bone is to be removed, and the line e, together with the nasal portion of the line d, is used when the whole bone is to be taken away. The masseter is covered with a strong fascia continuous with that over the parotid gland. Internally to this a sheet stretches forward upon the buccinator muscle which partly arises from it. The thickened edge of this fascia behind the insertion of the buccinator constitutes the so- called pterygo-maxillary ligament. Region of the Lower Jaw.-The skin of this re- gion is even more closely united to the subcutaneous tis- sue than is the case elsewhere upon the face. Frequently its configuration occasions marked peculiarities, among which may be noted the dimple at the point, which has been considered a notable mark of beauty, and the "double" chin, which is hereditary in some families, notably that of the Bourbons. The prominence of the chin usually keeps pace with that of the forehead, both being marked characteristics of man, and not possessed by any anthropoids. Owing to the thick and dense felt- ing of the skin and superficial fascia, abscesses do not usually discharge externally, but within the cavity of the mouth. When the lower lip is lost, its place may be supplied by a flap from other regions, but the operation cannot be said to successfully restore the appearance of the counte- nance, as no provision can be made for the loss of the orbicularis. The muscles of the lower jaw are very pow- erful, as they act to much better advantage than do those of most other regions. Rapidity of movement is obtained by the temporals pulling upon the coronoid processes; power, by the masseters and pterygoids, acting directly. The feats of the " iron-jawed" acrobats attest the reality of this power. The muscles are peculiarly liable to be affected by causes originating in the central nervous sys- tem (trismus, hydrophobia, etc. See Cranial Nerves, page 327 of Vol. II.). The inferior maxillary bone is, from its shape and structure, one of the strongest in the body. Fracture is therefore rare, and when it does occur, is usually to one side of the symphysis, as this is the strongest part. The bone being subcutaneous or submucous throughout, makes diagnosis of fractures or tumors very easy. The alveolar process is very thick and strong, and the pull- ing of teeth is sometimes a serious matter, involving a fracture of the jaw if too energetic means are employed. Hyrtl thinks at least a year elapses before the completion of the absorption of the process, so that this period must be over before false teeth can be expected to be accurately fitted. The inferior dental nerve, which traverses a special canal in the body of the bone, emerges from the mental foramen under the second bicuspid tooth as the mental nerve. It is frequently the seat of neuralgia, and may be found painful on pressure. Its excision is easy, it being readily reached from within the mouth by an incision through the mucous membrane. The changes which occur in the jaw from age are quite marked. In childhood the ramus joins at an oblique angle as in apes, and the alveolar process not be- ing developed, the mental foramen is near the upper edge, and the dental canal is large. In adult life the union of the two parts of the bone is nearly at right angles ; and in edentulous age the ramus slopes backward again, because of the pull of the muscles which have no teeth to counteract them, and the foramen is again high as in childhood. This shaping is modified somewhat when false teeth are worn. The articulation of the jaw will be treated in a separate article. Frank Baker. 1 Merkel (Fr.); Handbuch der Topographischen Anatomie. Braun- schweig, 1885. 2 Camper (Pierre): Dissertation but les diff6rences reelles que pre- sentent les traits du visage chez les hommes de differents pays et de differents ages. Paris, 1791. 3 Rimmer 0V.): Art Anatomy. London. 1884. 4 His: Anatomie menschlichen Embryonen. 6 Cusset (Jean): ktude sur l'appareil branchial des vertebras et quel- ques affections qui en derivent chezl'homme. Paris, 1877. 6 Mason (F.) : Lectures on the Surgery of the Face. 7 Froriep (R.): Die Charakteristik des Kopfes. Berlin. 1845. 8 Weisse (F. D.) : Practical Human Anatomy, a working guide for students of medicine and a ready-reference for surgeons and physicians. New York : William Wood & Co., 1886. 9 Meynert (Theodor) : Psychiatric. Wien, 1884. 10 Duchenne de Boulogne : Mecanisme de la Physionomie humaine. Paris, 1862. 11 Darwin (Charles) : The Expression of the Emotions in Man and Animals. New York, 1873. 12 Baker (Frank) : Darwin on the Expression of the Emotions. Ad- dress before the Darwin Memorial Meeting of the Biological Society of Washington, May 12, 1882. In Proc. Biol. Soc. Washn., vol. i., Novem- ber 19, 1880, to May 26,1882. 13 Piderit (Theodor) : Mimik und Physiognomik. 2d revised edition. Detmold, 1S86. 14 Macalister (A.): The Morphology of the Arterial System in Man. Jour. Anat, and Phys. London, 1886, xx., 200. 16 Allen (Harrison): A System of Human Anatomy. Philadelphia, 1883. FACHINGEN is located on the northern side of the Taunus slope, Province of Nassau, Germany, at an eleva- tion of 367 feet above the sea-level. Its chief interest is its mineral spring. Its situation is romantic, being sur- rounded on all sides by forest-covered hills which serve to protect it from the heat of the sun in summer and the cold winds of winter. Notwithstanding its adaptability for a resort, however, it is little frequented, owing in part to a lack of accommodations, and in part also to the monotony of a sojourn there. The spring affords a water that is remarkable for its richness in alkaline salts and free carbonic acid. The chief ingredient is the carbonate of sodium, the carbonates of lime and magnesium also existing in considerable quantities. A chemical analysis by Fresenius shows the following solids in each pint: Grains. Sodium carbonate 19.4763 Magnesium carbonate 1.3580 Calcium carbonate 2.0110 Sodium chloride 4.5574 Sodium sulphate 0.1372 Sodium phosphate 0.0506 With traces of the carbonates of iron, lithium, and strontium, calcium chloride, and other salts to make a total 27.9397 Cub. in. Carbonic acid gas 82.975 Nitrogen 025 Fachingen water is recommended chiefly for catarrhal states of the urinary organs and a tendency to uric- or lithic-acid formations. Good results are reported from its use in chronic bronchial catarrhs. As it differs little in composition from seltzer water, containing a larger amount of carbonic acid and less chloride of sodium, it is considered by many more palatable. It is drunk plain, with wine or with milk. The exportation of Fachingen water is reported as rapidly increasing, it be- ing carried for the most part to the various countries of Europe. J. M. F 15 Fac^ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FACIAL HEMIATROPHY. Synonyms.-Trophic neu- rosis of the face (Romberg), laminar aplasia (Lande), uni- lateral progressive atrophy of the face (Eulenburg). History.-This disease, which consists of a limited atrophy of the muscles of the face, was originally de- scribed by Parry,1 and afterward by Bergson2 and Rom- berg? Schott,4 Moore,6 Meyer,8 Fremy,7 and Lande 8 have contributed upward of twelve cases, and in this country Robinson,9 Draper,10 Hammond,11 and Bannister 12 have shown several others. Definition.-The disease under consideration is one beginning by such superficial cutaneous changes as uni- lateral discoloration and hairy disappearance, eventually ending in loss of underlying cellular tissue, muscle, and bone, and, as a rule, unaccompanied by loss of motor power or sensibility. Symptoms.-The disease, which seems more often to affect women, begins by the appearance of brown stains or white spots, or cutaneous eruptions of a lichenous type, which cover the face, and rarely the neck. Sometimes there are repeated attacks of herpes, the lips and other parts supplied by the fifth nerve of one side bejng their seat. With this there is some diminution of temperature, and Pierson has detected this lowering in the external auditory meatus. In a few months after the appearance of such evidences of cutaneous malnutrition we find a wasting of the muscles of the same side of the face. In Dr. Draper's case (Fig. 1124), which may be considered typical, the wasting was confined to a space bor- dered by the symphysis of the lower jaw, angle of the nose, and middle of the upper lip in front, lower edge of zygoma above, and ramus of the inferior maxillary be- hind. The skin is white, tense, and bound down to the tissues beneath. The power of blushing is gone sometimes. In some cases there is no interference with the secretion of the skin. The atro- phy may involve the tongue, and of twelve cases this wasfound, inhalf, to be the case. So far as the time of appearance of atrophy is con- cerned* cases have been observed in which it began when the subject was but three years of age, in others as late as twenty or thirty. In some cases it was preceded by spasm of the masseter muscles. In one case the tonsil was atrophied, and in two there was deafness. When the disease is advanced the bones are often so much atrophied as to present a conspicuous asymmetry. The left side is more commonly affected than the right. All observers agree that the electrical reactions of the affected muscles are not altered. Causes.-Whooping-cough, scarlatina, or intermittent fever have existed as predisposing causes. Traumatism is reported as a cause, and one case of pressure from ill- applied forceps during delivery is mentioned. Toothache is mentioned as a cause, and a preliminary stage of trigem- inal neuralgia has resulted in the malady. In several cases, notably those of Meyer and Brunner, the hemi- atrophy occurred in epileptic subjects. Pathology.-Various theories have been advanced as to the pathology of facial hemiatrophy. Virchow be- lieves that the disease is a primary affection of the periph- eral nerves, and Lande is of the same opinion, holding that it is a primary atrophy of the fatty tissues, the elas- tic tissues being exempt, and that the retraction of the latter causes a contraction of the capillaries and diminu- tion of nutrition. On the other hand, a host of able investigators are of the opinion that it is a veritable dis- ease of the nervous system, dependent either upon a lesion of the cervical sympathetic, the fifth and seventh nerves, or the medulla. The prominent champions of the sym- pathetic theory are Brunner, Pierson, and Fox. The brown staining and various unmistakable symptoms which attend other diseases (in regard to the pathology of which there can be little or no doubt) go to show that, if not the primary cause, the sympathetic is involved in as- sociation. Those -who advance the trigeminal origin of the disease are Vulpian, Baerwinkel, Romberg, Dresch- field, Stirling, Mierzejewsky, and Erlizky, and these writers have had cases in which the atrophy and other changes were supposed to be due to disease of the ganglia of the trigeminus, the vasomotor nerves of the trigemi- nus, the sensory fibres of the same, the third branch of this nerve, or to a circumscribed lesion at the floor of the fourth ventricle, in the motor nucleus of the fifth (Fox). So far as I can judge from the cases I have seen, the disorder is by no means so simply explained, and I am now inclined to look upon it as one due to involvement of the trigeminus as well as the sympathetic fibres which supply the locality in which the morbid expressions are found. Diagnosis. - Progressive muscular atrophy and old facial paralysis may somewhat resemble the disease. It is rare for the former to affect the face unilaterally, and never until other parts are first attacked, so a search will disclose the existence of an associated main en griffe, or some other evidence of previous trouble. Facial paraly- sis is also a disease which can hardly be mistaken. The sudden onset, buccal asymmetry, and loss of electric con- tractility which belong to the latter are diagnostic marks which are infallible. Prognosis.-So far no fatal cases have been reported. The prognosis is certainly bad, as the disease is undoubt- edly one of a progressive nature. In one case, that of Belot, the disease seemed to be arrested after one year, and then remained stationary. I have seen two cases in which there seemed to be no new symptoms after the full establishment of the atrophy. Treatment.-No therapeutical measures have afforded the least benefit so far in established cases of the disorder. If the malady be recognized at a sufficiently early stage, the galvanic current should be energetically used. Moore has employed it with indifferent success. Allan McLane Hamilton. 1 Cited by Rombersr. 2 De ProsopodyHmorphia sive nova atrophia; facialis specie. Berlin, 1837. 3 Klinische Ergebnisse, 1846. 4 Referred to by Fox. 6 Dublin Quarterly Journal, 1852. 6 Referred to by Fox. 7 fltude Critique de la Trophonevrose. 1873. 8 These de Taris, 1869. 9 See Journal of Nervous and Mental Diseases, October, 1876. lu American Psychological Journal, February, 1876. 11 Diseases of the Nervous System, 1876. 12 Journal of Nervous and Mental Diseases, October, 1876. Fig. 1124.-Dr. Draper's Case of Facial Hemi- atrophy. FACIAL NEURALGIA. Synonyms.-Trigeminal neu- ralgia, tic douloureux, prosopalgia. Etiology.-Heredity is one of the most important fac- tors in the etiology of all forms of neuralgia, and partic- ularly in that of the trigeminus nerve. The disease is sometimes conveyed directly from the parent to the off- spring, i.e., both suffer from facial neuralgia. But in a large proportion of cases the neuropathic taint in the family crops out in different ways in different members. Thus, a migraine or epilepsy in the parent may reappear in the children as chorea, neuralgia, insanity, etc. Further- more, the same individual may manifest this interchange- ability of the functional neuroses in his own person, at different periods of life. In one of our patients, facial neuralgia alternated at different times with chorea, brach ial neuralgia, acute mania, sciatica, and intercostal neu- ralgia. Facial neuralgia sometimes seems to act as a sort of safety-valve to the central nervous system, and to take the place of other and more serious maladies. It is a very peculiar fact that neuralgia may make its appearance in several children belonging to the same fam- 16 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fac. Hemiatrophy. Fac. Neuralgia. ily, although the parents and other relatives present no history of any form of nervous disease. In an instance of this kind which came under our observation, neural- gia was inherited by the children of one of the patients. Anstie would have us believe that phthisis in the par- ents may give rise to neuralgia in the children, but con- vincing proof of this proposition has not been offered. Another important etiological factor is' excessive men- tal work, especially when associated with worry. The latter element is almost always an active element in such cases, as it is in the causation of not a few other func- tional neuroses. For this reason the disease is often found among the members of the learned professions, particu- larly the legal profession, and among active business men. The causes in question produce a direct depressing and exhausting effect upon the central nervous system. Their effect is furthered by the want of sleep which is such a common feature of these cases. Malaria is a very frequent cause of the disease, but this infectious agent acts very generally upon only one branch of the trigeminus, viz., the supra-orbital nerve. Indeed, the connection between the two is so frequent that the existence of supra-orbital neuralgia should arouse a suspicion of malarial poisoning. We must be on our guard, however, against regarding the periodicity of the paroxyms of pain as an infallible indication of their malarial origin. Periodicity is fre- quently observed, not alone in other forms of neuralgia, but also in various other spasmodic nervous affections, and even in painful affections caused by organic lesions of the nerves or nerve-centres. In a case under our ob- servation the paroxysms of pain caused by cancer of the vertebrae and dura mater of the spinal cord for a time ran as typical a course as an ordinary tertian intermittent fever. In comparatively rare cases trigeminal neuralgia is the result of other infectious causes, such as secondary syphi- lis and typhoid fever (usually in the prodromal stage). Exposure to cold is often mentioned by patients as the cause of the disease, but this is by no means so frequent a cause as such statements might lead us to believe. In- dividual paroxysms are often the result of " rheumatic" influences in those who are predisposed to the disease. Individuals wflio are enfeebled from previous protracted diseases, excessive discharges, anaemia, etc., are much more apt to suffer from prosopalgia than full-blooded, robust individuals. In a comparatively small proportion of cases the disease is the result of direct irritation or compression of the nerve by a lesion which may be situated in any part of its course, from the Gasserian ganglion to its distribution in the face. A great variety of lesions of this character have been observed, such as aneurisms of the internal carotid (compressing the Gasserian ganglion), tumors growing from the base of the brain or skull, periostitis or exostoses of the petrous portion of the temporal bone, gummy tumors and meningitis, tumors or other affections of the orbital cavity, foreign bodies, diseases of the alve- olar processes, etc. In another group of cases the disease is reflex in its ori- gin. The source of reflex irritation may be found in affections of the nasal cavities (chronic rhinitis, nasal polypi, etc.), caries of the teeth, misplaced wisdom teeth, affections of the eye (in our own experience, ocular af- fections give rise, except in very rare cases, to headache and other symptoms of asthenopia rather than to true neuralgia), diseases of the stomach and intestinal tract, diseases of the uterus and its adnexa, pregnancy, diseases of the male genital organs, etc. A few cases have been reported in which neuralgia of the trigeminus nerve was the result of injury to a nerve in a remote part of the body. The majority of cases occur among females. Among 263 of our own cases, 159 were observed in females, 104 in males. The larger number of cases begin between the ages of twenty and forty years. The disease is observed, not in- frequently, at a much more advanced period of life. It is extremely rare in early childhood. With the exception of a case in an infant aged five months, reported by Demme, no case has been reported, to our knowledge, under the age of five years. Clinical History.-Facial neuralgia consists in the main, and sometimes exclusively, of paroxysms of pain, with an inter-paroxysmal condition in which the patient is free from suffering. The attack may begin suddenly, or it may be preceded by prodromata. The latter gener- ally consist of a feeling of uneasiness or coldness in the side of the face, numbness, tingling, and mental depres- sion. The pain usually attains its greatest intensity in a very short time. It is always of a shooting or lancina- ting character, and usually darts from the centre to the periphery. Occasionally the pain is said to run in the opposite direction. The most remarkable similes are em- ployed by the patients in describing the severity of their sufferings. The pain is compared to that produced by drawing a coal of fire along the course of the nerve, to cutting the nerve with a sharp knife, tearing the bones asunder with pincers, etc. It is sometimes so excruciat- ing that the patient, in a vain attempt to obtain relief, rubs the skin until it is raw, dashes his head against the wall, and numerous sufferers have committed suicide in order to escape their terrible tortures. The duration of the paroxysms varies from a few7 mo- ments to hours, in the most severe cases even days. In the latter event, of course, the pain is not continuous. The patient experiences a single shock, or a number in rapid succession ; then follows a brief interval (during which the pain disappears entirely, or varying degrees of tenderness persist), then another shock of pain, etc. The attacks sometimes appear to come on spontaneously, at other times they are produced by various exciting causes, such as talking, the movements of mastication, a draught of air, mental excitement. Vcry violent attacks are apt to be associated with con- vulsive, twitching movements of the muscles of the face on the affected side. These seizures are known as tic douloureux. According to Trousseau, this is a distinct variety of the disease, which bears intimate relations to epilepsy, and has accordingly been called by him true epileptiform neuralgia. It is more probable, however, that tic douloureux is merely a very severe form of the disease, and is unusually intractable because it occurs so often at an advanced age. Moreover, we have sometimes noticed the tic in cases of moderate severity. In severe cases of trigeminal neuralgia it is not uncom- mon to find, at the height of the paroxysm, that neuralgic pain is also experienced along the course of the occipitalis major nerve (usually on the same side as the affected trigeminus), and in rare cases in the course of more re- mote nerves. The pain in the back of the neck some- times is almost as severe as that experienced in the face. Painful points (puncta dolorosa) form an important and very frequent symptom of facial neuralgia. They constitute small, circumscribed localities which are ex- ceedingly sensitive to slight pressure during a paroxysm. Sometimes pressure upon them will also send a thrill of pain through the affected branch of the nerve. The puncta dolorosa are found at the exit of the branches of the nerve from bony foramina, and from beneath fibrous fasciae, or at their emergence beneath the skin. Upon raising the skin over such points into a fold, and then irritating it, we sometimes find that the integument is anaesthetic, although the subjacent parts may be ex- tremely sensitive to pressure. The puncta dolorosa are observed most frequently dur- ing a neuralgic paroxysm, but they are present occasion- ally in the intervals between the paroxysms. They are by no means so constant as was claimed by Valleix, w'ho regarded them as pathognomonic of the disease. The following are the situations of the most constant painful points in the different forms of trigeminal neu- ralgia. In neuralgia of the ophthalmic branch, a supra-orbital point, at the supra-orbital notch, a parietal point, over the parietal eminence, a nasal point, on the upper part of the side of the nose; in neuralgia of the superior max- illary branch, an infra-orbital point, at the infra-orbital 17 Facial Neuralgia. Facial Neuralgia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. foramen, a nasal point, on the lower part of the side of the nose, a malar point, over the middle of the malar bone, a superior gingival point, in the upper gums; in neuralgia of the inferior maxillary branch, a temporal point, immediately in front of the lobe of the ear, a mental point, at the mental foramen, an inferior gingival point, in the lower gums. Trousseau called attention to a painful spinal point (point apophysaire) which is situated over the spinous process of the second or third cervical vertebra. This is observed in quite a number of cases, but not infrequently the pain is felt on pressure to one side of the spinous pro- cess. It is sometimes found that not alone is pain produced in the part upon 'which pressure is exerted, but a dart of pain may also be felt along the affected branch of the fifth nerve, or the pain appears to pass directly through the head into the forehead. A considerable proportion of the cases present symp- toms which are not of a sensory character. Prominent among these are the vasomotor disturbances. The most constant symptoms in this category are redness and in- creased heat of the skin, sometimes occurring only along the course of the affected branch of the nerve, sometimes on the entire side of the face. The integument may also be slightly swollen. The carotid and temporal arteries are found to throb more violently. An erysipelatoid condition of the integument is ob- served not infrequently. In our experience, this is more apt to develop when the supra-orbital nerve is affected than in neuralgia of other branches. Herpes, more rarely other cutaneous eruptions, are oc- casionally noticed. Herpes occurs almost exclusively in the distribution of the ophthalmic nerve. The vesicles form upon the upper lid and forehead, much more rarely upon the cornea (resulting in the production of keratitis), and sometimes even upon the iris, where they may give rise to iritis. Cavafy reports a case of left trigeminal neuralgia which recovered spontaneously in nine days. Three days later acute eczema, with confluent vesicles, appeared on the left side of the face and scalp. This recovered promptly under local treatment. The integument supplied by the affected nerve may undergo hypertrophic or atrophic changes, the .former much more frequently than the latter. The subcutane- ous cellular tissue may also take part in these changes. The mucous membrane of the tongue and mouth on the affected side may also present excessive proliferation of the epithelium, and be much more thickly coated than the opposite side. A large number of cases have also been reported, in which changes in the hair were observed. These are con- fined almost exclusively to the distribution of the supra- orbital branch. The affected hairs grow coarse and brit- tle, or their color changes to gray or white, usually in patches along a vertical line. I have also seen a similar affection of a lock of hair in the distribution of the oc- cipitalis major nerve, in a patient in whom neuralgia of this nerve complicated trigeminal neuralgia. The color of the hair may gradually return to the normal after the attack of neuralgia has subsided, but it is apt to recur during subsequent attacks, and finally becomes perma- nent. V. Stofella reports two cases in which a new formation of dentin occurred in the pulp cavities of several teeth during the course of facial neuralgia, and he looks upon this as a trophic change. Secretory disturbances are noticed very often in this disease. The lachrymal secretion is very often increased in amount, the tears streaming down the cheeks and into the nasal cavity. The discharge from the nose on the af- fected side may also be increased. In one of my cases the nasal discharge was sero-purulent in character, and a luemorrhagic secretion has also been described. The salivary secretions may also be increased ; very rarely the production of saliva is inhibited during the paroxysm. A number of cases have been reported in which the periosteum and bones near the puncta dolorosa, sometimes over the entire side of the face, were thickened, but it is doubtful whether these changes did not develop pri- marily. Facial neuralgia is almost always unilateral. Among two hundred and sixty-three cases I observe only three in which both fifth nerves were affected. Except in very violent cases, particularly tic douloureux, all of the branches of the nerve are not implicated. In a large pro- portion of cases the supra-orbital nerve alone is involved. The superior and inferior maxillary branches are attacked with approximately equal frequency. In rare cases, very small twigs of the nerve are affected-for example, the ciliary and lingual nerves. In very many cases the disease appears to have no ef- fect upon the general condition. But the general nutri- tion of the body is apt to become seriously impaired if the disease is violent and protracted, and if the pa- tients dread to take food because the act of mastication provokes a paroxysm of pain. In other cases the con- stant recurrence of the attacks, and the constant endeavor on the part of the patient to avoid all possible exciting causes of a seizure, give rise to a condition of hypo- chondriasis, extreme mental irritability, impairment of judgment, etc. Cases have been described in which the neuralgic attacks alternated with attacks of insanity. Diagnosis.-Trigeminal neuralgia is often mistaken for migraine, though the two affections are entirely distinct. The former is rare in childhood, the latter very often begins at this period of life. The pain of migraine does not pos- sess the sharp, lancinating character of neuralgia, nor does it follow the course of certain branches of the nerve. It often continues uninterruptedly for a period of twenty- four hours, and is sometimes accompanied by hallucina- tions of sight and hearing, or other abnormal cerebral phenomena. The puncta dolorosa are absent in migraine. The disease is pre-eminently hereditary, the heredity being manifested chiefly on the female side. The headache of anaemia is distinguished by the pres- ence of other evidences of anaemia (pallor, weakness, irri- tability of the heart, haemic cardiac murmurs, etc.), the location of the pain (usually at the vertex or forehead), and its character (dull, lifting, tensile). Furthermore, the headache of anaemia is not paroxysmal in character. Clavus hystericus is distinguished from neuralgia by the existence of other hysterical manifestations, and by the fact that the pain is usually limited to a very small, circumscribed part of the scalp, in which it is sometimes felt continuously for hours. Syphilis, it must be remembered, sometimes gives rise to trigeminal neuralgia, but the ordinary syphilitic head- ache is an entirely distinct affection. The pain is boring or shooting (but not along definite nerve-branches), often excruciating, and is usually located in the bones or deeper structures. The affected parts (generally the forehead or parietal region) are often extremely sensitive to pressure, and may present circumscribed swellings (gummata, peri- ostitis). Exacerbations usually occur at night. The pain sometimes continues with unabated severity for weeks and even months. It is also important, in regard to prognosis and treat- ment, to ascertain the cause of the disease. For this pur- pose we should enter carefully into the family history and previous history of the patient, and endeavor to ascertain the existence of any constitutional predisposing condition. If such an examination throws no light upon the ques- tion we must look for local causes of the disease, either lesions which act directly upon the nerve, or those which act as a source of reflex irritation. The causa morbi is so much more apt to be situated centrally the greater the number of branches of the nerve which are affected. In not a few cases our search will prove fruitless, and the affection must then be relegated to the unsatisfactory category of " idiopathic" cases. Prognosis.-Thisdepends in great measure upon the etiology, the previous duration of the disease, and the age of the patient. In cases which are the result of some irremediable or- ganic lesion, the disease is usually incurable. But if the cause of the disease is readily removed, the neuralgia, as 18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Facial Neuralgia. Facial Neuralgia. a rule, soon disappears. In many cases, howrever, the long continuance of the disease appears to give rise to a sort of neuralgic habit, and it may then continue as an in- dependent affection even after the removal of its cause. As a rule, the prognosis is so much more favorable the shorter the previous duration of the disease. The existence of an hereditary taint clouds the prog- nosis and increases the tendency to a relapse, as it does in all other neuroses. The variety of neuralgia which begins at an advanced age enjoys an extremely unfavorable repute, particularly the form described by Trousseau as epileptiform neural- gia. This writer goes too far, however, when he claims that all these cases are incurable. The unfavorable prog- nosis of this form of the disease is closely connected with the degenerative organic changes incident to old age. Even in the most favorable forms of the disease re- lapses are apt to occur, sometimes after very trifling exciting causes. Treatment.-In every case of neuralgia the recogni- tion of its etiology should be regarded as one of the most important therapeutic problems. In not a small propor- tion of cases our search will be fruitless, and in many other cases we will find ourselves powerless to remove the cause after it has been discovered. It is unnecessary to enter into the consideration of all the measures which are requisite when the disease can be traced to the action of some definite morbific agent. Malarial neuralgia must be treated with large doses of quinine, in obstinate cases with arsenic ; syphilitic neuralgia requires the exhibition of large doses of mercury and iodide of potassium ; in neuralgia due to anaemia we prescribe ferruginous prepar- ations, etc. In cases of a reflex nature brilliant results are some- times secured by the treatment of the primary affection. Thus, a case is reported in which a cure was effected by the successful treatment of a circumscribed rhinitis. In several cases recovery followed the removal of nasal polypi. Holst relieved a case by the removal of the en- larged and indurated portio vaginalis of the cervix. Numerous similar cases are found scattered through the periodical literature of recent years. In the large category of idiopathic neuralgias our ob- ject must be to maintain the tone of the system, particu- larly of the nervous system, and to administer certain remedies which we know from experience to be useful in this affection. To secure the former object, njental and bodily rest, a generous diet (particularly nitrogenous and fatty articles of food) are all essential. The medicinal agents which have been employed to re- lieve neuralgia are almost innumerable. In our own hands Duquesnel's aconitia has proved the most serviceable in the largest proportion of cases. It may be administered in solution or in the form of gran- ules or tablet triturates. Some patients are extremely sus- ceptible to its influence, so that great caution must be exercised in its administration. Unless the pain is ex- tremely violent, it is our practice to give gr. to T|s t.i.d. for the first day, and then to increase the amount by one dose daily until the physiological effects arc produced (tingling or numbness in the tips of the lingers and tongue, a peculiar sensation in the roof of the mouth, dryness of the throat, fulness in the head, a feeling of faintness). If the pains are unusually severe the initial dose may be re- peated every three hours until the physiological effects be- come evident, but under such circumstances the patient should be carefully watched. The effects of the remedy are sometimes almost magical. We have noticed not infrequently that violent neuralgias, which had resisted numerous other methods of treatment, would disappear as soon as the first evidences of the physiological action of the drug made their appearance. A number of cases have been reported (two have come pnder our own obser- vation) in which this drug produced recovery after neurec- tomy had been unsuccessfully performed. Arsenic is another valuable agent in this disease. It is best given in the form of Fowler's solution or arsenious acid. Beginning with five or six drops of the former, or gr. 3V of the latter, as an initial dose, the amount is in- creased pretty rapidly, until physiological effects become evident (gastric irritability, puffiness under the eyelids, etc.). The drug should then be continued in doses which fall short of producing such effects. Arsenic is especially useful in protracted malarial neuralgias and in the ob- stinate neuralgia of old age. We have seen marked improvement of " epileptiform" neuralgia from its admin- istration, but in obstinate cases a month or more some- times elapses before the curative effects of the remedy become manifest. Quinine often produces good results in cases which are not associated with malaria. It should be given gener- ally in 10 to 15 grain doses three or four times a day, and may be discontinued when the ringing in the ears and the head symptoms become very annoying. Some writers have recommended the exhibition of enormous doses of this remedy, even as much as 75 grains at a dose. Morphine should be administered with great caution in the treatment of facial neuralgia, for in no disease is the morphine habit so apt to be acquired as in this. If the patient is under our frequent supervision, it is preferable to administer the drug hypodermically. Our object should be to relieve the pain as completely and quickly as possible, since complete relief from pain sometimes appears to break up the " neuralgic habit " of the nerve, and produces recovery. But such cases are comparatively infrequent. In the much larger number morphine acts merely as a palliative, and renders the patient's condition endurable until other remedies have had an opportunity to exert a favorable effect. In very obstinate or incura- ble cases, the amount of morphine taken must be gradu- ally increased, until finally the patient may take truly appalling doses. A combination of atropia with the morphine (at the beginning of this plan of treatment) is sometimes found useful. Strychnia seems to exert a happy effect in a small series of cases. Like arsenic, it must sometimes be given for quite a long time before its beneficial action becomes evident. The initial dose is gr. to 3V Osmic acid has been recently employed hypodermically in this disease, either in aqueous solution (one per cent.) or with the addition of a little glycerine; about 0.50 to 1.00 should be used at each injection. The needle should be introduced as near as possible to the site of pain. The injections themselves are sometimes very painfid. The integument over the site of injection may become hard and thickened for a time. The published reports on the use of this agent have not been very favorable, but it merits a trial. Gelsemium sempervirens will be found useful in a cer- tain number of cases, particularly in dental neuralgia. It should be given in the shape of fluid extract, five to ten drops being administered at a dose, and gradually in- creased. Its action upon the heart should be carefully watched, since it is apt to produce annoying symptoms in susceptible individuals. Innumerable other remedies have been tried in this disease, but we will mention only the principal ones : phosphorus, bromide of potassium, chloral hydrate, cro- ton chloral, tonga, nitrite of amyl, napelline, cocaine, salicylic acid, iodide of potassium, nitrate of silver, the application of a vibrating tuning fork over the nerve, etc. In some cases electrical applications will effect a rapid cure, in others they form a valuable adjuvant to other methods of treatment. The faradic current should rarely be employed, except in those cases in which a "point apophysaire " is present in the cervical region. In such cases very brilliant results are sometimes obtained from the application of a strong current, by means of the wire brush, to the tender point on the spine. In the majority of cases the galvanic current is indicated. One electrode (cathode) should be applied to the back of the neck or the sternum, the other, small electrode (anode), to the puncta dolorosa in the course of the affected nerve. The current should not give rise to much pain, it should be applied without interruption for from five to ten min- utes, and the sittings should be held daily, or every other day. If no improvement whatever be felt at the close of 19 Facial Neuralgia. Facial Neuralgia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the first sitting, electrical treatment will rarely prove suc- cessful. In protracted cases we will often be compelled to make trial, in succession, of all the remedies which we have men- tioned above, since we are rarely in a position to deter- mine in advance whether a certain remedy will prove useful in a given case. When medical appliances have been exhausted, we must resort to surgical measures in order to relieve the sufferings of the patient. The surgical operations which have been performed for the relief of trigeminal neuralgia include neurotomy, neurectomy, stretching the nerve, compression and liga- ture of the carotid artery. For the details of these various operations we must re- fer the reader to the following article. It will suffice to mention here that neurotomy is the most unreliable of all these operations, because the cut ends of the nerve unite very rapidly ; and that ligature of the common carotid, while it is a dangerous operation, does not prevent the possibility of a relapse. According to A. Wagner's statistics, 6 death's occurred among 134 cases of neurectomy, so that this operation, likewise, is not devoid of danger. Among this number, furthermore, the result was unknown in 24, relapses oc- curred in 52, the operation had no effect in 9, recovery lasting for a number of years occurred in 25 cases, and recovery for months in 18 cases. Many patients, however, suffer such terrible torments that they are willing to run any risks in the bare hope of obtaining relief. Leopold Putzel. point of emergence from the skull, and, as an incidental measure, the sympathetic ganglion may be removed. Operative interference is demanded when the peripheral points of irritation have been removed without benefit, and the lesion is not rapidly fatal and central, provided the recurring pain is persistent and exhaustive. J. Ewing Mears, M.D., of Philadelphia, in an article read before the American Surgical Association in 1884, on the "Study of the Pathological Changes occurring in Trifacial Neuralgia," has formulated six propositions, of which the first two express the usual conditions to be considered before resorting to a neurectomy. " First. That in the majority of cases of chronic proso- palgia the infra-orbital and inferior dental branches of the fifth nerve are implicated, and that these branches are involved to the exclusion of other branches of the second and third divisions of the nerve. " Second. That as filaments of these branches terminate in the teeth and the alveoli which contain them, we must look for the initial lesions in morbid conditions of these organs." These propositions apply more uniformly to the inferior than to the superior maxillary branch. A vertical line drawn from the junction of the inner with the middle third of the upper margin of the orbit through the space between the two bicuspids of the lower jaw will cross the points of exit of the supra-orbital, the infra-orbital, and the inferior dental nerves. The incision for the resection of the supra-orbital branch should be three or four centimetres in length, par- allel to the eyebrow, and preferably above it. This inci- sion must be carried fairly down upon the bone in a curved line just below the superciliary ridge. The soft parts are to be detached from the margin of the bone, and then by loosening the tissues of the orbit from its roof the nerve may be traced backward, even to its junc- tion with the supra-trochlear branch, and divided. It is then to be withdrawn through the foramen and re- moved. The operations on the infra-orbital and the inferior den- tal nerves testify to the boldness and the ingenuity of surgeons. Carnochan's operation for the section of the superior maxillary nerve, as also Joseph Pancoast's operation for the section of both the superior and inferior maxillary nerves, although bold and destructive, will in rare cases be demanded. Carnochan's operation is commenced by an incision sharply convex, or triangular, with the two ends resting on the inferior border of the orbit. The flap thus made is turned upward so as to expose the anterior wall of the antrum below the infra-orbital foramen. A trephine two centimetres (three-quarters inch) in diameter is then placed so that its upper margin will include the lower border of the foramen, and a button of bone is removed. This exposes the cavity of the antrum. The floor of the orbit is then broken down and chiselled away until the infra-orbital nerve is exposed. A button from the poste- rior wall of the antrum is then to be removed with a smaller trephine. The nerve and Meckel's ganglion are thus exposed in the spheno-maxillary fossa. If thought best, the ganglion may be removed, but the nerve must be divided as near the foramen rotundum as possible, and removed to the point where it is lost in the tissues of the cheek. The dental branches of the nerve can also be de- stroyed. Professor Joseph Pancoast's operation gives access both to the superior and the inferior maxillary divisions in the spheno-maxillary fossa. Two parallel incisions are car- ried well down toward the base of the jaw-one of them beginning at the malar bone, and the other at the zygoma. The duct of Steno must be avoided by limiting the depth of the vertical incisions. The two lower extremities are united by an horizontal incision, and the flap formed of the soft tissues loosened from the ramus of the jaw is turned upward, the masseter muscles included. The coronoid process is then separated from the ramus of the jaw, and detached from the temporal muscle, which is pushed upward into the zygomatic fossa. The internal FACIAL NEURALGIA, OPERATIONS FOR. Neural- gia is almost uniformly within the province of the physi- cian, for it is usually dependent upon some constitutional disturbance, such as anaemia, malaria, neurasthenia, ex- cessive work, or exposure to cold. These conditions are generally amenable to hygienic measures and tonic treat- ment, but sometimes a neuralgic habit is established, or from some cause, either general or local, the neuralgia becomes fixed and permanent. Operative treatment is then invoked to give relief to the sufferer. The fifth nerve most frequently demands such inter- ference, for neuralgic pain-sharp, paroxysmal, remit- ting, and situated over the track of this nerve-is here frequently persistent and exhaustive. Central lesions, such as a tumor, an aneurism, diseased meninges, or in- flammation of the bone, may induce it. Diligent search should, however, be made for every possible peripheral point of irritation ; and, if any is found, it must be re- moved. The teeth should be examined, the antrum ques- tioned, and the mouth inspected. The primary focus of irritation is, in the great majority of cases, found in the teeth, or in the membrane lining the alveolar socket. Observation and experience prove that a neuritis may be excited by continued irritation, and that this neuritis occasionally begets a neuralgia that persists long after the original irritant has been removed. We cannot so classify cases as to promise definite relief from operative procedures, for these operations are based upon experi- mental facts rather than upon any well-defined knowledge of the pathological condition to be removed. The com- plete abrogation of the function of a nerve does, if not uniformly, at least occasionally, produce an atrophy of the nerve itself, as also of the part of the central ganglion from which it takes its origin. Neuralgia, then, even if dependent on a neuritis of central origin, may be relieved by a neurectomy. Experience has demonstrated the futility of a simple neurotomy. Hence, the most efficient, feasible, and least destructive of the operative procedures suggested for the resection of the nerve involved should be practised. The neurectomy should be complete, and the portion of the nerve encased in bone should, as a rule, be removed. The sympathetic ganglia connected with the second and third divisions of the fifth nerve have been removed with these nerves, but it is doubtful whether it adds anything to the efficiency of a complete neurectomy. It will occa- sionally be necessary to follow the diseased nerve to its 20 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Facial Neuralgia. Facial Neuralgia. maxillary artery is then sought and ligated. The supe- rior origin of the external pterygoid is to be detached from the sphenoid. After clearing the space thus ex- posed of loose tissue, the second and third divisions of the fifth nerve can be severed. The second division should be secured by the forceps or a ligature before it is cut. Then, as suggested by J. Ewing Mears, the infra- orbital and the inferior dental nerves may be released by using the surgical burr at the infra-orbital and mental fo- ramina. These nerves are then to be withdrawn through the spheno-maxillary fossa. The lingual nerve may be cut with the scissors near its origin, or in the mouth, when the tissues at the angle of the jaw are made tense by the traction on it. These radical and somewhat destructive operations are not, however, always necessary or desirable. Where the neuralgia is dependent upon a neuritis which has involved the nerves even up to their points of exit from the skull, it may be proper to resort to them, but even in this con- dition the fact that nerves atrophy after their functional activity has been destroyed should be remembered. The great majority of the cases which demand operative inter- ference can be relieved by the simpler operative pro- cedures now to be described. Langenbeck used a long tenotome, which he inserted beneath the external palpebral ligament along the outer wall of the orbit into the spheno-maxillary fissure, then turned inward the edge of the knife and depressed the handle so as to divide the superior maxillary nerve be- fore it enters the orbit. The nerve may then be removed through the infra-orbital foramen, by exposing the fora- men and using a blunt hook to pull the nerve from its bed. Professor D. Hayes Agnew, of Philadelphia, on p. 316, vol. i., of his " Principles of Surgery," recommends the excision of the infra-orbital branch by loosening the tissues of the orbit from its floor, and then exposing the nerve by dividing the periosteum, lifting it from its bed in the groove and excising it with scissors. The late Professor John T. Hodgen, in an article read before the American Medical Association in 1880, de- scribed methods of neurectomy which are applicable to the second and third divisions of the fifth pair, as fol- low's : " In making the section of the infra-orbital nerve, it is proposed to divide it in the spheno-maxillary fissure, and in the report of this operation, made by myself, to the Missouri Medical Association, in April, 1876, I gave credit to Dr. John Green, of St. Louis, for the suggestion as to the mode in which this section may best be made. He proposed that an incision be made along the inferior border of the orbit down to the bone ; an elevator is then to be used to separate the soft parts from the orbital plate of the superior maxillary bone, and when the posterior border of the surface is reached the nerve is found lodged in the groove which terminates anteriorly in the infra-orbital canal. The groove in the bone at its pos- terior part is readily found with a blunt hook, which should be bent at right angles two millimetres from its end. The infra-orbital canal runs almost directly back- ward from the infra-orbital foramen. "The groove at the posterior part of the canal is found by the blunt hook which is moved to the inner side of the groove, pressed hard upon the bone, and pushed backward until it passes over the posterior border of the orbital plate of the superior maxilla. The hook is then turned outward and made to sweep behind the posterior termination of the groove in which the infra-orbital nerve and artery are lodged. Thus, both vessel and nerve are caught in the hook and drawn upward. Straight, nar- row scissors, guided by the shaft of the hook, are carried backward between the hook and the orbital plate until the nerve is reached and severed. To this proposition of Dr. Green I added the following part of tlie operation : The soft parts are separated from the facial surface of the superior maxilla down to the infra-orbital foramen, and the blunt hook is made to sweep around this foramen and hook up the artery and nerve at their exit from the bone. Now, using the hook as a lever, the nerve is readily drawn out of its canal, and the portion of it which extended from the spheno-maxillary fissure to the infra- orbital foramen is thus removed. " The section of the inferior dental nerve is effected through an incision two centimetres long, made with a strong knife and carried well down to the bone. The in- cision should extend forward in the axis of the bone, but should begin at the base and a little to the inner side of the most prominent part of the coronoid process of the in- ferior maxillary bone. The periosteum is now separated to the width of five millimetres (one-quarter inch), and a small spear-pointed drill, driven by a dentist's engine, has its point placed one centimetre in front of the posterior termination of the incision in the soft parts, and just behind the site of the last molar tooth. The drill is di- rected downward, backward, and a trifle outward toward the canal. The firm shell of bone is penetrated and quickly passed. The hard bone on each side after reach- ing the cancellated tissue will indicate to the surgeon the proper direction. If the drill is spear-pointed it will not cut through the dense bone on either side, but will follow the cancellated tissue to the canal which contains the blood-vessels and the nerve. A severe twinge of pain and a free flow of blood announce the severing of the nerve and vessel; they should be cut near the dental fora- men. The haemorrhage is slight. A burr is now used in- stead of the drill. The opening is enlarged, and the burr is moved freely to the right and left in the canal, to make sure that all the fibres of the nerve are severed. The loss of sensibility in the lower lip will indicate the success of this step of the operation. ' ' The next step in the operation is the withdrawal of the nerve from the canal between the dental and mental foramina. An incision is made opposite the bicuspid teeth at the junction of the lips with the gum. The soft parts are then detached with an elevator down to the foramen. The blunt hook is made to pass around the foramen and hook up the nerve. This hook is used as a lever, and that part of the nerve encased in the bone and distal to the point of severance is drawn out, of course breaking off those filaments that supply the teeth." The description above quoted is, with a few minor ex- ceptions, the one given by the author. These operations constituted a very important advance on the accepted operations of the day. Both of them are effective. I believe a more efficient and easier resection of the in- ferior dental nerve may be made after a method first practised by myself. I used the drill and burr to divide the nerve in its bony canal through an incision along the alveolar margin at the site of the second bicuspid tooth. It can be perfectly divided by moving the burr from side to side in the canal, after the drill has opened the way. The nerve must then be caught by a short, blunt, right-angled hook, introduced through an incision three centimetres (or one inch) in length made along the inner border of the coronoid pro- cess, beginning above its middle point and extending downward and forward beyond the junction of the body with the ramus. The short arm of the hook should be about five millimetres long. This hook must be carried through the incision down to the bone; it is then kept close to the inner surface, and the dental foramen sought. The border of the foramen is sharp, and is readily out- lined by the blunt point of the hook ; when the foramen is located, the hook is to be slipped behind it, when the point is turned outward and drawn upward and for- ward above the opening, thus engaging the nerve and lifting it through the incision. Firm traction is made, until the nerve slips from its bed in the bone ; two inches of the nerve may thus be removed. The haemorrhage is slight, for the artery is lacerated, not cut, and there is no danger in the operation. Excessive traction on the proxi- mal end may be avoided by seizing the nerve with a pair of forceps when it is first lifted from its position by the hook ; the pull can then be made entirely on the distal part of the nerve. The lingual nerve may be caught by the hook, but the error will be recognized by the elevation of the tissues alongside of the tongue, and it can be re- leased. 21 Facial Neuralgia. Facial Paralysis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. J. Ewing Mears suggested, as a modification of Pancoast's operation, the use of the surgical burr to re- lease the nerves at their point of exit. I think this method feasible, and perhaps better, for the operation last de- scribed, than the use of the surgical engine with drill and burr to divide the nerve, by entering the canal from the alveolar border, as I have described. These operations for the resection of the infra-orbital and the inferior dental nerves are so feasible and effect- ive, and yet so conservative in their character, that I be- lieve they or some modification of them will supersede the more formidable ones first described, as well as others that have been long practised and have found favorable mention in our text-books. II. II. Mudd. it may spread from one group of muscles to another (when it is the result of compression by a slowly growing exter- nal tumor or other lesion which acts in a similar manner). In the majority of cases all the muscles are affected in an approximately equal degree. The appearance of the face is well shown in Fig. 1125, taken from a photograph of a patient who is now under my observation. This patient was directed, at the time of taking the photograph, to contract all the muscles of the face, but, as is evident from the illustration, power over the left facial muscles is entirely lost. The left eye- brow is slightly elevated, the palpebral fissure is enlarged, the naso-labial fold is effaced, the angle of the mouth droops slightly and is drawn nearer to the median line (this is observed even when the face is in repose), the mouth on this side is kept a little open, and the tip of the nose deviates slightly to the healthy side. A patient suffering from complete facial paralysis is FACIAL PARALYSIS (Bell's Palsy). Etiology.-In a large proportion of the cases, peripheral facial paralysis is the result of so-called rheumatic influences, such as ex- posure of one side of the face to a draught, working in a damp room, sudden chilling of the body while in a state of perspiration. The disease may also be occasioned by a large number of organic lesions, which may be situated in the cranial cavity, in the course of the nerve through the Fallopian canal, or after its exit from the mastoid foramen. The lesions within the cranial cavity which may give rise to this disease include basilar meningitis, tumors or exostoses situated at the base of the brain, syphilitic le- sions in this situation, aneurisms of the vessels of the base of the brain. Within the Fallopian canal the paralysis may be the result of caries of the petrous portion of the temporal bone, otitis media, tumors which extend into the canal from adjacent parts, fracture of the base of the skull ex- tending through the temporal bone, syphilitic deposits within oy near the nerve, an accumulation of wax in the external auditory canal. After the exit of the nerve from the mastoid fora- men, the paralysis may be produced by direct vio- lence to the nerve (a slap on the face, fall, etc.), pres- sure upon the nerve-for example, the pressure of the forceps during parturition (a few cases have also been reported in which facial paralysis occurred dur- ing difficult and tedious labor, although the forceps had not been used)-extension of inflammation to the nerve from adjacent parts (scrofulous abscesses of the glands situated near the angle of the jaw, paro- titis, incised wounds during operations in this region, etc.). A case has also been reported in which the disease was produced by leukeemic infiltration of the nerve. In comparatively rare cases facial paralysis follows cer- tain of the infectious diseases, such as diphtheria, small- pox, erysipelas, typhoid fever. Several cases have also been reported in which the disease occurred during the secondary stage of syphilis, and was attributed to the direct action of the syphilitic virus. A number of writers have observed facial paralysis as- sociated with herpes zoster. The disease is more frequent in males than in females. It occurs very rarely during childhood and infancy. Clinical History.-Facial paralysis is almost always confined to one side of the face. In very rare cases it is bilateral (diplegia facialis), and in such cases the paraly- sis sometimes appears on the two sides at different times. Sometimes a similar cause operates upon both facial nerves (usually the so-called rheumatic influences) ; some- times one lesion acts upon one nerve, an entirely different lesion upon the other nerve. Diplegia facialis is also a symptom of certain bulbar affections, but the considera- tion of the symptoms which distinguish the peripheral from the central variety will be reserved for the section on diagnosis. Ordinary peripheral facial paralysis may begin sud- denly, or it may be preceded for some time by a feeling of fulness and puffiness in the face, and peculiar gusta- tory sensations on the affected half of the tongue. The paralysis may occur suddenly and completely in all branches (in rheumatic cases from a couple of hours to one or two days from the action of the exciting cause), or Fig. 1125. unable to wrinkle or corrugate the brow, on account of the paralysis of the frontalis and corrugator supercilii muscles. On making a vigorous effort to close the eye- lid the globe is rolled upward and inward (or rarely out- ward), so that often only the sclera remains visible. But the upper lid descends a little, even when the nerve ap- pears to be completely paralyzed. The descent of the eyelid has been attributed to a partial relaxation of the levator labii superioris, but it must be confessed that this explanation is not very satisfactory. On account of the paralysis of the orbicularis palpebrarum the puncta lachrymalia are no longer kept applied to the globe, and consequently the tears cannot make their way into the lachrymal canal and nasal cavity. Hence, the .patients suffer from overflow of tears. The paralysis of this mus- cle also prevents winking and the closure of the eye during sleep. The consequent irritation of the eyeball may give rise to conjunctivitis and keratitis, though this does not happen very often. The lower lid may become everted. The ala nasi on the paralyzed side cannot be distended as vigorously as on the healthy side, and hence smell is 22 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Facial Neuralgia, Facial Paralysis. somewhat impaired. This impairment of smell is in- creased still further owing to the fact that diversion of the tears from the nasal cavity causes dryness of the Schneiderian mucous membrane, and hence interferes with the olfactory sense. The angle of the mouth droops a little, and is drawn slightly toward the median line. This phenomenon is in- creased upon bringing into play the muscles which are inserted into the opposite angle of the mouth, as in the act of laughing. The lips cannot be closed on the affected side, and hence whistling is rendered impossible. The pronunciation of labials may be interfered with, but in many cases articulation is undisturbed. The cheek on the paralyzed side flaps loosely to and fro when the patient attempts to puff it out. Mastication is also interfered with to a certain extent, on account of the paralysis of the buccinator muscle. The food is apt to accumulate between the cheek and teeth, and must be dislodged fre- quently by the patient's finger. In a considerable pro- portion, perhaps the majority, of cases taste is impaired upon the anterior third of the tongue on the paralyzed side, and sometimes the patient complains of peculiar subjective sensations in this locality. This is owing to the fact that the chorda tympani nerve, which supplies the anterior third of the tongue with gustatory fibres, is united with the seventh nerve during a part of its course through the Fallopian canal. The tongue is protruded in a straight- line, but, on ac- count of the displacement of the oral fissure toward the healthy side, there is an apparent deviation of the organ toward the paralyzed side. In certain cases (vide the section on diagnosis) the palate and uvula are found to be paralyzed. Upon in- spection the paralyzed velum palati is seen to hang lower than on the opposite side, and the uvula may be deflected to one or the other side (the latter phenomenon is some- times observed in healthy individuals). These parts also remain almost motionless during phonation, or when re- flex action is excited by irritation of the fauces. Deglu- tition is also interfered with to a certain extent, so that the patients often swallow* the wrong way. As a rule, the sensibility of the integument remains un- affected, but in a few cases the patients complain of a feel- ing of numbness of the skin. In these cases, however, we have never been able to detect any objective evidences of disturbed sensation. The symptom in question is prob- ably the result of an implication of some of the recurrent fibres of the trigeminus in their course along the facial nerve. Hearing may be affected, sometimes as the result of the lesion which gave rise to the paralysis, sometimes as the result of the paralysis itself. In the latter event the pa- tient suffers from hyperacusis (also called oxyokoia), i.e., increased sensitiveness to auditory impressions. This has been explained by the paralysis of the stapedius muscle (which is supplied by the facial nerve), and the consequent predominance of the action of the tensor tympani (sup- plied by the fifth nerve). The electrical reactions of the paralyzed nerves and muscles often present very interesting changes. In some cases the muscular and nerve irritability remains normal throughout the course of the disease. Such cases usually recover spontaneously and with great rapidity. Sometimes the so-called degeneration reaction is pro- duced. The nerve and muscles are then found to pre- sent entirely distinct changes. The excitability of the nerve to the faradic and galvanic currents begins to diminish in a few days after the onset of the paralysis (sometimes preceded by a brief period of increased excitability), and is entirely lost within a week or ten days. This extinction of excitability continues until the disease begins to recover. It is a peculiar fact -and one which is noticed quite often in rheumatic facial paralysis-that the nerve may conduct the stimulus of the will before it becomes excitable to the electrical current. In other words, the patient may be able to produce volun- tary movements of the paralyzed muscles before electri- cal stimulation of the nerve gives rise to muscular con- traction. The electrical excitability of the muscles is not alone different from that of the nerves, but their faradic and galvanic irritability are also entirely distinct. The faradic irritability of the muscles diminishes very rapidly and disappears pari passu with the excitability of the nerve. The galvanic excitability presents very nota- ble changes. For the first week or ten days it may be diminished to a considerable degree (it was abolished tem- porarily in two cases of recovery under our observation), but it then begins to increase very markedly, and soon greatly exceeds the excitability of the corresponding healthy muscles. We may then find that the paralyzed muscles respond to a current which is so mild as to be hardly appreciable. A change takes place likewise in the mode of muscular contraction. The fibres contract in a slow, long-drawn-out manner, in vivid contrast to the quick, brief contraction of the healthy muscles. This phenomenon, which is very characteristic of the degener- ation reaction, is well shown by placing one electrode upon the median line of the chin, and thus bringing the healthy and paralyzed muscles into simultaneous action. At the same time it will be noticed in many cases that the muscular contraction of the paralyzed parts continues during the entire period of the passage of the current. In addition to the changes just mentioned, we also find a marked difference in the formula of muscular contrac- tion. In healthy muscles the contraction on cathodal closure is much greater than that on anodal closure, and the contraction on anodal opening is greater than that on cathodal opening. If the current is very mild contraction is produced only on cathodal closure. The other modes of contraction appear in the order mentioned above, on increasing the strength of the current. In complete degeneration reaction, on the contrary, the contraction on anodal closure becomes greater than that on cathodal closure (the latter may even disappear at a certain stage of the disease), and the contraction on cath- odal opening equals or even exceeds that on anodal open- ing. After this peculiar change has lasted for a certain length of time (varying usually from one to three months) there is a gradual return to the normal mode of muscular contraction. At the same time the excitability of the nerve is gradually restored. Many cases present various stages of transition from normal electrical excitability to the complete form of de- generation reaction. Indeed, we find not infrequently that one case presents various conditions of electrical ex- citability in different muscles and branches of the nerve. If the patient does not recover from the disease the elec- trical irritability of the muscles gradually diminishes, and is finally abolished. According to Neumann, the difference in the reaction of the muscles to the two currents is owing to the fact that the changed muscles will react only to a current which possesses a certain duration. As the faradic current is only momentary in duration, the muscles do not respond to this stimulus. Neumann found that they also failed to respond to the galvanic current if its duration was made to approximate that of the faradic current by means of a suitable mechanism. Experimental investigations have shown that the degen- eration reaction is the result of certain lesions of the par- alyzed nerve and muscles. When the degeneration reac- tion is at its height, it is found that the axis cylinder has disappeared, the medullary substance has undergone fatty degeneration, and the nuclei of the sheath of Schwann are increased in number ; the interstitial connec- tive tissue and nuclei undergo proliferation. At the same time the muscular fibrillae are diminished in size and their nuclei increased in number; the transverse striae are less distinct or absent, and the interstitial con- nective tissue is increased in amount. If recovery en- sues all these changes gradually disappear. Ina few cases recovery is not complete, and spasmsand contracture of the muscles are left over as sequelae. These conditions may exist apart, but they are usually as- sociated with one another. The spasms consist of short, quick contractions of the muscles, occurring irregularly, and very much resembling facial tic. These spasmodic 23 Facial Paralysis. Fa haiti. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. movements are unattended with pain and are often un- noticed by the patient. Contracture is observed particularly in the levator pal- pebrae superioris alaeque nasi and zygomatici muscles, and causes retraction of the angle of the mouth upward and outward. It thus tends to overcome the original deform- ity produced by the paralysis. When the contracture is very marked, the deepening of the naso-labial fold to which it gives rise may create a deceptive appearance of paralysis upon the opposite side of the face. An error in diagnosis may be obviated by directing the patient to laugh, whereupon it becomes evident that the contrac- tured muscles remain motionless, while those on the healthy side contract normally. If complete paralysis of the muscles remain perman- ent, they will undergo atrophy, so that the affected half of the face looks smaller than the other side. In diplegia facialis the face presents a remarkable ap- pearance, inasmuch as it is absolutely devoid of expres- sion, and even the most violent emotions are experienced by the patient without the slightest change of counte- nance. The lower lip droops, and saliva is constantly flowing from the mouth. Articulation and deglutition are interfered with to a very marked degree. Diagnosis.-The differentiation of peripheral from central facial paralysis is usually quite easy. In the lat- ter affection the muscles of the forehead and eyelid are very slightly involved. As a rule, however, on directing the patient to close only the eye on the paralyzed side, it becomes evident that this is done with less vigor and promptitude than on the healthy side. The affected muscles present no changes of electrical excitability, how- ever profound the paralysis may be. It will also be no- ticed that the voluntary and reflex contractility of the paralyzed muscles are often in marked contrast to one another, the latter being much greater than the former. Furthermore, the clinical history of the two affections is usually decisive. In the cerebral variety the facial par- alysis is almost always associated with paralysis in some other part of the body, usually the arm and leg upon the same side. In addition, cerebral facial paralysis gener- ally develops after an apoplectic seizure, which may or may not be accompanied by unconsciousness. In a certain proportion of cases the disturbance of gus- tation on the anterior portion of the tongue, the paralysis of the velum palati and uvula, and the history of a pre- vious disease which may have produced a lesion of the seventh nerve, will aid us in clearing up any possible doubt in diagnosis. In rare cases, however, facial paralysis produced by lesions of the pons Varolii presents most of the charac- teristics of peripheral facial paralysis. If the lesion is situated in the lower half of the pons, the facial paralysis is associated, as a rule, with hemiplegia of the opposite side of the body. When the lesion is situated in the up- per half of the pons (before the decussation of the seventh nerves), the face and limbs are paralyzed on the same side of the body. The frontalis and orbicularis palpe- brarum may be entirely paralyzed, as in ordinary periph- eral paralysis, and, in addition, there may be marked changes in the electrical excitability of the facial nerve and muscles. But a mistake in diagnosis is usually obvi- ated by the presence of other symptoms of a pons lesion, such as contraction of the pupils, marked difficulty in swallowing and articulation, and paralysis of various cere- bral nerves (trigeminus, abducens, hypoglossus), etc. After the diagnosis of the peripheral character of the disease has been made, we should also endeavor to deter- mine its location more accurately. As a rule, this can be done with great certainty on account of the peculiar ana- tomical relations of the nerve. If the lesion is situated above 5 (Fig. 1126), the patient will suffer from paralysis of all the facial muscles, of the uvula and velum palati, and from disturbances of hear- ing, but gustation will be unimpaired. This is owing to the fact that the chorda tympani nerve enters the facial nerve, in all probability, at the ganglion geniculatum through the petrosus superficialis major nerve, psm (from the trigeminus). The chorda tympani leaves the facial nerve between 2 and 3, cht, and then joins the lingual branch of the trigeminus. If the lesion is situated between the ganglion genicu- latum and the point at which the nerve to the stapedius muscle, stp, is given off, the symptoms will consist of paralysis of all the facial muscles, disturbances of hear- ing, and impairment of taste on the anterior third of the tongue. The velum palati is unaffected in this case, probably because its motor fibres are given off at the ganglion geniculatum, gg. If the lesion is situated be- tween the origin of the stapedius nerve and the point at which the chorda tympani, cht, leaves the facial nerve, the symptoms just mentioned will be present, with the exception of the disturbances of hearing. A lesion below the point at which the chorda tympani is given off will simply produce paralysis of the superficial muscles. It must be remembered, however, that these remarks hold good only in those cases in which the lesion is of such a character as to entirely destroy the conductibility of the nerve at the affected part. Prognosis.-The prognosis depends chiefly on the character of the lesion which has given rise to the paraly- sis, and therefore varies according to that of the primary Fig. 1126.-Schematic Representation of the Ramifications of tlie Facial Nerve. (After Eichhorst.) fc. Trunk of facial nerve; ac, trunk of acoustic nerve ; pat, internal auditory foramen ; gg, ganglion genicu- latum ; psm, nervus petrosus superficialis major; stp, nervus stape- dius ; cht, chorda tympani ; fst, styloid foramen ; nap, posterior auri- cular nerve ; bv and sth, nerves to the digastric and stylo-hoid muscles; trg, trg', trg", trg'", trunk and branches of the trigeminus; gsp, sphe- no-paliitine ganglion; Ig, lingual nerve. disease. When the nerve is involved directly, as in cases of rheumatic origin, or those due to infectious diseases, etc., the prognosis may be determined, in great measure, by the changes in electrical excitability. When the excitability of the nerve and muscles is un- changed, the disease will usually recover spontaneously in two to four weeks. If complete degeneration reaction is present, recovery cannot be looked for in less than three to six or nine months. But the case should not be regarded as absolutely hopeless, even if the electrical ex- citability is abolished for a short period. The development of muscular spasms and contracture is a very unfortunate event. In no case of this kind which has come under our observation has recovery oc- curred. The contracture usually continues to increase in severity, and after a while the muscles undergo a certain amount of atrophy. These two factors may give rise to considerable disfigurement of the face. As a rule, the disease runs a longer course in those 24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Facial Paralysis. Faham. cases in which the lesion is situated within the Fallopian canal. Treatment.-The causal treatment varies with the nature of the primary disease (affections of the middle ear, syphilitic lesions, tumors, etc.). The use of leeches, blisters, and the administration of strychnine, which are strenuously recommended by some writers, have been at- tended with such unsatisfactory results in our hands that we now rely exclusively upon electrical treatment. In those cases in which the electrical excitability of the paralyzed nerve and muscles is unchanged, treatment is unnecessary, since recovery occurs spontaneously. When complete degeneration reaction is present, elec- tricity should be applied both to the nerve and muscles. In applications to the nerve the galvanic current alone should be employed. A small electrode, the anode, is placed immediately over the mastoid foramen (between the mas- toid process and the lobe of the ear) on the affected side, the cathode (with a similar electrode) over the opposite mastoid foramen. The current will therefore pass through the petrous portion of the temporal bone, and act upon the nerve in its passage through the Fallopian canal. It should not be strong enough to produce a feeling of pain or vertigo, no interruptions should be made, and the sit- tings should be held for three or four minutes every other day. With this method we may combine labile galvani- zation of the muscles. One medium-sized electrode (usu- ally the cathode) is placed upon the back of the neck, the other small electrode is slowly passed over the affected muscles. The frontalis and corrugator supercilii muscles are brought into play by passing the electrode horizon- tally across the forehead, a little above the eyebrow. The levator labii superioris alaeque nasi, zygomatici, and buc- cinator are brought into play by passing the electrode along the side of the nose (beginning near the inner angle of the eye), and then outward across the cheek, immedi- ately below the malar bone. Labile applications may also be made directly to the orbicularis oris and chin muscles. In applications to the orbicularis palpebrarum, we are in the habit of placing a very small electrode upon the muscle, at the outer angle of the eye, and then inter- rupting the current (by means of an interrupter in the handle of the electrode). Moritz Mayer is of the opinion that in severe cases, which are recognized by the degeneration reaction or the absence of faradic excitability, it is useless to begin the peripheral treatment of the paralyzed nerve and muscles before the reunion of the divided nerve-fibres is mani- fested by the restoration of the normal formula of reac- tion in the nerve or the restoration of slight faradic ex- citability. Until this takes place he thinks we should act directly upon the locus morbi, partly by local abstraction of blood, partly by the application of the constant cur- rent. The question raised by Mayer is one which, in our opinion, cannot be settled with certainty, for the simple reason that we are unable to tell, in a given case, under treatment, what the course of the disease would have been if treatment had not been employed. It seems probable to us, however, that the employment of the current, even before the return of the normal formula of reaction, will at least aid in maintaining the nutri- tion of the paralyzed muscles, thus perhaps prevent- ing their nutrition from sinking to such a low ebb that recovery is no longer possible. Furthermore, in the absence of any evidence to show that such electrical applications will work injury, it seems to be advisable to begin the applications at the earliest possible mo- ment. In some cases the excitability of the muscles has sunk to such a low ebb that it becomes necessary to employ the intra-buccal method of galvanization. One electrode is then placed upon the muscle which we desire to stimu- late, the other directly opposite upon the mucous mem- brane of the cheek. After the nerve has recovered its electrical excitability, the faradic current may be employed, either to the mus- cles themselves, or by simply passing the electrode along a vertical line immediately in front of the ear, in order to stimulate the pes anserinus as it spreads out in this lo- cality. We may attempt to relieve contractures by stabile gal- vanization of the affected muscles, the negative pole being applied to the mastoid foramen, the positive pole to the contractured muscle. Massage of the muscles has also been employed for this purpose. In all electrical applications in this disease, the elec- trodes should be very thoroughly moistened, and the current should merely possess sufficient strength to pro- duce visible muscular contractions. Leopold Putzel. FACIAL SPASM. Involuntary contractions of the muscles of the face may be a part of a more or less ex- tended disorder, dependent upon some derangement of the nervous centres, as in epilepsy, hysteria, chorea, etc., or the spasms may be limited to one or more of the mus- cles supplied by the facial nerve. The affection is then known as facial spasm, and presents an example of cer- tain peripheral spasmodic disorders which are observed in various parts of the body. Facial spasm may be tonic or clonic. The clonic variety is the more common. It is gener- ally unilateral in its manifestations, and occurs in par- oxysms of variable duration and frequency. Usually the spasms continue for a few moments only, and are repeated at tolerably uniform intervals, though they sometimes last uninterruptedly for many minutes. The contractions are increased and intensified by emotional excitement, or by the concentration of the attention upon the irregular movements. They generally cease during sleep, and are arrested temporarily by close and absorbing mental occu- pation, and by steady pressure over the track of the facial nerve. In the tonic form of the affection the face is fixed in a distorted position, and the functions of the implicated muscles are seriously impaired, or totally destroyed. The recognized causes of facial spasm are exposure to cold, pressure upon or irritation of the facial nerve, carious teeth, and other reflex influences of divers kinds ; or it may be a sequel of facial paralysis. The constant tendency of this disease is to become chronic, and unless the cause is amenable to the resources of our art, the prognosis is unfavorable. The treatment has reference mainly to the modifica- tion or relief of any immediate or remote cause that may be suspected or ascertained. Of the drugs that have been used with apparent ad- vantage, quinine, iron, morphine, belladonna, aconite, arsenic, and bromide of zinc may be mentioned. The constant galvanic current applied to the nerve and to the affected muscles is serviceable in some cases. Division of the muscle or muscles involved has not yielded sat- isfactory results. Mechanical pressure over the facial nerve frequently arrests the paroxysms, but it can only be borne in sufficient force for a short time. In chronic cases facial gymnastics may be tried. In spite, however, of all treatment, a large proportion of cases remain un- relieved. James B. Baird. FAHAM, Codex Med. The dried leaves (and stems) of a deliciously fragrant orchid from Bourbon and Mau- ritius, Angracum fragrant Dup., Th., which are said to be used for a pleasant drink, like tea, by the inhabitants. The leaves are long and narrow, almost linear, with a deep notch at the top and two rounded apices ; they are thick, leathery when softened, parallel nerved, and have a bitterish taste, and a tonka-, mellitot-, or, less nearly, va- nilla-like odor. They contain, it is said, cumarin, traces of essential oil, and a little tannin. Faham is scarcely employed outside of French coun- tries ; a tea made from it for those who cannot drink that of China is sometimes given. It is also employed as a bitter tonic, mild sudorific, etc., and in perfumery (Bailion). Allied Plants, Allied Drugs.-See Vanilla. IK. P. Bolles. 25 Fahrenheit. Fallopian Tubes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FAHRENHEIT AND CENTIGRADE SCALES. The following table, showing the value in degrees, tenths of a degree, and hundredths of a degree, according to the Fahrenheit scale, of every tenth of a degree of tempera- ture from 52° to -45° Centigrade, while perhaps belong- ing more properly in the article entitled " Thermometer," is introduced in this place for the reason that such early introduction is likely to prove a convenience to many readers of the Handbook. II. R. c. F. C. F. C. F. C. F. C. F. C. F. C. F. 52.0 125.60 44.0 .20 1 36.0 .80 28.0 .40 | 20.0 68.00 12.0 .60 4,0 .20 .9 42 .9 111.02 .9 .62 .9 .22 .9 .82 .9 .42 .9 39.02 .8 .24 .8 .81 .8 .44 .8 82.04 .8 .64 .8 .24 .8 .84 .7 125.06 .7 .66 .7 .26 .7 .86 .7 .46 7 53.06 .7 .66 .6 .88 .6 .48 .6 96.08 .6 .68 .6 .28 .6 .88 .6 .48 .5 .70 .5 .30 .5 .90 .5 .50 .5 67.10 .5 .70 .5 .30 .4 .52 .4 110.12 .4 .72 .4 .32 .4 .92 .4 .52 .4 38.12 .3 .31 .3 .94 .3 .54 .3 81.14 .3 .74 .3 .34 .3 .94 .2 124.16 .2 .76 9, .36 .2 .96 9 .56 9 52.16 .2 .76 .1 .98 .1 .58 .1 .18 .1 .78 .1 .38 .1 .98 .1 .58 51.0 .80 43.0 .40 35.0 95.00 27.0 .60 19.0 .20 11.0 .80 3.0 .40 .9 .62 .9 .22 .9 .82 .9 .42 .9 66.02 .9 .62 .9 22 .8 .44 .8 109.04 .8 .64 .8 .24 .8 .84 .8 .44 .8 37.04 .7 .26 .7 .86 .7 .46 .7 80.06 .7 .66 .7 .26 .7 .86 .6 123.08 .6 .68 .6 .28 .6 .88 .6 .48 .6 51.08 .6 .68 .5 .90 .5 .50 .5 94.10. .5 .70 .5 .30 .5 .90 .5 .50 .4 . 72 .4 .32 .4 .92 .52 .4 65.12 .4 72 .4 32 .3 .54 .3 108.14 .3 .74 .3 .34 .3 .94 .3 .54 .3 36.14 . J .36 .2 .96 .2 .56 9 79.16 .2 .76 2 .36 9 .96 .1 .18 .1 .78 .1 .38 .1 .98 .1 .58 .1 .18 .1 .78 50.0 122.00 42.0 .60 34.0 .20 26.0 .80 18.0 .40 10.0 50.00 2.0 .60 .9 .82 .9 .42 .9 93.02 .9 .62 .9 .22 .9 .82 .9 .42 .8 .64 .8 .24 .8 .84 .8 .44 .8 64.04 .8 .64 .8 .24 .7 .46 .7 107.06 .7 .66 .7 .26 .7 .86 .7 .46 .7 35.06 .6 .28 .6 .88 .6 .48 .6 78.08 .6 .68 .6 .28 .6 .88 .5 121.10 .5 .70 .5 .30 .5 .90 .5 .50 .5 49.10 .5 .70 .4 .92 .4 .52 .4 92.12 .4 .72 .4 .32 .4 .92 .4 .52 .3 .74 .3 .34 .3 .94 .3 .54 .3 63.14 .3 .3 .34 .56 9 106.16 2 .76 .2 .36 .2 .96 .2 . 56 9 34.16 .1 .38 .1 .98 .1 .58 .1 .18 .1 .78 .1 .38 .1 .98 49.0 .20 41.0 .80 33.0 .40 25.0 77.00 17.0 .60 9.0 .20 1.0 .80 .9 120.02 .9 .62 .9 22 .9 .82 1 .9 .42 .9 48.02 .9 .62 .8 .84 .8 .44 .8 91.04 .8 .64 .8 .24 .8 .84 .8 .44 7 .66 .26 .7 .86 .7 .46 .7 62.06 .7 .66 7 .26 .6 .48 .6 105.08 .6 .68 .6 .28 .6 .88 .6 .48 .6 33.08 .5 .30 .5 .90 .5 .50 .5 76.10 .5 .70 .5 .30 .5 .90 .4 119.12 .4 72 .4 .32 .4 .92 .4 .52 .4 47.12 .4 72 .3 .94 .3 .54 .3 90.14 .3 74 .3 .34 .3 .94 .3 .54 > .76 2 .36 .2 .96 9 .56 .2 61.16 9 .76 .2 .36 .1 .58 .1 .18 .1 .78 .1 .38 .1 .98 .1 .58 .1 .18 48.0 .40 40.0 104.00 32.0 .60 24.0 .20 16.0 .80 8.0 .40 0.0 32.00 .9 .22 .9 .82 .9 .42 .9 75.02 .9 .62 .9 2 I - .1 .82 .8 118.04 .8 .64 .8 .24 .8 .84 .8 .44 .8 46.04 9 .64 .7 .86 7 .46 .7 89.06 .7 .66 .7 .26 7 .86 - .3 46 .6 .68 .6 .28 .6 .88 .6 .48 .6 60.08 .6 .68 - .4 .28 .5 .50 .5 103.10 .5 .70 .5 .30 .5 .90 .5 .50 - .5 31.10 .4 .32 .4 .92 .4 .52 .4 74.12 .4 .72 .4 .32 - .6 .92 .3 117.14 .3 .74 .3 .34 .3 .94 .3 .54 .3 45.14 _ 7 .74 9 .96 • 2 .56 2 88.16 9 .76 2 .36 .2 .96 - .8 .56 .1 .78 .1 .38 .1 .98 .1 .58 .1 .18 .1 .78 - .9 .38 47.0 .60 39.0 .20 31.0 .80 23.0 .40 15.0 59.00 7.0 .60 -1.0 .20 .9 .42 .9 102.02 .9 .62 .9 .22 .9 .82 .9 .42 .1 30.02 .8 .24 .8 .84 .44 .8 73.04 .8 .64 1 .8 .24 .2 .84 .7 116.06 .7 .66 7 .26 .7 .86 7 .46 .7 44.06 .3 .66 .6 .88 .6 .48 .6 87.08 .6 .68 .6 .28 .6 .88 .4 .48 .5 .70 .5 .30 .5 .90 .5 .50 .5 58.10 .5 .70 .5 .30 .4 .52 -4 101.12 .4 72 .4 .33 .4 .92 .4 .52 .6 29.12 .3 .34 .3 .94 .3 .54 .3 72.14 1 .3 .74 .3 .34 .7 .94 2 115.16 .2 .76 .2 .36 9 .96 9 .56 2 43.16 .8 .76 .1 .98 .1 .58 .1 .18 .1 .78 .1 .38 .1 .98 .9 .58 46.0 .83 38.0 .40 30.0 86.00 22.0 .60 14.0 .20 6.0 .80 -2.0 .40 .9 .62 .9 .22 .9 .82 .9 .42 .9 57.02 .9 .62 .1 22 .8 .44 .8 100.04 .8 .64 .8 .24 1 .8 .84 .8 .44 .2 28.04 7 .26 .7 .86 .7 .46 7 71.06 .7 .66 .7 .26 .3 .86 .6 .08 .6 .68 .6 .28 .6 .88 .6 .48 .6 42.08 .4 .68 .5 114.90 .5 .50 .5 85.10 .5 .70 .5 .30 .5 .90 .5 .50 •4 . 72 .4 .32 .4 .92 .4 .52 .4 56.12 .4 72 .6 .32 .3 .54 .3 99.14 .3 .74 .3 .34 .3 .94 .3 .54 7 27.14 .2 .36 .2 .96 .2 .56 .2 70.16 .2 .76 .2 .36 .8 .96 .1 .18 .1 .78 .1 .38 .1 .98 .1 .58 .1 .18 .9 .78 45.0 113.00 37.0 .60 29.0 .20 21.0 .80 13.0 .40 5.0 41.00 -3.0 .60 .9 .82 .9 .42 .9 84.02 .9 .63 .9 .22 .9 .82 .1 .42 .8 .64 .8 .24 .8 .84 .8 .44 .8 55.04 .8 .64 .2 .24 .7 .46 .7 98.06 .7 .66 .26 .7 .86 7 .46 .3 26.06 .6 .28 .6 .88 .6 .48 .6 69.08 .6 .68 .6 .28 .4 .88 .5 112.10 .5 .70 .5 .30 .5 .90 .5 .50 .5 40.10 .5 .70 .4 .92 .4 .52 .4 83.12 .4 . 72 .4 .32 .4 .92 .6 .52 .3 .74 .3 .34 .3 .94 .3 .54 .3 54.14 .3 .74 7 .34 .2 .56 .2 97.16 9 .76 .2 .36 .2 .96 .2 .56 .8 25.16 .1 .38 .1 .98 । .1 .58 . .1 .18 .1 .78 | .1 .38 .9 .98 26 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fahrenheit. Fallopian Tubes. c. F. C. * F. C. C. F. c. F. 1 i F. c. F. -4.0 .80 -10.0 14.00 -16.0 .20 -22.0 .60 -28.0 .40 -34.0 .20 -40.0 -40.00 .1 .62 .1 .82 .1 3.02 .1 .78 .1 .58 .1 .38 .1 .18 .2 .44 .2 .64 .2 .84 .2 .96 .2 .76 .2 .56 2 .36 .3 .26 .3 .46 .3 .66 .3 -8.14 .3 .94 .3 .74 .3 .54 .4 24.08 .4 .28 .4 .48 .4 .32 .4 -19.12 .4 .92 .4 Y* j .5 .90 .5 13.10 .5 .30 .5 .50 .5 .30 5 -30.10 .5 .90 .6 .72 .6 .92 .6 2.12 .6 .68 .6 .48 .6 .28 .6 -41.08 Y .54 .7 .74 .7 .94 Y .86 .7 .66 Y .46 Y .26 .8 .36 .8 .56 .8 .76 .8 -9.04 .8 .84 .8 .64 .8 .44 .9 .18 .9 .38 .9 .58 .9 .22 .9 -20.02 .9 .82 .9 .62 -5.0 23.00 -11.0 .20 -17.0 .40 -23.0 .40 -29.0 .20 -35.0 -31.00 -41.0 .80 .1 .82 .1 12.02 .1 22 .1 .58 .1 .38 .1 .18 .1 .98 .2 .64 .2 .84 .2 1.04 9 .76 .2 .56 Q .36 .2 -42.16 .3 .46 .3 .66 .3 .86 .3 .94 .3 .74 .3 .54 .3 .34 .4 .28 .4 .48 .4 .68 .4 -10.12 .4 .92 .4 .72 .4 .52 .5 22.10 .5 .30 .5 .50 .5 .30 .5 -21.10 .5 .90 .5 .70 .6 .92 .6 11.12 .6 .32 .6 .48 .6 .28 .6 -32.08 .6 .88 Y .74 .7 .94 .7 .14 .66 7 .46 Y .26 .7 -43.C6 .8 .56 .8 .76 .8 - .04 .8 .84 .8 .64 .8 .44 .8 .24 .9 .38 .9 .58 .9 - .22 .9 -11.02 .9 .82 .9 .62 .9 .42 -6.0 .20 -12.0 .40 -18.0 - .40 -24.0 .20 -30.0 -22.00 -36.0 .80 -42.0 .60 .1 21.02 .1 .22 .1 - .58 .1 .38 .1 .18 .1 .98 .1 .78 .2 .84 o 10.04 9 - .76 .2 .56 9 .36 .2 -33.16 .96 .3 .66 .3 .86 .3 - .94 .3 .74 .3 .54 .3 .34 .3 -44.16 .4 .48 .4 .68 .4 -1.12 .4 .92 .4 .72 .4 .52 .4 .32 .5 .30 .5 .50 .5 .30 .5 -12.10 .5 .90 .5 .70 .5 .50 .6 20.12 .6 .32 .6 .48 .6 .28 .6 -23.08 .6 .88 .6 .68 Y .94 9.14 .7 .61 .7 .46 .7 .26 Y -34.06 .7 .86 .8 .76 .8 .96 .8 .84 .8 .64 .8 .44 .8 .24 .8 -45.04 .9 .58 .9 .78 .9 -2.02 .9 .82 .9 .62 .9 .42 .9 2> -7.0 .40 -13.0 .63 -19.0 .20 -25.0 -13.00 -31.0 .80 -37.0 .60 -43.0 .40 .1 .22 .1 .42 .1 .38 .1 .18 .1 .98 .1 .78 .1 .58 .2 19.04 9 .24 9 .56 9 .36 .2 -24.16 .2 .96 2 .76 .3 .86 .3 8.06 .3 .74 .3 .54 .3 .34 .3 -35.14 .3 .94 .4 .68 .4 .88 .4 .92 .4 .72 .4 .52 .4 .32 .4 -46.12 .5 .50 .5 .70 .5 -3.10 .5 .90 .5 .70 .5 .50 .5 .30 .6 .32 .6 .52 .6 .28 .6 -14.08 .6 .88 .6 .68 .6 .48 Y 18.14 .34 Y .46 Y .26 . 7 -25.06 Y .86 .7 .66 .8 .96 .8 7.16 .8 .64 .8 .44 .8 .24 .8 -36.04 .8 .84 .9 .78 .9 .98 .9 .82 .9 .62 .9 .42 .9 22 .9 -47.02 -8.0 .60 -14.0 .80 -20.0 -4.00 -26.0 .80 -32.0 .60 -38.0 •40 -44.0 .20 .1 .42 .1 .62 .1 .18 .1 .98 .1 .78 .1 .58 .1 .38 .2 .24 .2 .44 .2 .36 .2 -15.16 .2 .96 .2 .76 .2 .56 .3 17.06 .26 .3 .54 .3 .34 .3 -26.14 .3 .94 .3 .74 .4 .88 .4 6.08 .4 .72 .4 .52 .4 .32 .4 -37.12 .4 .92 .5 .70 .5 .90 .5 .90 .5 .70 .5 .50 .5 .30 .5 -48.10 .6 .52 .6 .72 .6 -5.08 .6 .88 .6 .68 .6 .48 .6 .28 .34 Y .54 .7 .26 .7 -16.06 Y .86 Y .66 Y .46 .8 16.16 .8 .36 .8 .44 .8 .24 .8 -27.04 .8 .84 .8 .64 .9 .98 .9 .18 .9 .62 .9 .42 .9 .22 .9 -38.02 .9 .82 -9.0 .80 -15.0 5.03 -21.0 .80 -27.0 .60 -33.0 .40 -39.0 .20 -45.0 -49.00 .1 .62 .1 .82 .1 .98 .1 .78 .1 .58 .1 .38 .2 .44 .2 .64 .2 -6.16 9 .96 .2 .76 2 .56 .3 .26 .3 .46 .3 .34 .3 -17.14 .3 .94 .3 .74 .4 15.08 | .4 .28 .4 .52 .4 .32 .4 -28.12 .4 .92 .5 .90 । .5 4.10 .5 .70 .5 .50 .5 .30 .5 -39.10 .6 .6 .92 .6 .88 .6 .68 .6 .48 .6 .28 .7 .54 Y .74 .7 -7.06 .7 .86 Y .66 .7 .46 .8 .36 .8 .56 .8 .24 .8 -18.04 .8 .8 .64 .9 .18 .9 .38 .9 .42 .9 .22 .9 -29.02 .9 .82 Fahrenheit and Centigrade-Continued. FAIRVIEW SPRINGS. Location and Post-office, Kosse, Limestone County, Tex. Access.-By Houston & Texas Central Railway to Kosse. Analysis (C. F. Chandler).-One pint contains: Grains. Chloride of sodium 0.220 Sulphate of soda 0.706 Sulphate of magnesia 1.228 Sulphate of lime 0.163 Alumina and its sulphate 0.675 Protosulphate of iron 0.257 3.249 The analysis does not suggest any therapeutical value. G. B. F. both sun and winds, it maintains a cool and pleasant temperature in summer, although the climate is some- times excessively warm. It is more frequented, how- ever, as a winter resort, especially for the treatment of consumptives, and for this purpose every comfort is afforded. The treatment is similar to that instituted by Dr. Brehmer at Davos, and consists chiefly in a judicious use of cold water, exercise, and nutritious food. The early stages of phthisis more especially are made the ob- ject of treatment. In the vicinity of the resort are the chalybeate springs of Kronthal and the tepid salt-springs of Soden, whose waters are frequently resorted to. J. F FALLOPIAN TUBES, DISEASES OF. Until very recently diseases of the Fallopian tubes have not been treated of by authors on diseases of women as of much importance. A small number of the standard works de- vote a short chapter to this subject, but most of them dis- miss it with a few remarks. In the writings of Kiwisch, Forster, Rokitansky, Scan- FALKENSTEIN is a prominent health-resort situated in the valley of Taunus, Province of Nassau, Germany, one mile and a half from the railroad station of Cronberg. Located at a height of one thousand seven hundred feet above the sea, in a well-wooded region, protected from 27 Fallopian Tubes. Fallopian Tubes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. zoni,and later in those of Martin, Klob, Schroeder, Henning, and other German authors, minute and clear descriptions of the pathological anatomy of these diseases can be found. Practically, but little advance had been made in their treatment until Mr. Lawson Tait made known his remark- able success in removing diseased tubes by laparotomy. The writings of Battey in America, and Hegar in Ger- many, on removal of the ovaries for other diseases than that of ovarian tumors, also had much influence in de- veloping the proper method of treating diseases of the uterine appendages. Many of the symptoms and local conditions which are the result of salpingitis were supposed to be due to cellu- litis and displacements of the uterus. In our text-books on gynaecology hundreds of pages are devoted to these subjects, and only a few pages to diseases of the Fallopian tubes. The revelations and re- sults obtained by laparotomy, combined with the well- known views of the best pathologist on pelvic cellulitis, promise soon to cause a change in the generally accepted ideas concerning pelvic inflammation, adhesions, etc. Etiology.-It is probable that disease of the Fallopian tubes is in most cases caused by the extension of dis- ease, or the passage of septic material from the cavity of the uterus directly into the tubes. Thus, a catarrhal or a specific endometritis may pass from the lining mem- brane of the uterus directly to that of the tubes. A septic endometritis may also pass into the tubes, especially if the cervix be contracted, so that the uterus becomes filled to distention with septic material, which is then forced by mechanical pressure directly into the tubes. This is especially liable to happen after early abortions, for the cervix uteri, not being prepared to dilate, is irri- table, and may contract firmly before or after the escape of the foetus, thus interfering with free drainage, and in addition the disease, or the results of the injury which caused the abortion by acting upon the uterus, may ex- tend to the tubes. After abortions both the patient and doctor are prone to be remiss in taking the same precau- tion to prevent sepsis, or to secure involution, as after labor. Not only do the tubes become diseased, but, on account of their construction, any unusual amount of fluid is almost certain to escape from the open end into the peritoneal cavity and thus cause peritonitis, either local or general. As early as 1871, Dr. Noeggerath advanced the opinion that gonorrhoea, not only in its acute stage, but also when in a latent form, caused salpingitis, and he afterward read an able paper on the subject before the American Gynaecological Society, in 1876. There is no doubt but that gonorrhoea is a very frequent and, in many instances, an unsuspected cause of salpingitis. Even when treated with the greatest care, specific vaginitis may cause spe- cific endometritis, and from the endometrium pass to the tubes, and cause salpingitis and local peritonitis. Syphilis may cause salpingitis, just as it does otitis or ozama, and the inflammation may also be of tubercular origin. Hydrosalpinx may possibly be caused by other than venereal or catarrhal disease, but this has not yet been determined with certainty. Haematosalpinx may occur from haemorrhages into the tube, and closure of the ends by the products of inflammation. Anything that occludes or diminishes the lumen of the tubes may obstruct drain- age, and thus cause disease. Subjective Symptoms.-Perhaps the most reliable symptom of disease of the Fallopian tubes is the occur- rence of repeated attacks of local peritonitis, or active pelvic congestion, without other evident good reasons for such attacks. A fall or direct injury, wet feet, or exposure to cold, may be exciting causes of local peritonitis, but in such cases a careful examination generally reveals a latent salpingitis, or distended Fallopian tubes, as the real cause of the attack. "A peculiar burning pain over the seat of the tube af- fected is somewhat characteristic, but many patients have no such sensation, and a dull pain over the tube or ovary, with some aching in the back, may be all that is complained of. Dragging pains or sensations will often be present when the patient stands, or there may be backache and headache such as is supposed to be due to displacement of the uterus. So many uterine diseases are found associated with diseased tubes, that it is very difficult in many instances to say which produces certain symptoms. Dysmenorrhoea is very frequently complained of, but, as a nde, this is due to endometritis, or is caused by the hyperaesthesia and contracted state of the endometrium, the result of the uterine disease ; and when the stenosis or endometritis' is cured, the dysmenorrhoea disappears, although the disease of the tube remains the same. A free menstruation will often relieve the pain due to sal- pingitis, but the increased vascular tension which pre- cedes menstruation may, and usually does, cause an ex- acerbation of the pain due to the disease, for a week or two preceding the catamenia. Menorrhagia, or metror- rhagia, is often associated with salpingitis, but I think it will most frequently be found to be due to vascular changes in the lining membrane of the uterus, and a thorough curetting with a good instrument will effect a cure, although great care must be exercised in preparing the case for operation, lest the salpingitis be so disturbed as to start up peritonitis. When both tubes are affected sterility is sure to exist, for even in mild cases of salpin- gitis the fimbriated extremities are closed by adhesions ; but when only one tube is affected, and the proximal end of the tube is closed so that the contents of the tube cannot enter the uterus, pregnancy is possible, and may go to full term. Sometimes a sudden flow of fluid from the vagina, that cannot be accounted for by the condi- tion of either the vagina or uterus, may come from the tubes. Objective Symptoms.-In acute cases there is usually so much swelling and tenderness that about all we can make out is a fulness or thickening of one or both broad ligaments, associated with more or less fixation of the uterus. Take such a case and keep the patient in bed until the painful symptoms completely subside ; then place thin pledgets of cotton, saturated in pure glycerine, against the cervix uteri, two or three times a week, and, as the case becomes subacute, add alum to the glycerine, and continue the pledgets for from three to eight weeks. The inflammatory products will be so much absorbed or stretched that the uterus will become movable, and an expert may be able to define an enlarged tube, or a mass that he can make out to contain a diseased tube or ovary, more or less prolapsed and adherent in one or both broad ligaments. In subacute cases a diagnosis may be more easily made, but often a doubtful case can be cleared up by the same treatment recommended for acute cases. A diagnosis is especially easy when only one side is affected, and the uterus is not retroverted. After the prolonged use of pledgets of cotton soaked in a mixture of alum and glycerine, a distended tube can be readily defined by bimanual examination. Of course, much will depend upon the thinness and laxity of the abdominal walls, and now and then a case will be found in which, to get a clear diagnosis, it is necessary to examine the patient under ether. In some cases the floor of the pelvis is so fixed by adhesions, and there is so much venous congestion or enlargement of the pam- piniform plexus, especially of the left side, that a certain diagnosis cannot be made ; a prolapse of, or adhesions to, the sigmoid flexure, may complicate affairs, and make a diagnosis more difficult. In some cases of catarrhal in- flammation the tubes are not distended, but feel like a thin band of adhesions. The ovaries are apt to be more or less cystic, or are often infiltrated and enlarged by inflammatory products, and are nearly always prolapsed with, and folded under the tubes, on either side. Sometimes, when the proximal end of the tube is patu- lous, the discharge will enter the uterus, and I have seen one or two cases where, from an accurate knowledge of the state of the uterus and vagina, it could be made plain that the gleety discharge had come from the distended tube ; after cleaning the vagina and uterus, fresh pus could be made to appear in the vagina by slowly pressing upon the distended tube. The fluid may escape intermit- 28 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fallopian Tubes. Fallopian Tubes. tently into the uterus, and, if irritating, may set up each time an acute endometritis. Now and then a distended tube will empty a large amount of fluid into the uterus at once, and this, for the time, flows freely from the vagina, and the tube will refill and again discharge. Pathology.-As has been before stated, salpingitis is nearly always caused by the extension of disease from the endometrium to the lining membrane of the tubes. Aside from the difference in character of the mucous mem- brane of the uterus and that lining the tube, the differ- ence in shape, size, and position of the tubes, and of the uterus also, causes a dissimilarity in the results of the in- flammatory process. Inflammation of the endometrium causing enlargement of the uterus may result in displacement, imperfect drain- age, and parametritis, but this is not the rule ; besides, the uterus is accessible and directly amenable to local treatment, while inflammation of the lining membrane of the tube, which causes swelling, is most certain to result in prolapse of the tube and obstruction of the naturally small lumen, and thus cause imperfect drainage, and al- most always induces peri-salpingitis by reason of the es- cape of the contents of the tube through its open ex- tremity into the peritoneal cavity. The tube cannot be directly treated ; the lumen cannot be dilated, and perfect drainage secured as in endometritis. Hence, salpingitis nearly always becomes chronic, in many instances lasting as long as the patient. The first effect of disease reaching a tube is to cause it to become engorged with blood ; as it is loosely attached to the upper border of the broad ligament, it sinks lower in the pelvis covering or folding over the ovary ; and as the beginning of salpingitis, after labor or an abortion, is so often associated with an enlarged uterus, this organ also sinks lower, and as the patient during the acute stage is, as a rule, on herback, the fundus inclines back- ward. Now, suppose the uterus is enlarged, lying back- ward, and the disease affecting the uterus extends to the tubes : they swell, sag backward and downward, covering the ovaries, and as soon as the discharge or the disease reaches the peritoneum through the open end of the tube, this membrane becomes inflamed, lymph is thrown out, gluing the different organs together. As the acute stage subsides, the lymph contracts, bands of adhesion draw and distort the organs, and the folded, twisted, and ad- herent broad ligament holds the uterus in its backward displacement. As a rule, the peritoneal tissue covering the fundus is not adherent to the tissues behind the uterus, although this seems to be the case when an exam- ination per vaginam is made. The uterus may sink lower, being drawn down by contraction of the adhe- sions, and it may become retroflexed when the adhesions are extensive and the contraction great. Again, the tube being smaller and displaced, the lumen is occluded, the discharge accumulates, distends the tube above the point of obstruction, and leaks into the peritoneal cavity. Then a fresh attack of peritonitis sets in, more lymph is exuded, and as the acute stage subsides, the tubes and broad liga- ments are rolled back and folded in more and more ; as the contraction goes on, the tissues harden and the tubes may form strong cords, which, being adherent to the floor of the pelvis, fix the uterus in its retroflexed and retro verted position. Thus, we have cases of retroversion with adhesions, and it is the rolled-up ligaments and the tubes which fix the uterus backward ; and it is the em- bedded ovary and diseased tube in the hardened tissues of the broad ligament which makes it next to impossible to insert a pessary and hold the uterus up without causing pain, and running the risk of bursting or tearing a tube distended with septic or irritating fluid. By great pa- tience we can, in many cases, stretch the ligaments after a time, and by force get the fundus uteri into that ideal normal position; but to keep it there is the difficulty ; the rolled-up broad ligaments will not unroll, and when put on the stretch by the uterus being held up by force, they soon begin to ache, inflame, and may cause local perito- nitis. Suppose only one tube is affected, the retroversion will be less, and if the other side be not diseased the uterus may be even a little anteverted, unless the inflamed tube drops to the floor of the pelvis. If the ovary and the tube of the affected side are prolapsed and inflamed, as contraction takes place the broad ligament is shortened, especially on its lower side, and unless the tube and ovary are very much distended, so as to displace the uterus bodily, the cervix is drawn to the affected side, the fun- dus being tipped toward the healthy or less affected side, which is usually the rigit side, and the swollen ovary and tube may be forced backward somewhat behind the uterus ; thus, a lateral version is the result. When one side only is affected, it is usually the left ; the circulation on this side, from the arrangement of the veins and the proximity of the often distended intestine to the left broad ligament, seems to make it more sus- ceptible to congestion, prolapses, and disease than the right side. When both tubes are involved, the left is probably the first to become affected ; this, together with the natural position of the uterus being that with the fundus inclining slightly to the right of the centre, ac- counts for the fact that where both tubes are affected and the uterus is not retroverted the cervix is drawn to the left and the fundus to the right, the left ovary and tube being prolapsed, and the right usually much less so. In nulliparous women-especially in those cases in which the uterus is anteverted, or anteflexed, and in which the disease is gradual in its progress-this condition of right lateral flexion with the fundus forward is most likely to be found, whereas, after labor and abortions, salpingitis is frequently associated with retroversion. Sometimes the prolapsed tube, especially on the left side, is adherent to the sigmoid flexure or to the small intestine, and the omentum, when it has been thickened and the blood- vessels greatly enlarged by repeated attacks of local or general peritonitis, may have slipped down, especially when the uterus is retroverted, and become adherent over and in front of all the pelvic organs. To the inex- perienced this is a formidable barrier; years ago I saw even Dr. Sims close the abdomen rather than run the risk of going through the omentum to reach the ovaries beneath it. These are the cases concerning which emi- nent men will tell you that they opened the abdomen, but could not find the ovaries and tubes, and therefore closed it. When describing the operation, I think I can make it plain that by a simple procedure this apron of blood- vessels can be safely removed. It has enabled me to complete the operation of removal in even the worst cases. When the local peritonitis is limited, as the tubes open near the ovaries which protrude through the pos- terior surface, the adhesions are, as a rule, confined to the posterior layer of the broad ligament; this accounts for the rarity with which the bladder is affected by the adhe- sions. The ureters are not uncommonly affected by the adhesions, especially when the latter extend low down on the floor of the pelvis, and in tearing up very old and firm adhesions the ureter may be lifted up (on one occa- sion it would have been tied had I not recognized it as it was raised up by the operator). Now, as to the tubes themselves, in cases of simple catarrh, especially those associated with cystic ovaries- a combination which seems to be the most certain to produce hystero-epilepsy, hysteria, and all kinds of re- flex disturbances-the tubes may be very little enlarged, but very vascular and adherent, with the lining membrane in a mild catarrhal state. Later in the disease the tube is more commonly distended by fluid, and enlarged from the size of a lead-pencil to enormous dimensions, with the fimbriae turned in and the end of the tube closed ; or the fimbriae may be spread out and adherent to the surface of the ovary, the latter acting as a plug to the mouth of the tube. The end of the distended tube may be adherent to the side or floor of the pelvis, to an in- testine, or even to the other tube. The distended tube may be, and when large is, more or less convoluted, some- times constricted at one or more parts, and usually with the outer end much larger than the proximal end. The material distending the tube may be a clear, transparent, and watery, or a milky, or gleety fluid, or it may be a thick, greenish-colored, or a thin, broken-down pus. Cili* 29 Fallopian Tubes. Fallopian Tubes. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. ated epithelium is the chief microscopical characteristic of the clear fluids. When the tube is greatly distended and the adhesions slight, it is usually a hydro-salpinx, but when large, with many adhesions, it is likely to be pus that distends the tube. In the majority of instances the tubes will be found infiltrated with pus and serum, and degenerated rather than distended. In those cases in which abscesses are found formed in the substance of the ovaries a/id tubes, the tissues may be so rotten that in tying them the ligatures may cut through the degen- erated stump, and it may be necessary to pick up the arteries and ligate them one by one. These might fairly be called cases of pelvic abscesses. In old cases the tis- sues may have become atrophied and contracted to such an extent that it is difficult to remove all of the ovary and have a stump long enough to hold the ligature. In most cases the ovaries are covered with the inflamed tube and shreds of adhesions, and in pyo-salpinx they may be inflamed and filled with small abscesses, or infiltrated with pus, and are sometimes so degenerated that they are torn to pieces in being removed. Sometimes the inter- stitial tissue of the ovary is affected, and may be hard- ened and contracted, or the organ may be found ab- normally small and atrophied ; but the most common condition of the ovaries, if affected by an independent disease at all, is that of cystic degeneration ; usually the cysts are small but numerous, and filled with a gummy, translucent fluid. Superficial cysts with thin fluid are very commonly found, but when they are deep-seated and central, the condition may fairly be called cystic de- generation, and it is to this class of cases that I refer when speaking of cystic degeneration of the ovaries. In some cases the cellular tissue may be infiltrated and thickened by lymph, but the preparatory treatment al- most always more or less completely removes this lymph, and the real adhesions that bind and twist the or- gans out of place will be found to be peritoneal. Prevention.-It is important that the general health and strength of girls, while developing into women, should be kept up, so that the generative organs will fully develop and resist catarrhal disease. When there are symptoms of catarrhal disease, such as leucoiThoea and dysmenorrhoea, they should be treated early, before the inflammation has reached the Fallopian tubes ; and if the endometrium is affected by disease the uterine canal should be kept patulous, so as to secure perfect drainage, and thus lessen the chance of the inflammation entering the Fallopian tubes. The serious nature, and the almost certain consequences, of venereal diseases, should be ex- plained to and impressed upon all young persons, and definite instructions should be given, especially to all male patients suffering from gonorrhoea, to avoid inter- course until complete cure is effected. No doubt many of the cases supposed to be due to septic poisons after labor are really caused by gonorrhoea contracted from husbands who have been led astray while deprived of their usual indulgence during the confinement of their wives. The serious consequences of even a slight septic endometritis in causing a salpingitis makes more forcible the great importance of cleanliness, and the use of anti- septics or any other means that may lessen the chance of puerperal septicaemia. We know that subinvolution rarely exists without, sooner or later, the development of endometritis, and instead of taking it for granted that when a woman has passed the ninth day after labor the doctor's responsibility in the case is at an end, every lying-in woman should be examined locally before she is allowed to go about her usual duties ; and it is safer to keep her under observation until the uterus is normal in size, position, and condition before dismissing her. If treatment is needed, it is better to begin it not later than the end of the second week after labor. A few stimulat- ing applications of glycerine and alum, made twice a week during the third, fourth, fifth, and sixth week af- ter labor, will prevent subinvolution, retroversion, endo- metritis, and salpingitis in a delicate or weak woman who, without it, would be pretty certain to be affected with one or more of these serious troubles. When we have to treat an endometritis it is especially important that we should secure perfect drainage from the uterus. After abortions the greatest care should be taken to prevent septic infection and to insure removal of all the placenta and membranes. Especial care should be taken in these cases to secure perfect involution and drainage of the uterus, for after labor nature generally accomplishes this without help, but not so in abortions. Labor is normal, but abortions are abnormal, and must be regarded as almost certain to result in disease. Treatment.-During the acute stage complete rest in bed is the best treatment; anodynes and counter-irri- tants may be used, and as the active symptoms subside, the application of thin pledgets of cotton, saturated in pure glycerine, and applied to the cervix and vagina, may be made ; these are to be left in place twenty-four hours, then removed, and a douche of hot water given, and on the third day another pledget is put in. These applica- tions are kept up for a week or two, and later a solution of one part of boro-glyceride, one of alum, and fourteen of pure glycerine, is used to saturate the cotton in place of pure glycerine. After a week or so this softens out the products of inflammation and renders the uterus more movable, and enables one to make a more accurate diag- nosis. It improves the circulation, and often gives, for the time, more or less complete relief to all the local symptoms. While this simple local treatment is given, close attention should be paid to the general health and the condition of digestion, and especially the bowels should be carefully regulated, for impacted fecal matter in the lower end of the descending colon or rectum may materially aggravate the pain and other symptoms of the disease by pressing directly on the left broad ligament. After getting the uterus movable, so that it can be pulled pretty well down with the tenaculum without causing much pain, it will be safe to sound the uterus, and, if the canal is contracted and hyperaesthetic, it should be gently dilated, so as to secure good drainage and enable applications to be made to the mucous lining. If there is a history of excessive haemorrhage which is not corrected by tincture of cannabis indica, given in doses of twenty drops twice a day, if the uterus can be gotten movable by the use of medicated pledgets, it will be safe to curette its interior for the removal of granula- tions. I would always give the above treatment as pre- paratory to operation, except in those cases in which the diagnosis was plain, and immediate action was indicated to prevent rupture of a painful cyst, or to prevent septic poisoning and death after rupture. In these cases I would resort at once to the operation for removal. As- piration, through either the abdominal wall or vagina, can give only temporary relief by evacuating the con- tents of a cystic tube or ovary, but there is some risk and little or no permanent good attained. In three cases I have resorted to opening and draining by the vagina when a large amount of pus had accumulated and ab- dominal section was not permitted. In most cases the abscess or distended tube is too small to be reached safely in this way. If, after opening the abdomen and finding a large pus cavity, I wished to make a counter-opening through the vagina, I should introduce a small trocar and then enlarge the opening with dilators. In case of a large pelvic abscess pointing toward Poupart's ligament, I open by an incision in the groin, and should not enter the peritoneal cavity, above the abscess, except to secure complete removal or to get perfect drainage. When diseased tubes are plainly made out, and the pa- tient is bedridden, or suffers to such an extent that, after being clearly informed as to the effect and danger of the operation, she gives her consent, then we consider com- plete removal of both tubes and ovaries, if both sides are affected, to be justifiable. By softening the indurated tis- sue and improving the circulation of the pelvis, we can help but cannot cure. By atrophy and absorption nature may cure, but chronic invalidism may come before nature has brought about this result. Or, upon the bursting of a distended tube general peritonitis and death, instead of the usual attack of local peritonitis, may ensue. Many a case of so-called idiopathic peritonitis has been caused by 30 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fallopian Tubes, Fallopian Tubes, the bursting of a diseased Fallopian tube, and the patient might have been saved by a bold surgeon even after the peritonitis set in. Operation for Removal.-After giving the prepara- tory treatment with glycerine and alum pledgets as de- scribed, and having decided that an operation is proper, I have the patient's bowels well emptied and put her on pancreatized milk diet,with very little other plain food, for three or four days previous to the operation, the object being to remove all impacted fecal matter, and to lessen the amount of gas in the intestines, for the latter may be very troublesome by crowding down around the pelvic organs and out through the incision in the abdominal wall during the operation. When well prepared there will be little or no gas in the intestines, and they will be found to be like so many slippery ribbons. The day of the operation the bowels should be well moved, but not excessively. Before operating, my patient is thoroughly bathed, and clean clothing for her body and bed ordered ; just before being etherized one-quarter to one-third of a grain of morphine is given hypodermically. When under ether, the abdomen is shaved well down to the pubic bone, and thoroughly washed with soap and water, and before the skin is cut, again well washed with a solution of one to five thousand of mercuric bichloride. Instruments are all kept in solution of one to twenty No. 1 Calvert's acid, carbol., and sponges in a solution of one to ten thousand of mercuric bichloride. Besides the operator, only four assistants are needed : one to give ether, one to, handle instruments, one to clean sponges, and one to stand op- posite the operator and sponge. Ordinarily the man to hand instruments can be dispensed with, and I do not use anyone for this purpose except in my hospital clinics; for, of course, the number of persons helping adds to the danger of infection. All assistants are required to wash as clean as possible, and to use solution of bichloride af- terward. In putting the patient on the operating-table I place a soft pillow under the shoulders, and one under the head, and have the feet so fixed as to keep the knees about level with the abdomen. This relaxes the abdominal wall to some extent. The bladder is emptied, and the abdominal incision is made just above the pubes, the length of incision in the skin being from two and one- half to three inches, according to the amount of fat in the abdominal walls, the opening in the peritoneum being only large enough to allow the free use of both the index and middle fingers at the same time. This opening is rarely made larger, unless the size of the distended tube or ovary makes it absolutely necessary in extracting them. A larger opening is avoided, because it adds to the risk of septic poisoning, and makes ventral hernia more likely to follow. When ovarian and other large tumors are removed, the abdominal walls are relaxed, and there is less tension on the sutures, and perfect union is more readily secured than in those cases in which the intra- abdominal pressure is normal. When the subperitoneal fat is reached, it may be trou- blesome to get through it, for there is no distended tumor directly underneath it to keep away the intestines and hold the many layers of the peritoneum together, and when gas is in the intestines this difficulty is increased. Where the omentum is free from adhesion, it can be pushed up as one would the end of an apron. When it is adherent, as it often is, to the broad ligament and ante- rior wall or top of the uterus, it cannot easily be separated by pulling it from below upward ; but by passing the two fingers well to one side and getting them underneath, and thus separating the adhesions, many formidable-looking cases can be easily managed. As the adhesions separate, they should be lifted through the opening and any bleed- ing points tied. The principal vessels in adhesions of the omentum come from those of the omentum, and not from the pelvic organ; therefore, the end of the omentum is the part to be tied. If the adhesions are strong and vas- cular, as they may be in those cases in which there have been repeated attacks of local peritonitis, then the omen- tal adhesions can be ligated, tied first as low as possible, and then a little above this, and cut between the ligatures. By pulling the sides of the abdominal opening laterally with retractors, we can do this in most cases without en- larging the opening. In handling and tying the omentum care should be taken not to split or tear it, for it will in- variably bleed up in the angle of the split, and may be very troublesome. When the uterus is retroverted, the removal of the omentum, as a rule, frees the anterior part of the fundus and the anterior face of the broad liga- ments ; often the small intestines will have to be sepa- rated, but they are not usually very firmly adherent. The next step is to elevate the uterus by placing the fingers behind it. The back of the fundus may be adherent, but, as a rule, it is free, and is held back by the twisted and rolled-up state of the broad ligaments. The ovary will be found folded under the tube and broad ligament, and to get it up we must go down through this ligament, or we must unroll it. I have seen the former done several times, and it always adds greatly to the length of the operation, and necessitates tearing or tying off the outer attachments of the broad ligament before the tube can be gotten up and tied off with the ovary. Now, by putting both fingers directly down behind the uterus, and run- ning them laterally, guided by the Fallopian tube, as it is given off from the uterus, and gradually separating the adhesions and unrolling till we get under the ovary, the tube and ovary can be got up easily in the worst cases; when the adhesions are very firm, an assistant's finger in the vagina, as a guide, may be useful, for in scratching loose the adhesions the ureter may be raised, and the sig- moid flexure or rectum may be torn up, for it may be ad- herent to the tube or ovary on the left side. When both sides are adherent it may be well to lift up both sides before tying either; although in some cases, where the bleeding is free, it may be better to tie the first one lifted up. When the tissues are frail and the ligatures are in- clined to cut easily, it is safer to remove the tissues and tie the arteries separately. Two or three arteries will usually be found. When the broad ligament is much en- larged we may tie with two ligatures, one double, includ- ing the ovarian ligament and the tube within half an inch of the fundus, the other single, and tying off the outer end of the broad ligament. The pampiniform plexus may give trouble, as I have seen it so degenerated as to pull to pieces in being tied. I use firmly-twisted Chinese silk, and prefer to pass the ligature with a needle some- thing like an aneurism needle, but with a sharper point and longer handle than those found in the shops, and made to carry a double thread. In tying, except in cases in which one double ligature will suffice, I do not use Mr. Tait's Staffordshire knot, but I cross and interlock the two loops of all my double liga- tures, and so far I have never had a ligature slip after the operation. After tying, before cutting off the tube and ovary, I catch the tissue with pressure-forceps close to the ligature, so that I can cut off my ligatures and not be tempted to use them to lift up the pedicle after being once tied. Besides enabling me to keep the pedicle in sight, these forceps act as guides in cutting away the tube and ovary. Often the ovarian ligament is so short that it is not easy to get a satisfactory stump left and at the same time cut off all the ovary. I like to have a Paquclin cau- tery on hand, so as to touch any suppurating end of the tube in a stump or ovarian tissue that may be left on it after tying. The tubes and ovaries of both sides should be re- moved if there is any sign of salpingitis ; but in three cases I found only the left side affected, the right tube and ovary being free from even a single adhesion, and I removed only those of the diseased side. The cavity should be thoroughly dried with sponges, and time given for haemorrhage to make itself manifest before the wound is closed. When there are extensive ad- hesions, or any pus cavity is disturbed, or especially when there is any ascites, a drainage-tube should be put into the pelvic cavity. In these cases the peritoneal cavity should be washed out (irrigated) first with a solution of mercuric bichloride (1 to 10,000) followed by water that has been boiled. I prefer a large-sized tube of glass, with some small holes in the sides in addition to the open ends, 31 Fallopian Tubes, Fascia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and I use a large-sized catheter attached to an ordinary syringe for washing out the tube when needed. If there is no discharge I remove the large tube in twenty-four hours and slip a small rubber drainage-tube into its place, and the next day a still shorter and smaller one, each day, until about the fourth day, when the opening will usually be filled up from the bottom. In introducing the sutures in the abdominal wall, I am careful to secure not only perfect coaptation of the peritoneal coats, but also of the deep and thick abdominal fascia, for if good union of this is secured the risk of ventral hernia is very much lessened ; for it is this tissue, and not the muscles, which are longitudinal, that gives strength to the abdominal wall in the median line. For from thirty-six to forty-eight hours nothing is allowed to be taken except teaspoonful doses of water or broken ice, and enough morphine is used, for several days after the operation, to prevent pain and restlessness. An enema is usually given on the sixth day to move the bowels, and the sutures are removed on the eighth day. Either medium silk or silver wire is used in sutures for the abdominal walls. If the abdominal walls are thick from adipose tissue, the peritoneum will be found tense, as a rule, and will require more than usual care in closing properly. In such a case, after putting in from three to six silk sutures through the skin, deep fascia, and peritoneum, the perito- neum should be carefully closed with catgut sutures, and the deep fascia also separately closed in the same way. Then the first silk sutures should be closed, leaving room between them, in two or more spaces, for short drainage- tubes placed upright so as to drain the adipose tissue be- tween the fascia and the skin. Or if the walls are closed by silk sutures in the usual way, the skin, a little to the side of the cut, should be punctured so as to give vent to the grease that is certain to escape from the more or less bruised adipose tissue. I have seen mural abscess caused by this free fat, and it might enter the peritoneum and cause greater trouble. After sewing up and cleaning the wound, it should be freely sprinkled with iodoform and covered with a layer of absorbent cotton that has been squeezed out in one to five thousand mercuric bichloride, and over this several layers more of dry, absorbent cot- ton are to be placed, so that the whole abdomen will be evenly compressed when the adhesive straps and band are put on. Over the cotton a folded towel and mackin- tosh are placed, and firmly compressed by adhesive straps and a bandage. Except when a drainage-tube is inserted, this dressing can remain until the eighth or ninth day, when the sutures are removed, unless oozing appears through the dressing, or a rise of temperature takes place indicating septic poisoning, etc. In cases with extensive adhesions or in pyo-salpinx, especially where the tissues are infiltrated, we must expect a moderate rise of temper- ature during the first two or three days, caused by the small amount of septic material left in the pelvis; but this is readily absorbed and the local peritonitis caused by it soon subsides, and on the fourth or fifth day the temperature falls. When the patient fails to rally, and has a temperature at or below normal, or in some cases where all symptoms are favorable ami the temperature low until, on the afternoon of the third or on the fourth day, the temperature makes a steady rise, you have, as a rule, a fatal case of septicaemia to deal with, that death alone will stop-which it usually does within two or three days. Sometimes a case begins as a local peritonitis and gradu- ally spreads to general peritonitis, accompanied with vom- iting, and terminating in death. Still, I think the proper name for such a case is septicaemia. Complications.-As endometritis nearly always pre- cedes salpingitis, it is necessarily a frequent complication. It is rare to find salpingitis uncomplicated by local peri- tonitis, and this, by the formation and contraction of bands of adhesions, distorts and displaces the pelvic or- gans, and makes more or less permanent any displace- ment that may have previously existed. This was fully brought out in describing the treatment. The most seri- ous and dangerous complication is the rupture of a tube distended with septic fluid, causing general peritonitis and septicaemia. Should this happen and be diagnosed, or be indicated as the probable cause of peritonitis, it would be proper to open the abdominal cavity, remove the tube, and wash out and drain the peritoneum. The inflammatory process may become so intense in or about the tube, as to cause the tissues to break down, and form so large an abscess that the surrounding structures lose the power to protect themselves, and a perforation takes place into the rectum, vagina, abdominal wall, or through one of the openings in the pelvis, or into the bladder. This necessitates enlarging the opening to secure drain- age, and often before a cure can be effected counter-open- ings are necessary, and if these fail, an operation for re- moval must be resorted to. Results.-In cases operated on for severe local pain and physical inability to go about, if the patient survives the op- eration the results are nearly always most satisfactory. If the operation is done chiefly for reflex nervous symptoms, the immediate results are not always satisfactory, but many cases which at first are not benefited, recover en- tirely after six months or a year. The writer has per- formed the operation on 37 patients, with 4 deaths and 33 recoveries. Two of the fatal cases were complicated by acute pelvic abscesses, and a third by a haematocele. All 4 died of septicaemia. All of the 37 cases except 4 had decided peritoneal ad- hesions ; 14 were well-marked cases of pyosalpinx, 8 being complicated by pelvic abscesses. " IE Gill Wylie. FARMVILLE LITHIA SPRINGS. Location and Post- office, Farmville, Prince Edward County, Va. Access.-Farmville is located on the Norfolk & West- ern Railroad, about 150 miles from Norfolk, 70 miles from Richmond, and 50 miles from Lynchburg. Analysis.-In this group are found lithia, chalybeate, alum, sulphur, and magnesia springs. The published analysis of Lithia No. 2, by Professor E. T. Fristoe, is as follows : A wine gallon contains Grains. Sodium chloride 5.3040 Sodium sulphate 3.5888 Potassium sulphate 0.1759 Calcium sulphate 1.8139 Lithium carbonate. 1.9872 Calcium bicarbonate 1.3326 Magnesium bicarbonate 4.4862 Ferrous carbonate 1.2648 Manganous carbonate trace Alumina 2.5170 Silica 3.9189 Iodine trace Sulphuric acid trace Organic matter small quantity Total solids in one gallon 6.3893 Carbonic acid gas, 74.2 cubic inches. Therapeutic Properties.-The proportion of lithia in this water is well marked, and theoretically sustains the reputation of the spring as a valuable remedy in di- gestive and renal disorders. These springs are situated in a horseshoe-shaped val- ley, at an elevation of 550 feet above sea-level. The tem- perature ranges between 40° and 50° F. in winter, and 80° and 90° in summer. G. U. F. FASCIA. Portions of the original connective tissue of the body which have become condensed into sheets or bands, by reason of the stress which that tissue has un- dergone from muscular action. In Fig. 1127 let A A be a segment of the skeleton, and B and C other neighboring segments, the original connec- tive-tissue network in which they are laid down being indicated by the oblique faint lines. Let now a muscle be developed in this tissue, with its long axis between the points A and B, its contraction tending to make these points approach each other. The original connective tissue of the region interpenetrates the muscle, and re- mains permanently a part of it as its endomysium, cloth- ing the separate bundles of fibres. It is evident that the contraction of this muscle will cause a stress upon the surrounding tissue, and condense it into the form of a sheath, separating the more movable from the more sta- tionary portions, as indicated by the dotted line. Let 32 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fallopian Tubes. Fascia. another muscle, as A C, develop contiguously, it will also have its appropriate sheath of condensed connective tis- sue, which, along the line of contact with its neighbor will be thicker than elsewhere, it here receiving stress from two distinct sources. The degree of thickness of the separating fascia will depend upon the degree of in- dependence of the muscles. If they usually act to- gether, it will be thin ; if one is frequently inert while the other moves, it will be thicker ; and if, while one is acting on the point B, the other is always inert or stretched, as must, for example, necessarily happen when B is on the flexor side of a limb, while C is on the exten- sor side, the fascia becomes so thick and strong that it is named by some authors an " intermuscular ligament." It is obvious that the thickening will extend from one bone to the other in the direction of the line a b. The fascia immediately enclosing the muscle is known also as its sheath or perimysium. Those lying between the muscles are called intermuscular septa, and in a num- the joints that a great number of muscles end, the fascia there becomes continuous with the ligaments. The vessels and nerves of a region being developed within the connective tissue, they are naturally found between the muscles and within the layers of the fascia, which not only gives them an investment, but affords a valuable guide to them in surgical operations. If the fasciae of the body could be made to stand out independently and distinctly there would, therefore, be seen a series of partitions passing between separate por- tions of the skeleton and arranged both radially, connect- ing the skin with the bones and deeper structures, and concentrically, separating the layers of muscles from the skin and from each other. The thinner partitions sepa- rate single muscles, the thicker ones muscle-groups. Fascia is distinguished as superficial and deep, the superficial lying next the skin, being looser in texture, and containing (except on the scrotum and eyelids) a con- siderable amount of subcutaneous fat (panniculus adi- posus), which never entirely disappears even in great emaciation. The superficial fascia may usually be sepa- rated into layers, and where considerable strain is put upon it, as at the groin, these may become quite thick and well marked. In the face, neck, and scalp, and oc- casionally in other situations, muscular fibres may be found within it. These are much more developed in some mammals than in man, forming the so-called panniculus carnosus. The superficial vessels and nerves run in its deeper portions. The deep fascia affords, in many cases, origin for muscu- lar fibres, and when this is of considerable extent it is called an aponeurosis, from the fact that it usually covers, or is continuous with, the tendon of the muscle.* Bichat divided aponeuroses into two varieties, those of invest- ment and those of insertion. The first usually contain elastic fibres, which adapt the sheath to the muscle dur- ing its changes of form due to contraction. If the muscle atrophies, however, the sheath ceases to be adapted to it. and one of the causes of the feebleness of an emaciated person is the relaxed condition of the muscle-sheaths. Tension of the sheaths is also affected by the contraction of associated muscles. This is quite general throughout the muscular system, and Bardeleben1 has pointed out that at least two-thirds of the muscles have fascial inser- tions ; yet there are some muscles which seem to be specially assigned to the work, and to such the name of tensors of the fascia is given. It appears to be a general rule, that the usual action of a proximal segment puts into a somewhat tense condition the fascia of the succeeding segment, thus preparing the way for its muscles to act to the best advantage. In the upper limb, for instance, the pectoralis major renders tense the fascia of the upper arm covering ovei- the biceps and other muscles, the biceps in its turn stretches the fascia of the forearm, one of the muscles of which, the palmaris longus, renders tense the fascia of the palm. A similar arrangement may be made out in the lower limb. In some situations aponeuroses may stretch across the surface of other muscles, forming tendinous arches at- tached at either end to the skeleton, and from these muscular fibres arise. Examples of this are seen in the levator ani, and the arcuate ligaments of the diaphragm. Fasciae have an important function in determining the direction of muscular action, by confining the muscle in a definite manner. This may be but slight, as in the sterno-mastoid muscle of the neck, which is held forward by its investment in such a manner as to pull to more ad- vantage upon the head, and at the same time prevent any pressure upon the great vessels of the neck ; or it may be very considerable, as in the case where a special band of fascia holds down a portion of the muscle, so that the di- rection of the applied force is notably changed. Exam- ples of this occur in the omohyoid muscle of the neck, and near the hand and foot, when special thickenings of the superficial fascia, called annular ligaments, confine and change the direction of the tendons passing down A a A Fig. 1127.-Diagram showing the Formation of Fascia from Connec- tive Tissue. IS b C her of situations, where the peculiarities of the region have determined a band-like form, such bands have re- ceived special names as ligaments. Arising like the bones from special conditions of the connective tissue, the two are structurally continuous, the periosteum of the bones blending inseparably with the fascia, and fibres from thence passing through and through the osseous tis- sue. The lines and ridges on the bones indicate the in- sertion of fascia, and may be considered as very slight extensions of the process of ossification into those struct- ures. In pathological conditions this is sometimes ex- cessive, sheets of fascia ossifying like the ossification in membrane which occurs in the vault of the cranium. From this intimate union with bones it necessarily fol- lows that fasciae are intimately connected with the liga- ments of joints, which are also connective tissue struc- tures arising in a way essentially similar to that of fascia ; and, indeed, they cannot structurally be distin- guished from it (see Arthrology). As it is at or near * The Greek word •'evpoy was originally applied to tendon as well as to nerve. 33 Fascia Fascia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from the upper limb. There is also here a special invest- ment of the tendons derived from the deep fascia, and called a synovial sheath (see Bursae). The surgical importance of fascia is considerable. Composed of a tissue of low vitality, it is not readily af- fected by inflammatory processes, and consequently con- fines the products of inflammation, such as pus and exuda- tions. These, therefore, usually undermine the tissues along the lines where the fascia is weakest, and may ap- pear at points far remote from their origin. This may also be the case with any gas or foreign body which enters the tissues. Fasciae are also important by their mechanical qualities, and require to be divided in cases where there is a considerable swelling from inflammation. It is therefore of the first importance to ascertain whether a swelling is under the deeper fascia or superficial to it. Fascia is especially affected in certain disorders, such as rheumatism. In some cases it undergoes a shortening or contraction, which causes marked deformity, especially in the fingers and the feet. When a limb has been for a Head.-The crown of the head is covered with a fascial investment, the remains of a muscular sheet the re- sidue of which is the occipito-frontalis muscle. This in- vestment is known as the galea capitis (Fig. 1128). It is continuous at the sides with the temporal fascia. The separability of this sheet, united to the pericranium by lax connective tissue, permits the scalping practised by the Indians. The scalp has been gashed in childbirth in ignorant mistake for the membranes, and the skull ex- truded through the wound, the child's head being born peeled like an orange (Agnew). A similar case is rec- orded by Erichsen, where, from a fall, a sailor had the entire scalp peeled off, but yet made a good recovery. Suppuration beneath the galea may be very extensive. Bichet describes the entire scalp from one ear to the other raised by a suppurative process. It would be limited in front by the orbital line, behind by the superior curved line of the occipital bone, on the sides by the zygomatic processes. " The temporal fascia (Fig. 1128) covers over the tem- Orbicularis oris. Bucco-pharyngeal fascia. Fat-ball of Bichat. Galea capitis. Pterygo- maxillary ligament. Parotideo- masseteric fascia. Lower jaw bone. Temper a 1 fascia. , Tonsil. Styloid process. I Superior I constrictor. Preverte- bralfascia. Zygoma Parotid gland. । Second cervical vertebra. P a r o t i dl gland. J -Pterygoid process. Jugular vein and internal carotid artery. Parotideo- masseteric fascia. Pterygo-maxillary ligament. Lower jaw bone. Fig. 1128.-Frontal Section through Left Temporal Region, showing the Relations of the Fascia. Fig. 1129.-A Horizontal Section through the Head at the Level of the Lower Teeth, showing the Relations of the Fascia. long time flexed the fascia shortens and holds it in that position. Morphologically, fascia may be of importance as indi- cating the position of muscles of which all other ves- tiges are lost. Some remarkable examples of this have been lately shown by Sutton,2 who has found, by investi- gating the peculiarities of fascia, many vestiges in man of a musculature now possessed only by the lower animals. Bearing in mind the origin of the fasciae, it will be seen that a proper understanding of them depends entirely upon a knowledge of the muscle-groups and their relative importance. Each group has fascia separating it on either side from the other structures, A proper comprehension of this greatly simplifies a study often needlessly com- plicated. It remains to point out briefly the character- istics of different regions. The deep fascia only will be mentioned, the superficial being essentially the same in its arrangement throughout the body. poral muscle, passing from the temporal ridge to the zygo- ma. It is so thick and strong that it feels like a bone under the skin. Below the zygoma the muscle and its tendon are separated from the masseter only by a very thin septum. Pus under the temporal fascia burrows down along the tendon. The parotideo-masseteric fascia (Figs. 1128 and 1129) is properly a process of the cervical fascia, with which it is continuous behind. It confines the masseter muscle, passing from the zygoma to the lower jaw. It is very thick and strong, and fluctuation under it is felt with difficulty. As it confines the underlying parts, great pain is felt in any inflammation of the parotid from the presence of the inflammatory products. Under the paro- tid a layer of fascia passes behind the jaw to the pharyn- geal muscles. The bucco-pharyngeal fascia (Fig. 1129) covers the superior constrictor behind and the buccinator in front. 34 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fascia. Fascia. the division between the two being a band which passes from the hamular process of the sphenoid to the mylo- hyoid ridge of the lower jaw, and is called the pterygo- maxillary ligament. Before leaving the head there should be mentioned a delicate fascia which occurs in the orbit, surrounding the ocular muscles and ensheathing the globe of the eye so that it rolls within it as in a socket. This is known as the capsule of Tenon. It has a prolongation on each of the muscles. Neck.-The cervical fascia has enjoyed a rather unen- viable reputation. Malgaigne speaks of it as the ana- tomical Proteus that takes different shapes according to the fancy of the observer. Viewed according to the prin- ciples above set forth, it is not, however, of any great com- plication, as it strictly follows the laws therein set down. It is usual to describe first the superficial sheets, but the more logical method is to commence with those first formed, adding those of later development. Considered, therefore, from this point of view, the following layers may be made out. First, a layer enclosing the vertebral group of muscles which is constituted by the longus colli and the recti capitis antici in front, and the semi-spinalis, the com- plexus, the splenius, the levator anguli scapulae, scaleni, and others, laterally and behind. The sheet enclosing the muscles in front is called the prevertebral fascia. It is limited above by the occipital bone, and runs below over the longus colli muscle into the thorax. It is strong, maxillary ligament, continuous with the bucco-pharyn geal fascia mentioned above, passing down along the mylo-hyoid ridge of the lower jaw to the middle line. Below it is attached to the posterior border of the sternum in front, and descends into the thorax over the oesopha- gus, trachea, and great vessels, becoming continuous with the fibrous layer of the pericardium, and finally ending as the central tendon of the diaphragm (see Fig. 1131). This peculiar downward extension is deter- mined by the so-called descent of the heart (see Dia- phragm). Laterally it unites with the prevertebral fascia to form an investment for the great vessels of the neck, the common carotid, the internal jugular vein, and the pneumogastric nerve, and is firmly united to the pos- terior border of the clavicle. In the lower part it is very thick and strong, and its investment of the vessels is so firm that it holds them open, so that at every inspiratory act the dilated thorax exerts a suction-power upon them, assisting greatly the descent of blood through the jugular from the sinuses of the brain. This same fact makes a wound to vessels in this region very dangerous, as, in such a case, the air is usually drawn into the veins and the heart, and death results. The fascia has a tensor in the omo- hyoid muscle, which is invested by it and held in place by a process attached to the first rib. As the fascia stretches immediately over the pleurae, where it clothes the apices of the lungs behind the claviclcc, it was be- lieved by Bichet that the omo-hyoid, by its contraction, Pulmonary artery.- Pericardium. Fig. 1130.-A Transverse Section through the Lower Part of the Neck to Show the Arrangement of Cervical Fascia (diagrammatic). (From Treves.) a, Trapezius ; b, sterno-mastoid ; c, depressors of the hyoid bone ; d, platysma ; e, anterior spinal muscles; /, scalenus anticus ; g, carotid artery ; h, external jugular vein; i, posterior spinal muscles; T, trachea, with thyroid gland in front and oesophagus behind. Central Tendon. Fig. 1131.-Diagram showing the Continuity of the Visceral or Deep Layer of the Cervical Fascia with the Pericardium and Diaphragm. offering considerable resistance to suppurative action. Behind the spine (fascia nuchae) the intermuscular septa enclose considerable fat in their interstices, and this is the favorite seat of carbuncle. Laterally investments are sent to cover the great vessels of the neck, and as the muscles from the post-vertebral set detach themselves to go to the ribs (scaleni) or scapula (levator anguli scapula?), the fascia ensheaths them also, and passing down on the subclavian vessels and the brachial plexus, forms the axillary sheath, and joins the under surface of the costo- coracoid membrane. An injection of the space between the spine and the prevertebral fascia shows that fluids penetrate downward as far as the bifurcation of the trachea, that the tissues around the oesophagus are com- pletely infiltrated, and that outwardly they pass under the clavicle into the axillary space. Second, the visceral layer. The viscera of the neck in- clude the oesophagus, with its continuation of pharynx and mouth, the trachea, larynx, and thyroid gland. Over these a layer of fascia (lamina profunda) passes, attached above to the occipital bone, basis cranii, and pterygoid process as pharyngeal aponeurosis, forming the stylo- assisted to expel air from the upper part of the lungs. It is questionable whether this be of any importance. Any effusion between this layer and the pre vertebral fascia may pass downward into the posterior mediastinum, and as the connective tissue there is quite lax, it may push through and do considerable damage. Third, a shoulder girdle layer enclosing the external muscular mantle. This mantle is originally a broad sheet, which encloses the limb of the foetus as it buds out laterally from the trunk. It becomes differentiated, above, into trapezius and sterno-cleido-mastoid ; below into la- tissimus dorsi, deltoid, and pectoralis major, the shoul- der girdle developing transversely within it. In front there are no muscles belonging to this layer, but the mus- cles inserted upon the hyoid bone above and below, which are really a secondary visceral set, appear upon the sur- face. A layer of fascia (lamina superficialis) starts from the ligamentum nuchse behind, splits to enclose the tra- pezius, uniting again to cover over the posterior triangle of the neck ; then it splits again to receive the sterno-mas- toid, again reunites, and passing over the hyoid muscles, joins the similar sheet from the opposite side. It is a 35 Fascia. Fascia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. firm, close layer. Above, it is attached to the edge of the lower jaw, splitting to enclose the submaxillary gland ; below, there is a splitting just above the sternum, to re- ceive the anterior jugular veins. One sheet is attached in front and one behind the sternum. The sternal por- tion of the sterno-mastoid lies between these. It is at- tached to the external border of the clavicle and the spine a great resistance to pus finding its way outward ; when that does occur it penetrates along with the last inter- costal artery and nerve, or the hypogastric nerve, along a line from the last rib downward. The place shown in Fig. 1132, where the fascia splits to invest the abdominal muscles, is the point where it is usual to cut it to reach the colon or the kidney. Abdomen.-The external layer of deep fascia is derived, as just stated, from the lumbo-dorsalis fascia. Between adjoining muscle-sheets is the usual septum, which is also derived from that layer in the manner shown in Fig. 1132. These pass around in front and invest the rectus abdominis, meet- ing on the middle line to form a thick apo- neurotic layer, the linea alba. The invest- ment is somewhat different in the upper and the lower parts of the abdominal wall. Above (Fig. 1133 B) the sheath of the inter- nal oblique splits to enclose the rectus, and the aponeurosis of the transversalis passes behind. Below (Fig. 1133, A) everything passes in front except the delicate transver- salis fascia which constitutes the real limit- ing fascia of the whole group internally. This deficiency in the posterior wall of the rectus forms a curved edge with concavity downward, the semilunar fold of Douglas. It commences on a level with a line joining the anterior superior iliac spines. Above this, the fibres of the internal oblique and the transversalis take origin from fixed parts and are principally used in strong expulsive efforts ; below, they arise from movable parts and mainly aid in respiratory acts, pushing up the viscera from below. The fold of Douglas is, therefore, a more or less sharply defined boundary between the stronger, more energetically active region of the muscles and the weaker, more passive portion.3 In women who have borne many children, and consequently used the abdominal muscles much in strong expulsive eflforts, the fold is thicker and extends down farther.4 This interpretation is in strict accord with the laws of the formation of fascia, and seems more reasonable than that of Henle,5 who supposes the fascia here to be thinner, in order to accommodate the Fascia lumbo-dorsalis, posterior layer. Anterior layer with fascia transversalis. Middle layer. Latissimus dorsi. Serratus posticus inferior. Obliquus externus. Obliquus internus. Tranversalis. Iliac fascia. Vena cava inferior.' of the scapula. The stylo-maxillary ligament is a thick- ened portion extending from the styloid process to the angle of the jaw, between the parotid and submaxillary glands. The digastric muscle and its congener, the stylo- hyoid, may be said to act as its tensors in the upper part; and they thus effect a discharge of the secretion of the submaxillary gland. Below, the sterno-mastoid makes it tense, holding it forward toward the middle line. It is pierced above the clavicle by the external jugular on its way to the subclavian vein, and by numerous nerves and small vessels. The figure will show that it is continuous with the deeper fascia at certain points, as, for instance, in the posterior triangle and over the sheath of the great vessels. Abscesses between this layer and the one last mentioned do not often occur. Any effusion would penetrate over the great vessels and behind the sterno- mastoid into the supra-clavicu- lar fossa, and thence break through into the axilla. Back.-The trapezius, latissi- mus dorsi, and the rhomboidci have special coverings, but the most important of the invest- ments in this region is the one known as the fascia lumbo- dorsalis, which is attached on the one side to the spines of the dorsal, lumbar, and sacral ver- tebrae, on the other to the rib elements, viz., angles of ribs, transverse processes of lum- bar vertebrae, and the ilium, forming along the back a tubular space enclosing the erector spinae and deeper muscles (see Fig. 1132). Above, it passes into the fascia nuchae. Laterally, it becomes the external investment of the intercostal mus- cles above, and of the abdominal muscles below. It offers Peritoneum. Transversalis fascia. Transversalis muscle.. B Obliquus internus. Obliquus externus Peritoneum. Rectus. Linea alba. Transversalis fascia. Transversalis muscle. Obliquus internus. A Obliquus externus. Fig. 1133.-Arrangement of the Abdominal Fascia. A, above the fold of Douglas; B, below it. Rectus. Linea alba. deep epigastric artery and prevent its compression, or that of Retzius and Hyrtl,6 who think it is to accommodate the varying distention of the bladder. Gegenbaur1 has, however, pointed out that this area was occupied by the bladder in foetal life before the full development of the pelvis, the bladder being really developed as an extra- peritoneal viscus, within the body-wall. This transversalis 36 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fascia. Fascia. fascia, which has been mentioned, is a secondary structure which has developed by a thickening of the subperitoneal fascia is especially important, because of its relation to hernia. When the muscular tissue ends at the lower part of the abdominal wall, the several layers of fascia be- come condensed into a thickened cord which spans from one muscular insertion to the other. This is Poupart's ligament, certain reflections of which have received other names, the firm band attached along the ilio-pecti- neal line being called Gimbernat's ligament ; another variable band extending under the external ring to the opposite side, the triangular ligament. It is here that the spermatic cord in the male, or round ligament in the female, passes out (see Fig. 1134). The transversalis fascia being the innermost layer, becomes partly continuous in front with the fascia over the psoas and iliacus (iliac fascia), and partly joins the anterior portion of the sheath of the femoral vessels. Various portions of it have received different names. Where it passes under Poupart's ligament it is called the Fro. 1134.-The Outer Layers of Fascia of the Abdomen and Groin. a, b, The external oblique and its aponeurosis, crossing at c with the fellow of the opposite side, at d forming the pillars of the external ring; e, spermatic cord; /, g, suspensory ligament of the penis; A, Poupart's ligament. layer of connective tissue as a consequence of the erect position. Above, it blends with the fascia covering the diaphragm. Below, the arrangement of the abdominal Fig. 1136.-Diagram of a Section of the Pelvis, made on the Line marked B, B', Fig. 1135, and showing Part of the Diaphragm of the Pelvic Floor. (G. D. Thane, in Quain's Anatomy.) X a, Section of hip-bone behind the centre of the acetabulum ; b. bladder ; c, vesicula? semi- nales and vasa deferentia; d, rectum ; 1, obturator internus; 2. 2, the obturator fascia, in the lower part of which the obturator vessels and nerve are enclosed in a sheath ; 3, recto-vesical fascia: 4, its upper layer passing on to the bladder ; 5, its lower layer passing across in front of the rectum, and giving oil a process, 6, for the lateral invest- ment of the rectum; 7, levator ani (the dotted line on its external surface indicates the anal fascia, and the triangular space between this and 2 is the ischio-rectal space); 8, external sphincter; 9, 9, perito- neum, superposed upon the obturator fascia, the recto-vesical fascia, and the bladder. deep crural arch; where it covers over the internal ab- dominal ring, the infundibuliform fascia. The fascia of the posterior wall of the abdomen is known, where it covers the ilio-psoas muscle, as the iliac fascia. It follows the muscle and Poupart's ligament into the thigh, forming the posterior wall of the crural sheath. Pus arising from caries of the vertebrae usually runs down under this fascia into the leg, and points in the upper part of the thigh just outside the vessels. Perineum.-In order to an understanding of the perineal fascia, a few words as to the arrangement of the muscles are necessary. These are to be regarded as an apparatus not only for proper muscular func- tions, but for closing the outlet to the pelvic cavity, forming the floor on which, in the erect position, the main weight of the viscera rests. The pelvic cavity cop- tains the rectum, the bladder, and the internal genital organs, which must have their appropriate apertures, and the musculature and fascia must protect them also. The muscles are arranged, therefore, in two sets, which may be called the diaphragm of the pelvic floor, and the uro-genital diaphragm. The first is constituted by the levator ani and the coccygeus ; the second is in two layers from within outward: 1st, the constrictor urethrae and the levator urethrae, or muscle of Guthrie; 2d, the bulbo-cavernosus (accelerator urinae of male, sphincter vaginae of female), the ischio-cavernosus, and the trans- Fig. 1135.-Diagram of a Sagittal Section of the Male Pelvis, a Little to the Left of the Mesial Plane, to show the Arrangement of the Pelvic Fascia, and the Manner of closing the Inferior Outlet. (G. D. Thane, in Quain's Anatomy.) X /^. • a, a, Section of sacrum and coccyx ; b, section of pubis; c, bladder; d, prostate gland, above which are the vesicula seminalis and vas deferens cut obliquely ; e (near dotted line leading upward from A'), corpus spongiosum urethra;, covered by bulbo- cavernosus muscle; f. rectum : g, sphjpcter ani externus; x, levator ani; 1, anterior true ligament of the bladder ; 2, 2', sheath of prostate, forming in front the superior layer of subpubic fascia (triangular liga- ment), passing up behind between bladder and rectum to become the recto-vesical fascia ; 3, inferior layer of subpubic fascia (between it and the superior layer is seen Cowper's gland and the constrictor ure- thrae ); 4,4, peritoneum. The thick dotted line represents the level at which the recto-vesical fascia is reflected from the sides of the pelvis upon the bladder. The thinner lines A, A', and B, Bz, show where the sections represented in Figs. 1136 and 1137 are taken. 37 Fascia. Fasting. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. versus perinei. Each diaphragm and each layer has its appropriate fascia (Figs. 1135, 1136, and 1137). That lining the inner surface of the pelvic floor is known as the pelvic fascia, consisting of the obturator, the pyri- formis, and the recto-vesical (3 and 5, Fig. 1137; 2 and 3, Fig. 1136). The obturator and pyriformis fasciae are simply the perimysium of the muscles of the same name. From the inner surface of the former a thickened arch springs which gives origin to the recto-vesical fascia, the internal perimysium of the levator ani, but passing from it on to the prostate gland, rectum, and bladder, forming folds which are known as ligaments of those organs. It is continuous over the middle line, and closes in the pelvic outlet there. Processes from it invest the rectum, the prostate gland, and the vesiculae seminales in the male, and the vagina in the female. The levator ani has its external perimysium, a layer called the anal fascia (dotted line near 7, Fig. 1136). This lines the inner side of the ischio-rectal space. The deeper layer of the uro-genital diaphragm is en- closed between two layers of fascia, which are collectively known as the triangular ligament of the urethra or sub- pubic fascia, being stretched across under the subpubic arch. The superior (posterior) layer is a continuation of the anal fascia forward over" the subpubic outlet, prevented from pointing externally ; below it must come out upon the perineum, either in front, which is rarer, or behind. Any wound of the pelvic fascia (as in opera- tions on the urethra or bladder) is dangerous, because it opens up the subperitoneal tissue. The attachments of superficial fascia to the triangular ligament prevents effusions from passing outward upon the thighs, but allows them to pass upward upon the ab- domen. The fasciae of the limbs are treated in the different ar- ticles relating to the anatomy of those regions. See Arm, Axilla, Foot, Leg. Frank Baker. 1 Bardeleben : Muskel und Fascia, Jenaische Zeitschrift fur Natur- wissenschaften, vol. xv. 2 Sutton, J. B.: On the Nature of Ligaments, Jour. Anat, and Phys., London, xviii., 225; xix., 27, 245. 3 Solger, B.: Ueber die Bedeutung der Linea semicircularis Douglassi, Morpholog. Jahrbuch, Leipzig, 1885, xi„ 102. 4 Langer, C.: Lehrbuch der Syst. und Topogr. Anatomie, p. 131. Wien, 1885. 8 Henle : Muskellehre, 2d ed., p. 71. 6 Hyrtl: Topographische Anatomie. 7th ed., p. 740. 7 Gegenbaur : Anatomie der Menschen, 1st ed., p. 369. FASTING. Syn., abstinence, inedia, jejunum, inan- ition. This term signifies the partial or complete absti- nence from the normal quantity of food. It may include the absence of both liquid and solid food, or of the latter while water only is ingested. This process, when carried out to a fatal result, constitutes starvation, which for convenience is treated in the present con- nection. The somewhat cumbersome word inanitia- tion has been used to refer to the condition of the animal which is progressing toward inanition. The fasting animal carries on its vital functions, and whatever muscular action it may perform, not, as normally, by the conversion of food supplied by its in- gesta, but at the expense of its own tissues. The physiol- ogy of fasting, which has not as yet been thoroughly elu- cidated, may be studied to best advantage by experiments upon the lower animals, for, in addition to the ability to control conditions, we thus eliminate psychical influences, and those other disorders which complicate the problem in those instances where human beings undergo starva- tion while under the possibility of medical observation. Loss of Weight.-This is the earliest and most ob- vious symptom of the fasting animal. The daily loss is not, however, constant. It is greatest during the first day of the fast. Then it diminishes, and after a few days becomes a nearly constant quantity until the last days of life, when it again increases, but not usually to the amount of the first day. The proportional daily loss-that is, the loss in grammes per kilogramme of the animal's weight- is readily obtained fronf the absolute daily loss, the weight of the animal being known. But it must be remembered that the latter factor must be ascertained for each day in question, and must not be taken to be the original weight of the animal. Thus, for instance, a constant total daily loss of two hundred grammes in an animal originally weighing four kilogrammes, would at first mean a pro- portional daily loss of fifty grammes per kilogramme, but would, with every successive day, represent a larger pro- portional loss. The mean daily loss may be obtained by dividing the total loss in a given number of days by that number ; but of course it must be remembered, as said above, that the actual daily loss is not so constant. A mean daily proportional loss can, in the same way, be computed. This figure varies with the different species of the ani- mal kingdom. It is, as a rule, higher for the smaller an- imals. The horse loses less daily per kilogramme than the dog, and the dog less than the cat. This fact is in accord with the greater nutritive activity of the small an- imals. That this greater activity is not due to increased heat-production, is shown by the fact that these small animals consume more oxygen per unit of time and weight, even when placed in a medium of the tempera- ture of their bodies. An adult animal loses less daily, per kilogramme, than a young animal of the same species. The daily mean proportional loss varies widely, being ten per cent, of the weight in the young turtle, and only 0.7 per cent, in the horse and dog. Fig. 1137.-Diagram of a Frontal Section of the Pelvis, made on the Line A, A', Fig. 1135, showing the Uro-genital Diaphragm. (G. D. Thane, in Quain's Anatomy.) X K- a, Section of hip-bone passing through the centre of the acetabulum ; b, section of the ramus of the ischium ; c, bladder, from which the urethra is continued downward ; d, pros- tate gland; e, corpus spongiosum urethrae, covered by the bulbo-cav- ernosi muscles ; f, crus penis, covered with the ischio-cavernosus mus- cle ; 1, obturator membrane closing the obturator foramen of the pel- vis; 2, obturator internus muscle; 3, 3, obturator fascia ; 4, levator ani muscle, the fat between this and 3 being in an extension forward of the ischio-rectal space; 5, recto-vesical fascia, dividing into an as- cending layer attached to the bladder, and a descending layer forming the sheath of the prostate ; between the two are the veins of the pros- tatic plexus; 6, superior, and 7, inferior layer of the subpubic fascia (triangular ligament), between which is the deeper layer of the uro- genital diaphragm; 8, the constrictor urethrae muscle, embedded in which, close to the ischium, are the pudic vessels and dorsal nerve of the penis. For clearness the urethra is shown as laid open through the whole of the prostatic and membranous, and the commencement of the spongy portions, whereasthe lower halt of the prostatic portion would naturally be a little behind the plane of section. uniting at the sides with the obturator fascia. The in- ferior is firmly attached to the pelvic rami and connected below with the posterior layer (Fig. 1135, 2 and 3). The superficial uro-genital layer is enclosed between the fascia last described and a structure named the super- ficial perineal fascia-and rather unfortunately so, as it has nothing to do with the real superficial areolar fascia, which is quite well developed in the region. This fascia is continuous with the anterior layer of the triangular ligament where the muscular layer ends, viz., behind the transversus perinei, and is attached like it to the pelvic rami. The application of this arrangement to the retention of fluids may be readily seen. The pelvic fascia completely encloses the cavity. A pelvic abscess above it will be 38 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fascia. Fasting. If the total weight-loss during a period of starvation bore a constant ratio to the original body weight, we could easily compute, knowing the daily proportional loss, the length of time that life could last. It is, however, only true that the amount of the daily proportional loss, and the number of days that life can endure, are inversely pro- portional. Chossat stated that the total proportional weight-loss of an animal dy ing of inanition was forty per cent, of the initial weight. But further experimentshave shown that a fat animal may lose fifty ger cent, of its weight, while a lean one can lose only thirty-five per cent. Young animals in a growing stage have been ob- served to lose only thirty per cent, before they succumb- ed. Thus we have two reasons why young animals can endure fasting but a short time, namely, that their daily proportional loss is a maximum, and the total propor- tional loss of which they are capable a minimum. The reason of this last-mentioned fact seems to be that the demands of the growing organism have used up force which might otherwise be applied to the nutritive reserve of the body. The proportion of the entire weight-loss which falls upon the different structures of the body varies somewhat with different experimenters. Voit found that a rather lean cat, which died on the thirteenth day of its fast, lost 734 Gm. of solid material, of which 248.8 were fat and 118.2 muscle. The following table shows the most im- portant facts of the loss of several of the organs in pro- portion to their original weight, and in proportion to the entire weight-loss of the animal : night), in the fasting animal the mean noon temperature (prior to the last day) was 41.70°, and the mean midnight temperature 38.42°, giving an average diurnal range of 3.28° (four times as great as normal). The average loss of temperature at noon was only 0.52°, while that at mid- night was 3.06°. That is to say, the loss of tempera- ture at midnight was six times as great as at noon. Moreover, the diminution of temperature was progressive from the beginning to the end, as was also the amount of the daily oscillation. This latter was 1.9° the first day, and 4.3° the last day but one. The mean daily refrigeration during this period was 0.3°. As the animal grows weaker, the period of minimum (midnight) temperature begins earlier and lasts longer. On the final day of starvation there is a great exaggera- tion in degree and in duration of tins midnight refrigera- tion. Chossat gives it as a mean, in a number of pigeons, as 14°. In other words, the reduction of the animal heat is forty-seven times as great on the last day of life as on the average of the previous days. This final plunge of the temperature is observed in all cases of starvation, and there seems little reason to doubt that it is the immediate cause of the fatal result. In the mammalia there was not that regular daily loss of heat that was observed in the pigeons. . The temperature fell for the first day or two, but then nearly regained the normal, and so remained until the last day, when it rapidly sank. Chossat found that when this fall occurred, the resulting torpor, the precursor of death, could be dis- pelled by raising the temperature of the surrounding medium, and that sufficient vitality was thus imparted to allow of the taking of food, and consequent perfect res- toration of the animals. The nearly complete mainten- ance of temperature of warm-blooded animals for several successive days does not prove that the heat production was equal to the normal, for there is probably a lessen- ing of the heat expenditure. Senator found that with dogs, on the second day of the fast, when the rectal tem- perature was not sensibly lowered, the heat production was nevertheless diminished about ten per cent. Temperature studies in fasting men, of course, have been rare. Jurgensen found that in a healthy man, fast- ing for sixty-two hours, the rectal temperature, taken every ten' minutes during the first thirty-eight hours, showed a slight prolongation of the period of diurnal minimum, with but very slight reduction (0.1° to 0.2°) in the reading of the minimal temperature. But after that time there was a prolongation of the period of the maxi- mal temperature, which Jurgensen accounted for by sup- posing that the substance of the consumed body set free more heat than the materials metabolized under ordin- ary circumstances. Respiration.--The frequency of the respirations diminishes during fasting to four-fifths, or during the last day even to three-fifths, of the normal rate. Some- times, however, just before death the breathing becomes hurried, shallow, and panting. The quantity of carbonic acid exhaled, which normally exceeds that of the oxy- gen taken in in the proportion of about five pounds of carbonic oxide to four pounds of oxygen, becomes rela- tively smaller during fasting, and may even be absolutely less than the oxygen absorbed. Circulation.-No very constant effects have been noted in this connection, further than a general tendency to increase in the rate of the pulse accompanying exhaus- tion. One observer (Strelzoff) noted an increase in the blood-pressure, which he ascribes to an atrophy and ob- literation of a large number of the capillaries. Though this latter event occurs in the stomach and small intestine, and perhaps in other parts of the body, it probably is not sufficient to cause any general rise of blood-pressure. The mass of the blood proportionally to the total weight, as above indicated, seems not to suffer very great reduc- tion. Panum found no diminution in the number of blood-corpuscles when the animal (a dog) was allowed all the water desired. On the other hand, Malassez found that in the guinea-pig the corpuscles were reduced on the fifth day from 4,156,000 per cubic millimetre to 3,444, 000. In a chicken he observed a reduction, in an equal Organs and tissues. Loss in grammes per 100 Gm. of organ. Loss in Gm. of each organ per 100 Gm. of loss of whole ani- mal. Fresh. Dry. Osseous system.... 13.9 13.9 5.4 Muscular system... 30.5 30.2 42.2 Liver 53.7 56.6 4.8 Kidneys 25.9 21.3 0.6 Spleen 16.7 63.1 0.6 Pancreas 17.0 17.0 0.1 Lungs 17.7 18.0 0.3 Heart 2.6 2.6 0.02 Bram and cord 3.2 0.0 0.1 Fat 97.0 97.0 26.2 Blood 27.0 17.6 3.7 It should be said that Bidder and Schmidt, W'hose ex- periments were made upon a very fat cat, found the mus- cular system to lose sixty-seven per cent, of its original weight, the brain and cord 37.6 phr cent., the blood nine- ty-four per cent., and the fat eighty per cent. Some of these discrepancies seem irreconcilable. Others, like the fat-loss, depend on different conditions in the respective animals. That of the latter observers had so much adi- pose tissue that, though he lived seventeen days, he had consumed only eighty per cent, of his fat, while the cat experimented on byVoit had used up ninety-seven per cent, of his in thirteen days. What is substantially agreed is that the fatty tissue is the heaviest sufferer in the fasting animal; that certain glandular organs, principally those whose metabolic ac- tivity is greatest, come next, the average for all these be- ing greater than for the body at large. The loss of the voluntary muscular system is about in the same pro- portion as that of the whole body, as is also that of the digestive tube (thirty per cent.-Voit). Those structures which are most essential to the life of the organism are spared longest. The heart muscle and the central ner- vous system lose practically nothing, and though their metabolic activity is high, they are sustained at the ex- pense of less important tissues. Temperature.-The experiments of Chossat, upon pigeons, show a remarkable and continuous effect upon temperature from the beginning to the end of a period of starvation. This shows itself at first in an increase of the diurnal range, owing to a lowering of the midnight tem- perature. Whereas, in the healthy pigeon, the daily oscil- lation isonly 0.76° C. (from 42.22° at noon, to 41.48° at mid- 39 Fasting. Fasting. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. time, from 3,380,000 to 2,912,000. The diminution in both the last cases fell chiefly upon the latter days of the fast. The density of the blood was found by Frerichs and others to diminish during a fast. In a dog, in which be- fore the fast it was 1058.09, on the fourth day of the fast it was 1051.11, and on the twelfth 1037.69. On the other hand, in Voit's cat the density of the blood in- creased. Urinary Secretion.-The amount of the urine dur- ing the first day of the fast is not usually affected. After that time, however, it gradually grows less and less. The specific gravity has been found during this period to range between 1.025 and 1.034. The urea diminishes in the carnivora with every suc- cessive day of fasting, but never entirely ceases. The extent of the diminution depends upon the richness of the food in nitrogenous elements prior to the fast. The herbivora, on the other hand, which during a fast be- come carnivora, experience at that time a change in the character of the urine, which becomes denser, higher colored, acid, and richer in urea. At the end of life the urea diminishes rapidly. In guinea-pigs it has been found that the urine taken from the bladder after death had only one-eighth as much urea as that passed the pre- ceding day. The urea forming a measure of the decomposition of nitrogenous materials in the body, and nitrogenous in- gesta (with all other) having been stopped in the fasting animal, the daily secretion of urea affords a means of estimating the amount of nitrogenous matter consumed each day of the fast. Physiologists have been divided over the question of a luxus consumption, a term applied by Bidder and Schmidt to the metabolism of certain surplus proteid material which, though inside the body, did not form a component part of any of its tissues, but constituted a kind of reservoir of force upon which the organism could draw. Not to enter upon this question, however, we will simply say that it is found that the excretion of urea bears no fixed proportion, at any period of the fast, to the total weight of the animal, although after the first three or four days it tends to a uniformity for several days. If the animal possesses an abundance of fat there is a smaller consumption of proteids during fasting. This diminution of the urea is very noticeable in animals that have been freely fed, previously to begin- ning the fast, on fatty food. In the lean cat of Voit, already referred to, the urea was less for several days than in the fat animal of Bidder and Schmidt; but at the end of life (twelfth and thirteenth days), there was a rise of fifty per cent, in the urea excreted over that of the previous day, while the other animal showed no such increase even up to its death, on the seventeenth day. The former animal was found at the autopsy to have used up all his fat-tissues, and the final rise in the urea was due to the metabolism falling entirely upon albu- minoid material. Of the other constituents of the urine the phosphates and sulphates undergo a diminution parallel to that of the urea. The chlorides also diminish, but more rapidly from the first. Albumen has been noted in some cases, but is not constant. Faeces.-There is usually an evacuation from the bowels on the first day of the fasting, containing the residue from the preceding alimentation. After this the faeces are scanty, often none being passed for many days. They consist, after the second day, almost entirely of bile. Scarcely any gastric or pancreatic juice is formed. Sometimes a colliquative diarrhoea sets in on the last day of life. In the foregoing remarks we have had reference to a total deprivation, for a longer or shorter period of time, of food. It is now necessary to examine briefly the ef- fects when, although a completely nutritious diet is wanting, certain partial nutriments are allowed. As is well known, the proteid foods, though uneconomical in the quantity required, and in the tax imposed on the digestive organs, are of themselves competent to support life. Not so, however, with the non-proteid albuminoids, gelatin and chondrin, or the non-nitrogenous fats and sugars. Yet all these classes of food will spare the de- struction of a certain amount of the albuminoid matters of the body, and thereby prolong life. Gelatine is the most effective of these palliatives of starvation. Voit estimates that 100 Gm. of dry gelatine economize 50 Gm. of dry albumen. If fat be given with plenty of water, not only some of the fat-tissue of the animal is spared, but also some of the albuminoid, and there is a slight increase in the carbonic acid elimination over that observed in an absolute fast. Sugar also (if water be al- lowed) prolongs life, and under its administration the carbonic acid elimination is greater than when fat is al- lowed. We come now to the influence exerted by the allowance or withholding of water upon starving animals. Water allowed and Solids withheld.-The most important fact in this connection is that the administra- tion of a moderate amount of water materially diminishes the loss of body-weight and prolongs life to a corre- sponding degree. The elimination by the kidneys, and especially that by the lungs and skin, is increased by the drinking of water, but not to an extent equal to the water consumed. There is also less urea excreted when water is drunk. Contrary, however, to what might perhaps be expected from what has just been said, the fasting animal requires a less quantity of water than the one which has plenty of food. The reason of this is that a considerable quantity of water is set free and put at the disposal of the organ- ism by the destruction of tissue. Muscular substance contains 3.15 parts of water for each part of dry sub- stance. In a dog experimented upon by Pettenkofer and Voit there was a loss of 175 Gm. of albuminoid matter. This would set free 551.25 Gm. of water. The water eliminated was found to be, as a matter of fact, less than this amount, being only about 506.1 Gm., and in this case the animal, which was allowed to drink freely, took only 33 Gm. The ingestion of water, then, while postponing the fatal result of a fast, produces no important change in the mode of death from that occurring in simple in- anition. Solids allowed and Water withheld.-When an animal is deprived entirely of water and of foods contain- ing any considerable amount of moisture, starvation takes place almost as it does when solids also are withheld, for the animal soon ceases to eat. Two pigeons on which this experiment was tried by C. Falck and Scheffer, gave as a mean the following figures. At first, being given enough water and wheat to maintain a uniform weight, they took per 1,000 Gm. of body-weight, 103 Gm. of water and 85.5 Gm. of wheat, a total of 188.5 Gm., against which their total excreta were 187 Gm. For the next four days water was withheld and wheat allowed ad libitum. Of the latter they took only 25.5 Gm. per day, and their total daily excreta weighed 79.5 Gm. Again, for eight days they received all the water and wheat they wished. This amounted in the first day to 442 Gm. (342 of water and 80 of wheat). The excreta on this day were 180.5 Gm. The average total ingestion for the first four days was 248.5 Gm. (water 148.5 Gm., wheat 100 Gm.), the excreta 201 Gm. On the next four days the ingesta were 176 Gm. (water 91 Gm., wheat 85 Gm.); the excreta 176 Gm. They had thus regained their former nutritional equilib- rium. They were then again deprived of water until their death, which happened on the thirteenth day. The ingestion of wheat fell to 19 Gm., and the excreta were 56 Gm. The mean daily loss of weight in pigeons so treated is from 3.5 to five per cent, of their original weight, and the duration of life from nine to thirteen days. The total loss is from thirty-five to forty-nine per cent.-not materially different from what occurs where solids are withheld. Duration of Life during Fast.-As has been seen above, this has wide variations, depending as it does upon many factors, as the temperature of the surround- ing medium, the quantity of fat possessed by the animal, etc. Perhaps an average would be from eight to ten days, during which the animal loses say forty per cent. 40 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fasting. Fasting. of his weight. But, as we shall see in speaking of fast- ing in the human subject, this length of time may be enormously exceeded, as indeed it frequently is in ani mals. In the classical case of the fasting pig, the im prisoned animal, which was enormously fat, was released alive at the end of one hundred and sixty days, having fallen away in weight from one hundred and sixty pounds to forty pounds. In Man.-Inanition in man is usually more or less in- complete, but in a partial form it is not very uncommon. The insane frequently refuse food, and inanition may be- come quite advanced before the patients are put into an asylum, where, of course, they are fed, if necessary, forcibly. One such case is reported where a young man took nothing but water flavored with orange juice for sixty-one days. At that time he was seen by a physician and induced to eat, but, perhaps through injudicious treatment, he died on* the eleventh day afterward . Hysterical patients are particularly given to fasting, and reports of such cases often get into the daily press. Critical investigation usually develops the fact that there has been a good deal of deception of the attendants ; but it is undeniable that such patients do subsist for long periods on an incredibly small amount of nutriment. In one notable case investigated by Charcot, the urine and the vomitus showed, on a most careful analysis, that the daily excretion of urea was only five grammes. In a man, during complete abstinence, it was found to be not less than ten or twelve grammes. Many instances are on record where hysterical women have dropped off one arti- cle of food after another, and finally reached a point when, under perhaps one-tenth the normal amount of food, they pass a merely vegetative existence, lying on the back, obstinately constipated, with dry, rough skin, saying nothing, and, perhaps, only by a turn of the eye after a moving attendant, showing any appreciation of their surroundings. If they have practised deception they will sometimes, when put under strict surveillance, die of inanition without taking food. In the case of the so-called " Welsh fasting girl," who was reported to have lived without food of any kind for weeks, death occurred in eight days after she was placed under strict watch. Inanition sometimes declares itself during the period of convalescence from acute fevers. There has been a large- amount of tissue waste, with perhaps a small amount of nutriment taken. The importance of maintaining the nutrition in fevers is better recognized now than formerly, and probably extreme inanition is correspondingly rarer. But when the amount of food supplied has for some time been inadequate to the combustion maintained, we may expect to find the convalescence impaired by some of the symptoms of inanition. Patients suffering from stricture of the oesophagus and from cancerous affections causing obstruction of the upper alimentary tract, sometimes die of inanition, though the re- cent development of the surgery of the stomach has much diminished the frequency of that event. Still, inanition plays a part in the symptomatology of many cases of can- cerous disease, its effects being usually associated more or less indistinguishably with those of cachexia. In a case reported a few years since in The Lancet (November 27,1880), a patient having an oesophageal stricture was for ten months able to take nothing but milk. During this time he fell away in weight from one hundred and twenty to sixty pounds. For the next seven months he could swallow neither fluids nor solids, and was kept alive by rectal alimentation. He was able to walk about and his intellect remained unimpaired till three days be- fore his death. At death his weight was forty pounds. The new-born are subject to a form of inanition due to incapacity to digest and assimilate the food ingested. Here a diarrhoea frequently replaces the constipation which, as we have seen, is a usual attendant of starva- tion. There is progressive emaciation, which may in- crease to the extent of thirty or even forty per cent, of the original weight. The skin wrinkles and the feat- ures take on an old look. The skin inflames from the contact of irritating discharges or from pressure. Often pustules of ecthyma appear. The chest is deformed ; there is a sinking just above the epigastrium, while the xyphoid cartilage is pressed forward by the liver. The bones of the cranium overlap at the sutures and the fon- tanelle is depressed. The belly is flattened; the stools fetid. A peculiar odor, almost pathognomonic of starvation, ex- hales from the mouth and from the skin. The appetite at first is ravenous and the child calls for the breast con- stantly ; later the appetite fails. The pulse and temper- ature lower progressively as the inanition increases; occa- sional transient elevations of temperature may, however, occur. The weight-loss averages, in a child of three kilogrammes, perhaps one hundred grammes daily, and the duration of life may be eight or nine days. There is some reason to believe that robust infants succumb to in- anition quicker than weaker ones, perhaps because the latter require a less amount of force-production for their daily needs. Clinical Observations of Simple Fasting in the Human Subject.-Few experiments, naturally, have been made upon human beings, and such as have been possible from the willingness of individuals to subject themselves to deprivation of food, have, unfortunately, been almost entirely devoid of scientific value. One is alluded to above under the subject of temperature. In the summer of 1880, a man named Tanner accomplished, as was claimed, a fast of forty days in New York. For the first two weeks he was not watched by any regular physician, but after that time one or more physicians re- mained with him constantly, and there seems little reason to doubt that he did actually keep the fast as represented, though there was an unfortunate lack of scientific obser- vation of the phenomena presented. It being warm weather, there was comparatively little demand for heat- production. At the sixteenth day the man began to drink water, which was attended with marked improve- ment in his condition. The total loss of weight was thirty-two pounds. Toward the latter part of the time there was considerable nausea, ending in vomiting of bili- ary matter, mucus, epithelium, and a few blood-corpus- cles. There were very troublesome tympanites and ob- stipation after the first day. There was mental irritabil- ity, but no delirium. During the first part of the time he walked about and rode out daily, but later spent much of his time lying on a cot covered with blankets. One estimate of the urea gave on the first day twenty-nine grammes, on the fifth day eighteen grammes, on the eighteenth day fourteen grammes. Famine and siege, which in years past have carried off multitudes of human beings by starvation, are no longer, it is to be hoped, capable of causing such destruction, at least in civilized countries. Shipwreck, however, remains as a not infrequent cause of starvation, under varying conditions as to heat, moisture, etc. Medical observa- tions are not wanting upon the condition of men reclaimed at various degrees of inanition. The members of the Lady Franklin Bay expedition, under command of Lieu- tenant Greely, passed the winter of 1883-84 at lat. 78° 45' N., long. 74 15' W. From November 1st to March 1st, their daily ration was 14.88 ounces of solid food, the regu- lar army ration being 46 ounces. From March 1st to May 12th, the daily ration was ten ounces of bread and meat, with one to three ounces of shrimps. From May 12th to June 22d, there was no food but a few shrimps, reindeer moss, and black lichen scraped from the rocks. There was water, brackish in quality. The temperature of the surrounding medium was 5° to 10° F. There was no arti- ficial warmth. The men, in general, slept much of the time (sixteen to eighteen hours daily), approximating a condition of hibernation. There was not much pain, even after going several days without food. It was only after the ingestion of food that the craving became great. Con- stipation was excessive ; the intervals between the stools were eight to ten and even sixteen days. The men were obliged to dig out the hardened faeces with their fingers- the abdominal muscles being too weak to extrude them- and often fainted after evacuating the bowels. The deaths occurred seemingly from pericardial dropsy. There was oedema of the feet and face, then a short spasm of praecordial pain, and a slight general convulsion 41 Fasting. Fats. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. followed by death. The party consisted of twenty-five men; one died in January, of scurvy; sixteen died between March 1st and June 22d, when the survivors were rescued. The medical report showed the condition at that time to be as follows. (The report of one is given which is closely representative of all.) The patient fainted and vomited on first being removed. A sickly, offensive odor, as of stale urine, was emitted from the body, which was greatly emaciated, with skin hanging from the limbs in flaps. Weight one hundred and twenty pounds, the nor- mal weight being one hundred and sixty-eight. Mind excitable and irritable, at times almost irrational. Loss of memory, attended later by amnesic aphasia. At first very talkative. No pain. Tongue dry and cracked, ab- domen empty, and lying almost in contact with vertebral column ; had had no stool for six days ; ravenously hun- gry. Pulse fifty-two, soft, compressible. Blowing mur- mur over base of heart in systole. Respirations twelve per minute. Temperature (under tongue) 97.2°. No specimen of urine obtainable. Inability to move or stand without support. No sleep. Soreness and pain were felt in the muscles. In the next few days there were alvine dejections, small, dark, and highly offensive, and showing diminu- tion of bile. The skin became jaundiced for several days. The urine, normal in amount, was highly albuminous, and so continued for several days. No casts. Examina- tion of the blood showed marked increase of white cor- puscles (one to twenty red). The red corpuscles showed little tendency to cohere or to run into rouleaux. They lacked their distinctive bi-concave disk shape. On the third day there were three or four hours of natural sleep. The pulse and temperature gradually rose. The anaemic murmurs continued for some time, as did the albuminu- ria. After a week the patient had gained nine and a half pounds, and was able to sit up. The appetite was still voracious. The mental condition was tranquil, and the amnesic aphasia disappearing. In six weeks the normal weight had been regained. The diagnosis of inanition admits of no doubt except in cases where it is complicated with other conditions. Yet it is just here that the diagnosis is sometimes of most importance, as, for instance, in the convalescence from acute fevers, where the success of the treatment depends on recognition of this element. It is first important to bear in mind that inanition is liable to occur whenever the supply of nutrient matter to the body has been inter- rupted. In infants, as has often been remarked, most of the symptoms of inflammatory disease of the meninges may show themselves as the result of simple starvation. In fever convalescents there is sometimes delirium with headache, dimness of sight, and hallucinations. This condition has been mistaken for meningitis. But the headache in inanition is usually less severe, and the deli- rium, which probably corresponds to a condition of cere- bral anaemia, is generally, though not always, of a calmer type. Still the hallucinations which result from it may lead to suicidal or homicidal attempts. One important point is, that the temperature is usually normal or sub- normal, while in most other forms of delirium, save in light cases due to alcohol, it is elevated. The diagnosis of delirium due to inanition depends not so much on any peculiarity in the character of the delirium as upon the complexus of symptoms, the opportunity for starvation to have occurred, and the low temperature. Sometimes vomiting sets in during inanition, a fact which should be borne in mind, in order that there may be no cessation of the nourishment on account of a mis- apprehension as to the nature of the vomiting. The food must be made as easy of digestion as possible, and if re- jected, rectal alimentation must be used as a temporary expedient. There is nothing in the character of the vom- iting which is distinctive evidence of its source being in starvation. But, as with the more common symptoms just referred to, its nature must be diagnosticated from the other circumstances. Of course, vomiting may itself be the cause of inanition in cases of structural or func- tional disease of the stomach, but here we shall have a history of vomiting having preceded the excessive ema- ciation, instead of having followed it. Treatment.-Much care is required, in the dietetic treatment of persons who have been subjected to starva- tion, that the nourishment be given in small quantities, and that the ravenous appetite of the patient be not fol- lowed as an indication of the amount of food required. In extreme cases some stimulant is often required at first on account of the great reduction of temperature; exter- nal heat should be freely applied. Meat seems to be the article best adapted to the resumption of long suspended nutrition. Scraped raw beef is one of the most valuable foods, and should be given in teaspoonful doses, flavored, every hour or half-hour. The fluid preparations of beef are also very useful. Milk may be given in alternation with these. From these beginnings the diet may be built up in the usual way. When inanition has been due to some disease not necessarily fatal, the same method of feeding may be relied upon to restore to health ; but, of course, in cancerous and other destructive cases the treatment of the element of inanition is greatly circum- scribed. Rectal alimentation should, however, always be maintained as long as possible. A word should be added as to the use of fasting as a therapeutic measure, which formerly had more adherents than now, and was dignified with the name cura famis. With the increasing belief in the importance of maintain- ing nutrition for the sake of all vital processes, its appli- cation has become more and more limited. Its chief value is in the treatment of acute disorders of digestion, where the temporary withdrawal of food gives the organs a chance to obtain physiological rest. Charles F. Withington. FATS AND FATTY SUBSTANCES. The fats are ethers of the acids of the series CnH2nO2., and CnH2n_a O2, with glycerin. They are found in varying quantities in all parts of the animal organism, from which they can be extracted by simple processes. Fats vary very greatly in consistence. At high temperatures they are de- composed into combustible gases and acrolein vapors. Fats, when perfectly pure, are usually colorless, and without taste or smell, and contain very little free fatty acid ; but after standing exposed to the air the propor- tion of the latter is considerably increased. All fats are insoluble in water, and dissolve with difficulty in alcohol, but more readily in ether, benzine, chloroform, carbon disulphide, and aniline. They are emulsified by shaking, when melted, with -water. When treated with super- heated steam they split up into their component acid and glycerin ; the same result is obtained by the use of strong alkalies or the pancreatic ferment. Among the fats, using the term in a broader sense, are certain other substances which resemble the true fats in that they may be saponified, since they contain a fatty acid. They do not, however, yield glycerin, but certain monobasic alcohols. Thus, the waxes and spermaceti are ethers of the homologues of ethyl alcohol, while the fat of sheeps' wool are ethers of cholesterin and isocholes- terin. Constituents of the Fats.-Alcohols.-Glycerin : C3H5(OH)3, the basis of most fats, is obtained by the de- composition of tallow with water and a little lime, and concentrating by careful evaporation, and purifying by distillation with superheated steam. It has also been produced synthetically. Glycerin, CHa(OH).CH(OH).CH2(OH) is a very viscid fluid, transparent, colorless, of a sweetish taste, crystal- lizing when standing very long at a temperature of 0° C. (32° F.). It distills over at 290° C. (554° F.) undecomposed. If it contains salts it decomposes partially into water and acrolein, CH2(OH).CH(OH)CH2(OH) = CH2 CH.COH + 2H2O. By careful oxidation with nitric acid it yields glyceric acid, CH2(OH).CH(OH).CO.OH. At ordinary temperatures, with concentrated nitro-sulphuric acid, it yields nitro-glycerin, C3II6(O.NO2)3. With concentrated sulphuric acid it combines to form sulphoglyceric acid, and a similar combination may be produced with phos- phoric acid. 42 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fasting. Fats. Heated with fatty acids to 200° (392° F.) it forms ethers with them, e.g., with acetic acid the etherification may be thus represented : C3H5(OH)3 + CH3.CO.O1I = C3H6(OH.)2.O.CO.CH3 (Monacetin) 4- H2O ; and by heating'with more acid, diacetin, C3H6(OH)(O.CO.CH3)2 ; and with still more, C3H5(O.CO.CH3)3 triacetin. The natural fats correspond to the latter, e.g., C8HB(O. CieH3iO)3, tripalmitin, but they are always simple, that is, there is never a mixture of two or more different acid radicals. Cetylic alcohol, CibH33.OH. As the ether of palmitic acid, cetylic alcohol forms the principal part of sperma- ceti ; it is found free in the rump glands of birds. It crystallizes in shining lamina;, insoluble in water, but dissolves rather freely in alcohol and ether ; melts at 50° (122° F.), and distils at 344° C. When oxidized with nitric acid it yields palmitic acid, Ci6H32O2. Cerylic alcohol, C27HBBOH. The ether of cerotic acid with this alcohol constitutes the principal part of Chinese wax. It forms a crystalline, wax-like mass, insoluble in water, but dissolving in alcohol, ether, and benzol, and melting at 79° C. (174.2° F.). Myricylic alcohol, C3oHh.OH. Is found as the ether of palmitic acid in beeswax. It crystallizes in small needles, insoluble in water, but soluble in alcohol and ether, though not readily. The melting-point is 85°. Cholesterin and isocholesterin. Both these isomeric bodies occur partly free and partly as ethers in the wool- fat (woolschweisse) of sheep. Cholesterin is described in the article on the oils. Isocholesterin, C28H41.OH, separates from solution in aceton and ether, in fine transparent needles ; from alco- hol, in gelatinous masses or whitish flakes. It melts at 137° to 138° C., and turns the plane of polarization to the right [a] j - Ca. 4- 59.8°. The ethers of cholesterin and of isocholesterin, as existing in wool-fat, have not yet been obtained pure. The Different Fats treated according to their Respective Sources.-1. Solid Glycerin Fats.-Human- fat is of a yellow color, fluid at 20° to 25° (68° to 77° F.), solid at 12° to 15° (53.6° to 59° F.), contains the glycer- ides of oleic and palmitic acids, and in smaller proportion that of stearic acid (Heintz). According to Langer, the fat of the new-born contains more palmitic and stearic, and less oleic acid. Langer and Lerch found in it also minute quantities of butyric and caproic acids, but noth- ing resembling cetylic alcohol. . Hog's fat melts at 40.5° (104.9° F.), but that of the kid- ney of this animal at 30° (86° F.); it is white in color, and contains the glycerides of palmitic, oleic, and stearic acids. Goose-fat is of a whitish color, melts at 24° to 26° (75.2° to 78.8" F.), and contains the glycerides of oleic, stearic, palmitic, butyric, and caproic acids. Dog's fat is of a dull white color, with a consistence like that of goose-fat, and begins to melt at 22.5° (72.5°F.). Fox-fat, much like the former; begins to melt at 27° (80.6° F.), and becomes entirely fluid at 54° (129.2° F.). Elephant-fat is of a yellowish-white color, soft, and melts at 28° (82.4° F.). Mutton-tallow is white in color, very firm in consist- ence, and melts at 50° (122° F.); it consists chiefly of tri- stearin, tripalmitin, and a little triolein. Camel-fat, from the hump of the animal, is yellowish- white, rather soft in consistence, and begins to melt at 22.5° (72.5° F.). Ox-fat is of a pale yellowish or whitish color, melts at 47° (116. 6° F.), and solidifies at 37° (98.6° F.). As com- pared ■with mutton-tallow, it contains somewhat less tri- stearin, more tri palmitin, and about the same quantity of triolein. Calves' fat is white, less firm than ox-fat, and begins to melt at 52° (125.6° F.). Pheasant-fat is yellow in color, and becomes liquefied at 45° (113° F.). Jaguar-fat is yellow in color, of a very unpleasant odor, and becomes nearly hard at 29.5° (85.1° F.). Horse-fat is of a dull white color, of the consistence of thick turpentine, and begins to melt at 30° (86° F.). The fat of certain parts of the body is more solid than hog's lard, white, and begins to melt at 32° (89.6° F.). Hare's fat is a yellow, viscid fluid, which dries when exposed to the air ; it contains volatile acids, and begins to melt at 26° (78.8° F.). Badger-fat is yellowish-white, oily at ordinary tempera- tures, and contains valerianic, caproic, and caprylic acids. Sea-tortoise fat contains no stearin, but only palmitin and olein. Cantharides-fat contains stearin, palmitin, and olein; is green, somewhat granular, like butter, has an acid reac- tion, and possesses the odor of cantharides, the melting- point being 34° (93.2° F.). 2. Fluid Glycerine Fats (oils and blubbers).-The hoof- fat of oxen and sheep is of a pale yellow color, without taste or smell. Whale's blubber is oily, of sp. gr. 0.927 at 20°; it contains olein, palmitin, valerin, and other substances imperfectly known. Blubber of Delphinus phocana is pale yellow, sp. gr. 0.937 at 16°. Though of a neutral reaction it becomes acid when exposed to the air ; it contains olein, palmitin, and valerin. Blubber of Delphinus giobiceps resembles the preceding; it is of sp. gr. 0.918 at 20°; it contains olein, palmitin, val- erin, and other substances. Seal's blubber is a thick, yellowish-brown fluid of very unpleasant odor. Sp. gr. 0.9303 to 0.9317 at 11°. Shark's blubber (Squalus maximus) is faintly yellow, of sp. gr. 0.870 to 0.876 ; it seems to contain a peculiar oleic acid and is rich in iodine. Cod-liver oil, derived from the liver of the cod, is of a color varying from golden yellow to dull brown, and has a peculiar flshy smell and taste. It contains olein and palmitin, some butyric and capric acids, and other little- known substances (gaduin, gadic acid, etc.), and also iodine, bromine, phosphorus, and sulphur. 3. Cetylic, Cerylic, and Myricylic Fats.-Spermaceti is found mixed with other fats in recesses in the heads of certain varieties of whales. After the death of the ani- mal the fat crystallizes out, and may be freed from oil by expression. It consists of almost pure palmitic acid in combination with cetylic oxide, and crystallizes in large laminae, melting at 44° (111.2° F.). It is readily soluble in boiling ether, but dissolves with difficulty in boiling absolute alcohol. Chinese Bisect IFa^.-This substance consists almost wholly of the pure cerylic ether of cerotic acid. Beeswax is a mixture in varying proportions of cerotic acid and of the myricylic ether of palmitic acid (the for- mer soluble, the latter insoluble in alcohol), besides small quantities of a yellow coloring matter and of an oil melt- ing at 28.5° (83.3° F.) to which latter the wax owes its adhesive properties. When exposed to the sun in a moist atmosphere it becomes bleached and loses its taste and odor. According to Erlenmeyer and v. Planta-Reichenau, wax is produced in the bodies of the bees from non-ni- trogenous substances, that is, from sugar. Hoppe-Seyler is not convinced that wax is produced in the bodies of the bees, but believes that it is derived from plants, and he presents strong arguments in support of this view. Cholesterin and Isocholesterin.-Fats yielding these sub- stances on saponification have as yet been found only in sheep's wool. It is said that no glycerine fats are con- tained in the wool, but only those oleaginous matters yielding cholesterin and isocholesterin, together with a certain amount of free cholesterin, oleate of potassium, and certain other substances in small proportion. The Oleaginous Secretion of Certain Glands.- The various animal secretions, formed in glands opening externally, which evidently possess some function in re- lation to the preservation of the skin and its appendages or coverings, may be treated of together as having an analogous constitution. Among such secretions may be mentioned that of the rump glands of fowls, vernix caseosa, smegma praeputii, castoreum, ear-wax, etc. These all contain fats, fatty acids, and albuminous sub- 43 Fatty Degeneration* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stances, besides other unknown substances. The diffi- culty of obtaining the normal secretions in a quantity sufficient for analysis accounts for the little that is known of their chemistry. However, De Jonge has analyzed the secretion of the rump-glands of geese. It is a yellowish fluid of acid re- action, having a faint odor of goose-fat, and only partially soluble in water, alcohol, and ether. The results of this analysis are here presented in tab- ular form : pass through the fat-tissue, but do not, as a rule, termi- nate in it. Lymphatics are moderately abundant. If we examine the minute structure of individual, fully developed fat-cells, we find that the wall of the cell is formed of a very thin homogeneous membrane. Within this, at one or other side of the cell, is an oval or irregu- lar-shaped, sometimes prominent, sometimes very incon- spicuous, nucleus, which is, in some cases, seen to be sur- rounded by a small amount of granular protoplasm spread Secretion Secretion Constituents. of the of the goose. wild-duck. Water 608.07 584 66 Albuminous matters and nuclein 179.66 127.63 C Cetylic alcohol 74.23 104.02 , Oleic acid 56.48 Ethereal , L fatty -d 3.73 14.84 exuacfj Lecithin./. 2.33 [ Undetermined matters and loss.... 50.00 128.22 Alcoholic extract 10.90 18.31 11.31 Aqueous extract 7.53 A h J Soluble salts 3.71 9 35 "bU 11nsoluble salts 3.36 1.66 1000.00 1000.00 Sugar was not found. The presence of cetylic alcohol, which had previously been met with, and as a constit- uent of spermacetic, is noteworthy. The fatty acids were present chiefly as fats ; a smaller portion as soaps. The ashes contained potassium, sodium, calcium, mag- nesium, and chlorine. Ear-wax, according to Petrequin and Chevalier, con- tains water in small quantity, stearin, olein, a reddish coloring matter, two potash soaps (one soluble and the other insoluble in alcohol), a substance containing potas- sium (insoluble in alcohol, ether, and water), some lime, and traces of sodium. (The above article on the fats is taken in great part from Drechsel's admirable synopsis in Hermann's " Handbuch der Physiologic.") T. Wesley Mills. Fig. 1138.-Subcutaneous Fat from Rabbit, a. Fat-cell.with nucleus ; b, capillary blood-vessel; c, fat-crystals in fat-cell. out in the form of a thin sheet. In other cases this proto- plasm is not visible by the ordinary modes of prepara- tion. Finally, the entire cavity of the cell, exclusive of the space which may be occupied by the nucleus and protoplasm, is filled with a drop of oil or fat. In the liv- ing condition the oil is strongly refractile and homoge- neous, but after death it sometimes crystallizes, and then one or more stellate masses of acicular crystals may be seen within the cell-membrane (see Fig. 1138, c). Although in many cases, owing to its extreme thinness, no layer of protoplasm at all can be seen within the mem- brane of the fat-cell, this may be readily demonstrated by the method of Ranvier, by making an interstitial in- FAT-TISSUE. The fat which the human body nor- mally contains as a part of its substance is mostly en- closed in cells, whose protoplasm it in part, or almost en- tirely, replaces. The distribution of fat-tissue in the body is wide-spread, but the amount varies greatly in dif- ferent parts of the body and under different conditions. We do not now speak of the presence of fat in the paren- chyma cells of organs, such as the liver, or in epithelia of mucous membranes, etc., since this is temporary, and its presence does not constitute fat-tissue proper. Fat-tissue occurs in considerable quantity in the subcu- taneous tissue, forming the panniculus adiposvs. It is found beneath the serous membranes, usually along the larger blood-vessels, and forms considerable masses around some of the viscera, such as the heart, kidneys, etc. It exists also in the marrow of bones, about the joints, and in other places. Fully formed fat-tissue consists of a congeries of mi- nute vesicles-fat-cells-from 0.034 to 0.13 mm. in diam- eter, either spheroidal, or when packed closely together, polyhedral in shape. Between the fat-cells, and inti- mately connected with their development and physiolog- ical activities, are numerous capillary and larger blood- vessels, while connective-tissue fibrils and fascicles in varying numbers pass among them (see Fig. 1138). The fat-cells in well-developed fat-tissue, when it occurs in masses of considerable size, are arranged in larger and smaller clusters and lobules, and the lobules may be sur- rounded by a more or less distinct envelope of connective tissue. In some cases, particularly where the fat is pres- ent in small amount, the lobular structure is absent, and the fat-cells are either grouped in irregular rows or clus- ters, or scattered singly through the tissues. They are usually, however, found in the vicinity of larger or smaller blood-vessels. Nerves and nerve-fibres frequently Fig. 1139.-Blood-vessels of Developing Fat-lobules. From subcutane- ous tissue of foetal pig, ten inches iong; injected. For the sake of distinctness, the developing fat-cells, which lie in the meshes of the cap- illaries, are left out in the cut. jection (see Microscopical Technology) of fresh fat with an aqueous solution of silver nitrate, one to one thousand. Then the protoplasm swells up, and may be distinctly seen surrounding the fat-drop, and closely enclosed by the cell-membrane. Development of Fat-ttssue.-It is quite indispensa- ble to the understanding of the nature of fat-tissue to study somewhat in detail its mode of development, for in this way only can we appreciate its relations to other closely allied tissues, and comprehend its very peculiar cells. Most fat-cells, at a very early period of their de- 44 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fats. Fatty Degeneration, velopment, have the appearance of ordinary young con- nective-tissue cells. They may be spheroidal, fusiform, or branched. The nucleus is centrally situated, the pro- toplasm is granular, and there is no cell-membrane. In those parts of the body, however, in which permanent fat is to be formed in any considerable amount, these cells, which have the appearance of ordinary young connec- tive-tissue cells, are grouped in masses in the meshes of larger and smaller capillary tufts ; each tuft arising from a small arterial twig, and communicating with veins which accompany the artery (see Fig. 1139). These cap- illary tufts are larger or smaller, and more or less numer- ous, according to the size and character of the mass of fat-tissue which is to be ultimately formed. Each of the vascular tufts, moreover, with the cells enclosed in its meshes, is destined to form one of the lobules of the adult fat-tissue. If, now, we follow the changes by which a young con- nective-tissue cell becomes converted into a fat-cell, we find that at first minute granules, larger and darker than those of the protoplasm, appear in the cell-body. They are at first few in number and small. They gradually become larger, and after a time appear as distinct but small droplets of fat, which slowly increase in size. A number of these then coalesce, forming larger fat- droplets. As these fat-droplets accumulate in the cell- body, the nucleus is gradually crowded to one side and the protoplasm greatly diminished in amount (see Fig. individuals, fat-cells may partially or entirely lose their fat, and in a measure resume their protoplasmic charac- ters and their original shapes. This resumption of their original characters by fat-cells is, however, never com- plete in the true, permanent fat-tissue, for although the fat may largely or entirely disappear, the protoplasm seems to be mixed with a serous fluid which contains mu- cin. Such fat is often called atrophic or serous fat-tissue, and is frequently of a deep reddish-yellow color. It should be remembered, however, that the permanent fat- tissue usually retains a considerable amount of fat in some of its cells, even in very much emaciated individuals. Of the function of the fat-tissue as a storehouse of nutrient material and as a protective agency, nothing further need be said here. Bibliography.-Consult Toldt, " Lehrbuch der Gewe- belehre," 2d ed. A considerable bibliography is collected in a paper by Gage, "Fat-cells and Connective-tissue Corpuscles of Necturus (Menobranchus)," "Proceedings of the American Society of Microscopists," vol. iv. T. Mitchell Prudden. FATTY DEGENERATION. Fatty metamorphosis, fatty disintegration, fatty necrobiosis, fatty atrophy, more commonly, however, spoken of as fatty degeneration, are terms used to designate a process of degeneration in which the normal constituents of cells, tissues, or organs become transformed into fat. The German terms are : Fettdegeneration, or Fettiqe Entartung, or simply Verfet- tung. In French degenerescence graisseuse is alone em- ployed. The process under consideration being one of true de- generation, with a tendency to the disintegration of tissue, must be held to differ essentially from that other form of accumulation of adipose material known as fatty infiltra- tion (see p. 48). In the latter condition we observe a simple deposition of fat in various cells and tissues, with- out any chemical alteration of their constituent elements. In other words, fatty substances are superadded to the previously existing albuminoid principles. But in fatty degeneration these principles gradually disappear, and are replaced pari passu by fatty particles. It is plausibly as- sumed that a direct conversion of the albuminoids into fat occurs. In fatty infiltration cellular protoplasm is displaced ; in degeneration, as already stated, it is re- placed. In the former, the integrity of the corpuscular organisms suffers mechanically, that is to say, a pressure- atrophy often results. In fatty degeneration the cells suffer chemically, and are ultimately destroyed. But in spite of the differences just mentioned, it is, at times, practically impossible to clearly separate one process from the other. Certainly micro-chemical tests and histological appear- ances are not always sufficiently reliable for exact differen- tiation. The size of the oil-globules does not afford an ab- solute criterion for judgment, although, in a general way, it may be stated that in degeneration the fat is apt to be of molecular form, whereas in fatty infiltration larger droplets are the rule. The seat of the fatty deposits is a more reliable indication of the nature of the change. Thus in degeneration, cells that normally contain no trace of fat frequently fall victims to the morbid alteration. On the other hand, the favorite depots for the storage of the fat of infiltration are the subserous tissues, the sub- cutaneous connective tissue, the bone marrow, the liver, and other places that normally always contain fat. In this connection we may say that, as regards the liver, we meet with unusual difficulties in any attempt to separate the two processes in question. A physiological deposi- tion of fat-droplets is certainly the rule for the hepatic cells. Incipient degeneration, involving the destruction of protoplasm, does not always offer criteria sufficiently well defined to enable us to decide that the existing con- dition is not one of infiltration. For this and similar reasons, some authors have urged that the old distinction be entirely discarded, and that "fatty metamorphosis" be henceforth used to designate both processes. The writer of this article, however, sides with those who hold that the weight of evidence is decidedly in favor of maintaining the long-recognized, though not always de- Fig. 1140.-Developing Fat from Subcutaneous Tissue of Foetal Pig, eight inches long. Stained with osmic acid. The fat droplets are black. 1140). Finally the droplets of fat all coalesce to form one large drop, which crowds and flattens the nucleus up against the side of the cell. The outer layer of the cell, during these changes, becomes hardened and converted into a distinct membrane, beneath which lies, with the nucleus, a remnant, sometimes exceedingly small, of the cell-protoplasm. As the fat accumulates in the cell at the expense, so far as space is concerned, of its protoplasm, the cell becomes larger, and whatever may have been the shape of the original connective-tissue cell from which it was devel- oped, it at length becomes spheroidal. After a time, how- ever, if the above-described change is going on in masses of cells which are closely aggregated, the borders of the fat-cells touch one another, and then, as the fat still fur- ther accumulates within them, their sides become flat- tened, and they assume a polyhedral shape. The minute changes which take place in the develop- ment of individual fat-cells are the same, whether it oc- curs in masses of cells destined to form the permanent fat- tissue, or whether it occurs as a mere temporary deposit in scattered connective-tissue cells. But it is only in the former case, in which the relations of the cells to the blood-vessels are definite and oharacteristic, that we speak properly of fat-tissue. Under varying conditions, but especially in emaciated 45 Fatty Degeneration^ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. monstrable, difference between fatty infiltration and fatty degeneration. As regards the quality of the fat, it is chemically iden- tical in both processes. No matter whether it occurs in the free state or is more or less mixed with albuminoid compounds, the fat is invariably found to consist of the three glycerides, trioleine, tristearine, and tripalmitine, in varying proportions. Ultimately the fat is always de- rived from a splitting up of proteids. In both infiltra- tion and degeneration it represents products that have escaped being burnt up (oxidized), or otherwise decom- pbsed into carbonic acid and water. Fatty degeneration affects chiefly the cellular elements of the tissues, and notably the parenchyma of composite organs. It may occur in very normal structures, as well as in all kinds of new-forma- tions, e.g., exudations and tumors. Very frequently it is observed to follow in the wake of cloudy swelling, co- agulation-necrosis, and albu- minoid infiltration. Never- theless its primary occurrence in previously healthy tissues is by no means rare. The histological changes concerned in fatty degenera- tion are easily studied under the microscope. Cellular corpuscles show the beginning change by the appearance of a few bright, spherical granules, either about the nu- cleus, or within that body. In fatty infiltration, the drop- lets generally first appear at the periphery, as if they had entered from without. Indeed, this is known to be the case in many instances, as, for example, the molecu- lar fat observable in the columnar epithelium of the in- testines, during or immediately after digestion. But while the nucleus may be first affected, it is more fre- quently seen to resist the degenerative metamorphosis until quite late. It may even happen that the entire pro- toplasmatic cell-contents will become transformed into fat, and yet the nucleus remain intact. The small granules mentioned above as significant of the beginning change consist of molecular fat. They are well char- acterized by their dark and sharply-defined contour, their glistening appearance (due to the strong refractive power of fat), their negative behavior when subjected to ordi- nary stains, their inky blackness when treated with osmic acid, and finally, their com- plete solubility in ether and certain oils. As the process of degeneration con- tinues, these fatty molecules increase in number, and sometimes in size. The latter is due merely to the coa- lescence of several minute granules. Droplets of some considerable size may thus appear. At length the entire cell-substance is completely replaced by the fatty particles. At this stage, even when the nucleus has escaped destruction, it is quite hidden from view by the accumulated granular fat. It may be made to appear, however, by dissolving the fat in ether or chloroform. Although it was just stated that the oil-globules may coalesce to form larger droplets, they far more frequently continue separated from one another. This circumstance is doubtless due to the presence of a thin envelope of al- buminous matter around each individual granule, similar to what is supposed to exist in all true emulsions. Cells undergoing fatty degeneration generally increase in size. Sometimes they attain double, or even four times their original dimensions. At the same time their shape tends to become a decidedly globular or spherical one. Of course this tendency receives a natural check whenever the corpuscles lie embedded in a firm and un- yielding ground substance. When cells have become replete with fatty molecules, they often burst, whereby their contents are disseminated through the surrounding tissues, in which absorption may speedily occur. When absorptive action is interfered with, the fat accumulates to form what is known as "fatty detritus." The "cor- puscles of Gliige," the " inflammatory corpuscles " or " compound granular corpuscles," also the so-called "exudation corpus- cles," arc merely ex- pressions to denote cells that are found in a more or less ad- vanced stage of fatty degeneration. If, for any reason, absorption of the debris resulting from the final disintegra- tion of fatty cells does not take place, we observe the for- mation of crystals within that sub- stance. These crys- tals consist for the most part of choles- terine. But fatty acids (stearic, palmitic, and a mixture of both called mar- garic) are likewise frequently seen. The crystals of cholesterine appear as rhombic tables, with angles measuring about 80° and 100°. They have a marked tendency to form in groups, with their long sides parallel to one another. The following tests may serve to distinguish them from similar crystalline sub- stances. If a drop of strong sulphuric acid is added to a crystal of cholesterine, the latter is seen to melt away from the periphery inward. As it does so, a distinctly fatty-looking substance appears in its place, and gradually collects into a dark, brownish-red drop. On adding sul- phuric acid, mixed with a little iodine, to cholesterine, a beautiful play of colors is seen. The changes are from bright red to blue and green. Cholesterine is insoluble in water, but dissolves readily in hot alcohol, chloroform, ether, various fatty substances, and ethereal oils. Cells in a condition of fatty degeneration need not al- ways burst before the oil-globules are set free. Enough protoplasm endowed with vital contractility may remain to expel the fatty particles ; so that in such cases the cell may retain its life, while fat is continuously formed within its substance to be discharged like any specific glandular secretion. In all fat-forming glands, but espe- cially in the mammae during lactation, a process of this kind may be assumed to be constantly going on. Indeed, it is a well-known fact that, colustrum corpuscles, when examined on a heated stage, may be actually seen to expel some of the fatty particles that fill them. Fatty degeneration occurring in fibrous or fibrillar structures, does be- have differently from what has been described in connection with the cel- lular tissue elements. When we re- member that all the fibres and fibrils of the tissues represent cells more or less modified, this similarity of behavior is at once understood. Here, as there, the albuminoid constituents are transformed into molecular fat, the droplets coalesce, or, more frequently, remain separated, and finally complete disintegration of structure is witnessed. Typical fatty degeneration occurs within strictly phy- siological limits, although in itself it is a distinctly path- Fig. 1141.-Fatty Degeneration of Pericardial Epithelium, a, Cells containing molecular fat that still retain their original form ; b, "granular corpuscles," one ■with the nucleus still visible ; c, corpuscles showing disintegra- tion and the formation of fatty detritus. (Rinafleisch.) Fig. 1143.-Fatty Degeneration in an Athero- matous Aorta, a, From internal coat; b, muscle-cells from middle coat. (Coats.) Fig. 1142.-Fatty Degeneration of Celis in a Cancer of the Mamma, a, Slightly affected ; b, more so ; c, completely so. (Coats.) Fig. 1144.-Acute Fatty Degeneration of Stri- ated Muscle. 46 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fatty Degeneration. Fatty Degeneration. ological process. In the elaboration of their secretion, many glands afford fitting illustrations 4f this statement. The "lacteal secretion, that of the Meibomian glands, and the cutaneous sebaceous glands are well-known examples. A part of the pituitary body is regularly affected by fatty degeneration, and in the same way the outer zone of the suprarenal capsules melts away soon after birth. The formation of the corpus luteum, the post-partum invo- lution of the uterus, are the visible results of fatty meta- morphosis of cells and fibres. Quite a number of senile changes have a similar origin. The arcus senilis affords a good illustration of this, depending as it does upon fatty degeneration of certain corneal corpuscles. So, too, with advancing years, we find slowly progressive fatty degen- eration attacking the bone marrow, the crystalline lens, the epithelia of the seminiferous tubules, many blood- vessels, and finally cartilaginous and even bony struct- ures. Fatty metamorphosis (both degeneration and infiltra- tion) may generally be detected with the unaided eye. The affected organs and tissues appear yellowish-gray or simply yellowish. As a rule, this color is not uniformly distributed over the entire organ, but occurs in irregular streaks, patches, or reticula. A fatty organ is commonly much larger than normal, more or less anaemic, and of diminished consistency. But, of course, in all conditions of so-called fatty atrophy, the bulk of the affected organs is diminished. No better illustration of this can be found than the remarkably rapid diminution in size of the liver in acute yellow atrophy of that organ. As regards the duration of fatty degen- eration, no general rule can be formulated. It may occur within a few days or even hours, as in some acute inflammatory processes, and in poisoning from phos- phorus. But it may also be of such slow development that months and years are consumed before it reaches the acme of regressive metamorphosis. Moderate de- grees of fatty degeneration are not incom- patible with life and a continuance of nor- mal or nearly normal function. But in the highest development of this condition, functional activity becomes either very much impaired or else totally abolished. From such a state, complete regeneration or even partial restitution, is no longer possible. Among the causes of fatty degeneration various disturb- ances of circulation and nutrition are most potent for mis- chief. As is well known, if the nutrient vessel of a part suffers sudden complete occlusion, gangrene will follow, but any more gradual obstruction commonly leads to fatty degeneration. The prolonged functional inactivity of forced rest or other conditions of incapacity eventuates in fatty atrophy. This is notably the case in connection with the voluntary muscles. Disturbed innervation and the mechanical pressure of all kinds of new-formations, are powerful factors in the production of fatty degenera- tion. It is apparent that local anaemia must be largely responsible for the damage resulting to the tissues in all these conditions. Quite a large number of toxic sub- stances have a tendency to induce fatty metamorphosis. Among them, those which directly destroy the red blood- corpuscles are most active and consequently most danger- ous. Phosphorus, arsenic, antimony, chloroform, ether, alcohol, sulphuric acid, carbonic oxide, and strychnia- then again the virus of certain contagious diseases, such as variola, diphtheria, scarlatina, puerperal fever, septi- caemia, and pyaemia, may all lead to local or generalized fatty changes of varying degrees of intensity. In pyrexia and inflammatory processes, cloudy swelling is often ob- served to be the forerunner of fatty metamorphosis. To explain the degenerative change under these various cir- cumstances, we must suppose the circulating fluid to have become vitiated to an extent incompatible with adequate nutrition, though still sufficient for the maintenance of life. Regarding the sources of the fat which appears in con- ditions of degeneration, the following may be stated. Fat occurs in the body in the free state, and combined with albuminoid principles. The chemical union in the latter case is not a very close one. Slight disturbances suffice to cause these compounds to split up into their constitu- ent elements. Hence fat may easily and quickly ap- pear in places where its presence was not suspected. Nevertheless, it must be borne in mind that in very many cases more fat appears than any breaking up of existing compounds could account for. In all such instances we are, therefore, bound to assume a direct transformation of albuminoids into fat. Even in the normal state, many cells doubtless receive fat from the circulating fluids of the body. We may remember in this connection that a temporary fatty condition of the blood is a purely physi- ological state; for it shows itself normally in the blood after the ingestion of a meal containing much fatty mat- ter. If blood is collected from an animal after such a meal, on standing some time it will be found to show on its surface a distinct creamy layer, due to the collection of fatty particles (Pavy). Other cells produce fat by a metamorphosis of their proper substance. But, as in either case, it is speedily consumed by oxidation, it does not accumulate within the corpuscles in question. When, however, the burning-up process is rendered imperfect, then fat begins to be stored up in the cells. This applies, Fig. 1145.-Fatty Degeneration of Cerebral Vessels in Softening of the Brain. (Paget.) however, in much greater degree to fatty infiltration than to fatty degeneration. Nevertheless, it is of importance to know' that not all the fat of fatty degeneration results from conversion of albuminoids, but a certain proportion of it owes its presence to insufficient oxidation. Finally, as regards the only imperfectly understood etiology of the process under consideration, it may also be mentioned that cases are on record of generalized fatty degeneration, involving almost every organ of the body, for which no cause whatever could be ascertained. In generalized fatty degeneration affecting many or- gans, the fat does not appear in those places which are the favorite seat of its accumulation in the allied process of infiltration. That is to say, the subcutaneous connec- tive tissue, the mesentery and omentum, and the peri- renal tissues are not concerned in the change. But, in addition to the diaphragm, heart, and liver, we find it in the walls of the blood-vessels, in the renal tubules, and in glandular parenchyma generally. Again, if the heart or other muscular structures are affected, the fat-droplets appear, not between the bundles of muscle-fibres, as in conditions of infiltration, but within them. Whenever the blood suffers considerably from loss of haemoglobin, wide-spread fatty degeneration, usually of a severe type, is developed. Sometimes it may be ob- served in chlorosis ; but in leukaemia, and quite espe- cially in pernicious anaemia, it never fails to appear. It is interesting to remember in this connection that, in some cases of chlorosis, as well as after the repeated abstrac- tion of small quantities of blood, so far from fatty de- 47 Favus?e"eneratl°n' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. generation not occurring, there takes place an increased deposition of fat in the subcutaneous tissue. Again, in many cachectic conditions, and notably in the marasmus of phthisis, the liver becomes a depot for the accumula- tion of fat, that elsewhere in the body visibly melts away. This remarkable circumstance has been rather plausi- bly explained on the ground of imperfect oxidation, through the diminished number and impaired quality of the chief carriers of oxygen, namely, the red blood-cor- puscles. The effects of fatty degeneration consist in more or less softening, diminished or abolished functional activity, and finally destruction of the affected parts. It follows, therefore, that the physiological dignity of the tissue or organ involved must determine, cateris paribus, the amount of injury inflicted upon the system at large. Thus, for example, in progressive fatty degeneration of the cerebral blood-vessels, death from apoplexy is nearly certain. When the cardiac muscle becomes affected, grave disturbances must arise. If the tubules of the kidneys are attacked, life is placed in jeopardy. On the other hand, less important structures may undergo com- plete fatty atrophy without the slightest menace to life, or even without serious alteration of the well-being of the individual. Concerning treatment, no rules can be laid down. It must be our endeavor to prevent fatty degeneration by an avoidance of whatever is known to favor its de- velopment. The senile changes of this character are, of course, in no way preventable. Edmund C. Wendt. Fatty infiltration is observed, as a purely physiological process, in the growth and development of common adi- pose tissue. If, in a certain district containing ordinary connective tissue, the corpuscles of the latter become in- filtrated with fat, the transformed structure at once as- sumes the characteristics of adipose tissue. When the cells again give up their fat, the parts immediately resume the type of simple connective tissue. During and for some time following digestion a tem- porary fatty infiltration uniformly occurs in the intestinal epithelia, and in many hepatic cells. This, too, is a purely physiological event. Again, in conditions of perfect health, the suprarenal capsules are the seat of more or less fat of infiltration, and in not a few cells of the per- manent cartilages the same thing exists. The lesser degrees of fatty infiltration are not discern- ible with the naked eye. When the condition reaches a certain point, however, it is readily detected. The or- gans and tissues then assume a pale-yellowish look, which is owing in part to the fat, and partly to the anaemia that so generally accompanies fatty infiltration. At the same time an increase in the size of the affected organ is noticeable, and the consistency becomes much softer than normal. These characteristics do not suffice, however, to sharply separate infiltration from degeneration. And, indeed, histological appearances may also prove inade- quate or misleading, while a chemical examination, even when practicable, rarely throws any new light on the sub- ject. The problems here only indicated will be found more fully dealt -with in the article on Fatty Degenera- tion. Fatty infiltration of the liver, owing to the fre- quency of its occurrence, must be described at some length. The commonly em- ployed expression, "fatty liver," should be restricted in its application to this variety of adi- pose accumulation, and should not be used so as to in- clude true degen- eration. It is well known that a certain pro- portion of the se- creting cells of the liver normally contain a few fatty droplets; also that a temporary increase in their number is uniformly observed after meals, more particularly, however, following the ingestion of food rich in fatty substances. There is little doubt that the fat is deposited directly from the blood; for we find it in the outer zone of the hepatic lobules, where the portal capillaries spread their ramifications. Whether or not the fat traverses the cells of the lobules, and thus reaching the hepatic veins is once more returned to the general circulation, is not clearly settled. At any rate, it is safe to assume that a considerable proportion of it is consumed by oxidation in loco. It is apparent, also, that the vitality and functional activity of the hepatic cells do not suffer in consequence of this recurrent tem- porary infiltration. "Fatty liver" occurs in decidedly opposite conditions of the body, and differs in this respect from most other permanent accumulations of fat. Thus, we find it as one of a series of local manifestations in general obesity, while, on the other hand, it also accompanies a num- ber of wasting diseases that are characterized by a dis- appearance of the adipose material from its usual sites of accumulation. Certain chronic affections of the heart, but more especially long-continued pulmonary troubles, such as chronic phthisis, often beget fatty liver. In chronic suppurative conditions the same phenomenon may be witnessed, although there, amyloid degeneration is a more frequent occurrence. In all these cachectic states, it would seem as if the fat were really taken up from the subcutaneous and subserous tissues to be stored in the liver, perhaps for future use. An added factor FATTY INFILTRATION. By some writers this con- dition is included with fatty degeneration, under the com- mon designation of fatty metamorphosis. Since fatty in- filtration is not primarily a process involving regressive tissue-changes, it is more reasonable to consider it apart from adipose degeneration. Fatty infiltration signifies the deposition of fat within the tissues. The source of the fat is supposed to be the blood. Infiltration of fat results from its excessive formation, or its deficient consumption by oxidation, or more frequently from a combination of both processes. The fat of infiltration may, therefore, be regarded as true storage-fat, while that of degeneration is the product of regressive changes which culminate in atrophy and tissue-death. For a fuller account of the es- sential differences between the two processes, the reader is referred to the article on Fatty Degeneration (see p. 45). Many persons, especially those of luxurious habits, and they more particularly with advancing years, assimilate more carbohydrates than their system is capable of con- suming by oxidation. A superabundance of fat is the inevitable consequence. Once formed, this material is largely deposited in the subserous and subcutaneous tissue, in the perirenal structures, and in other favorite seats of fatty accumulation. Any general deposition of this kind leads to what is commonly known as obesity (lipomatosis, adiposity). This aspect of the subject will not be further discussed in the present article, since its practical impor- tance justifies separate and explicit consideration under the head of Obesity. When fatty infiltration affects the cellular elements of the tissues, their integrity, if it suffer at all, does so in a purely mechanical way. That is to say, the proto- plasmatic cell-contents are pushed aside by the deposit of adipose material. So soon, however, as the fat disap- pears by reabsorption, the cells are in every way as healthy as before. In fatty degeneration the cellular al- buminoids disappear by being converted into molecular fat. In the condition now under consideration, the fat generally occurs in droplets that show a marked ten- dency to coalesce and form larger drops. In this way a single oil-globule may at length occupy the entire cor- puscle, which then appears distended to its utmost capacity by the accumulated fat. Cells thus affected naturally suffer a loss of functional activity. But com- plete restitution is still possible. As for the minor de- grees of infiltration, they are quite compatible with a continuance of normal function. Fig. 1146.-Fatty Infiltration of the Liver. Isolated hepatic cells, with drops of fat of various sizes. (Coats.) 48 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fatty Degeneration. Favus. in this hepatic deposition may be found in the circum- stance that the normal liver-fat is incompletely oxi- dized, which is in turn the result of diminished circula- tory activity. Again, some fat doubtless remains in the liver, which, under normal conditions, would be con- sumed in the formation of the fatty acids and choles- terine found in the bile. This view receives support from the observation that the flow of bile is diminished, and its consistency becomes more watery than normal, in the conditions of dyscrasia alluded to. The "fatty liver" is increased in size. Indeed, ad- vanced stages of infiltration may lead to so enormous an enlargement of the organ that it may finally get to weigh more than the rest of the, usually, much-emaci- ated body. Such livers are doughy to the touch, pit on pressure, grease paper, and on section an oily fluid oozes out from the cut surface, and clings in minute globules to the knife. The specific gravity is dimin- ished, while the actual weight of the organ may consid- erably exceed the normal standard. Glisson's capsule looks smooth, tense, and shiny; the edges of the organ appear obtuse and rounded. Fatty liver has a variable color. In the minor degrees of infiltration the fat ac- cumulates only in the peripheral zone of the hepatic globules. Hence, in this condition we find a mottled ap- pearance, the result of central reddish-brown islands, sur- rounded by a rim of an opaque yellow ish-gray tint. The latter encroaches upon the former pari passu with the advancing infiltration. At length a stage is reached when the entire organ has assumed a uniformly grayish- functional inactivity results from any cause ; e.g., poison- ing, paralysis, anchylosis. Degeneration and infiltration often go hand in hand. Thus in so-called progressive muscular atrophy there is a combination of both processes. And in pseudo-hyper- trophic paralysis, while there is undoubtedly a true fatty atrophy of many muscular fasciculi, we also invariably find considerable fatty infiltration of the ordinary type. So, too, fatty infiltration affecting the heart may be the precursor of the graver condition of degeneration. Re- garding the fatty heart, the following may be said : A certain amount of fat is normally present beneath the pericardium. When an inordinate increase of this takes place, the entire heart may appear to be clothed in a mantle of pure fat. But on section the muscular parietes may be discovered intact. As a rule, however, this is not the case. Fat deposited in excessive amounts beneath the visceral pericardium gradually insinuates itself between the muscular fasciculi. Indeed, this may go on to such an extent that the walls, more particularly of the ven- tricles, may seem to be composed of fat alone. Never- theless the microscope still detects muscle-fibres in the abundance of adipose tissue that lends such hearts their color. But true degeneration rarely tarries long in these hearts to complete the transformation of contractile mus- cle into flaccid adiposity. Fatty hearts of this type of course seriously endanger life. In fact, it is universally accepted as true, that many cases of death which, on ac- count of their sudden happening, may seem enveloped in mystery, receive their adequate explanation through some form of unsuspected " fatty heart." Edmund C. Wendt. FAULENSEEBAD. A hospital for convalescents, on the southwestern shore of the Thuner-See, Germany. Its altitude is 2,500 feet above sea-level, in a highly pict- uresque location. A cold gypsum spring at this place has gained some reputation for the bathing of rheumatic swellings of the joints and muscles, as well as for the treatment of certain inflammatory affections of the skin. J. M. F. FAVUS (Latin, fames, a honey-comb). Synonyms: tinea favosa; crusted, or honey-combed ringworm ; Ger., Erbgrind; French, teigne faveuse. This vegetable parasitic eruption is rare in this country, occurring not more than three or four times in a thousand cases of skin disease; it is much more common in Germany and Scotland. The disease may affect any portion of the body, even the palms and soles, but is most common on the scalp. The typical lesions are in the form of small yellow cups surrounding a hair, from the size of the head of a very small pin up to that of a split pea. Commonly, however, there are yellowish masses, of a friable character, often darkened by dust or blood, which may give off a repul- sive " mousey " odor ; they are slightly adherent, and on removing them a depressed, reddened, shiny surface is seen. The hair becomes dry and harsh, and is easily extracted. In cases which have lasted some time there may be only a scaly condition, with thinned, dry hair, and depressed cicatrices here and there. When favus attacks other than hairy portions it is known as epidermicfavus, and then often resembles or- dinary ringworm from the trichophyton tonsurans ; but sooner or later the characteristic cups are seen. In rare cases favus has covered a large portion of the body, and has been reported as attacking the stomach and intes- tines. Diagnosis.-The cups and the dry, friable mass, with the shiny surface beneath, are quite diagnostic, and the mi- croscope can always determine the disease with certainty. Crusted cases might suggest an impetiginous eczema or syphilis; the more scaly ones, seborrhoea, psoriasis, or ringworm. Etiology.-The eruption is due entirely to the devel- opment, upon and in the skin and hair, of a vegetable parasite, Achorion Schonleinii, and is contagious, although individual susceptibility varies greatly; it may be pro- duced artificially by inoculation with the parasite. Fig. 1147.-Fatty Infiltration of Muscle. The muscular fibres are nar- rowed, and adipose tissue appears between them. (Coats.) yellow or dirty-white look, and no traces of acinous markings remain. Although capillary circulation must needs suffer in fatty liver, and although there is often profound anaemia, nevertheless haemorrhages are not observed, and all evi- dences of obstructed portal circulation are found want- ing. At times the bile-ducts suffer dilatation, and not infrequently tljeir mucous lining becomes the seat of chronic catarrhal inflammations. Fatty infiltration of muscle is also of sufficient practical importance to warrant a few special remarks. It is to be remembered that, although in the later stages of this process, atrophy of the muscular fibres is not common- ly observed, yet, when it does occur, it is solely in conse- quence of mechanical compression from the accumulating fat. In fatty degeneration, on the other hand, the sar- cous elements are primarily affected by a destructive process, whereby their albuminoid constituents become converted into molecular fat. The fat of infiltration is deposited in the connective tissue surrounding the primi- tive muscular fasciculi; that of degeneration arises within those fibrils. The interstitial fat of infiltration appears generally in large globules ; the intrastitial fat of degen- eration in minute droplets. Sometimes a regular alternation of single rows of oil- drops and muscular fibrils is observed, but more fre- quently the fat of infiltration is disseminated more un- evenly through the affected muscles. Fat is deposited in the muscles in the forced feeding of animals, and in the similar human occupation leading to obesity. Fat also appears in muscles during prolonged rest, or where forced 49 Favus. Febricula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pathology.-The vegetable parasite attacks the epi- dermal structures of the body, following down the cellular root-sheath, to the bottom of the follicle : its presence ex- cites some inflammation, leading to congestion of the surface, but rarely, if ever, to suppuration. A process of absorption and cicatrization goes on, so that the follicle is entirely destroyed in time, and a cicatrix and perma- nent baldness results. When a favus crust is crushed in equal parts of liquor potassse and glycerine, and magnified three hundred di- ameters, the field is seen to be covered with the parasite, exhibiting many short, sausage-like bodies, with rounded ends, and also longer, tube-like masses, with rounded ex- tremities, and often jointed and branched as shown in the accompanying Figure. If an affected hair be examined carefully, the same and historical interest. The present accommodations are supplied by a temporary wooden structure replacing the hotel, burned a short time since. There are churches and schools in the neighborhood. G. Ji. F. FEAR, FRIGHT. Fear is essentially an emotion, of a painful and depressive character. It is not always a purely emotional state, however, but is connected with an idea of some uncertain calamity. It is then a form of expectation. Fright is an acute form of Fear ; Terror and Horror are intenser forms ; Anxiety and Apprehension milder forms of the same mental state. Fear in an epi- demic form is known as Panic. From a medical point of view, fear may be considered as a cause of physiological changes in the body, as a cause of disease, and as a morbid state or disease in itself. The emotion of fear gives rise to certain physiological changes which are characteristic. The facial muscles are affected, causing a peculiar expression of terror or fright. The muscles brought into play are the frontal portion of the occipito-frontalis, the platysma myoid, the corrugator supercilii, and the depressors of the lower jaw. In fear the flexors of the body tend to contract, the indi- vidual bends the head, draws in the shoulders, the knees drop, and the forearms are drawn up. Just the contrary occurs under the influence of the emotion of courage, which is a feeling of a higher type. The heart in sudden fright is checked momentarily in its beat by powerful in- hibitory impulses sent through the pneumogastric ; this is followed by an apparent paresis of these inhibitory fibres and consequent palpitations ; the vaso-constrictor nerves are brought into play, the face is blanched, and the ex- tremities are cold. Fear, when excessive, checks the secretion of the salivary glands and dries the mouth, while at the same time it increases the secretion of sweat, and as the cutaneous blood-vessels are constricted at the same time, the sweat is generally cold. Anxiety, fear, and fright may suspend the gastric secretion, and sus- pend or change the character of the secretion of milk. Infants, in the latter case, are liable to have digestive troubles, and often they do not do well if the mother is suffering from the depressive effects of anxiety and fear. This latter emotion, when powerful and sudden, may check menstruation or cause profuse evacuations from the bowels and bladder. Milder feelings of fear excite a desire to urinate or to have a movement of the bowels. In certain animals fear causes a contraction of the skin muscles and the erection of the hair. It is a popular error that under the influence of fear the hair of the human head also may be erected. This is not the case, and is indeed a physical impossibility, since the skin muscles of the scalp (erectores pilarum) are not suffi- ciently powerful to affect the position of the long hairs. The effect of fright upon speech is commonly to suspend that function or confuse it, causing aphasia or aphonia. In most cases this is due to the mental state, the mind being confused and memory impaired (amnesic aphasia -Schreck-aphasia). In other cases the organs of articu- lation are at fault and there is true aphonia. The sub- jective sensations connected with the emotion of Tear or fright are those of shivering, epigastric oppression, prae- cordial distress, and choking, or globus hystericus. Fear or fright may be the exciting cause of a very large number of diseases. Most of these are functional dis- orders of the mind and central nervous system. But fright may be the starting-point of visceral and general nutritional changes also. I have only space here barely to enumerate these disorders. Fear or fright is put down as the exciting cause of from one to three per cent, of cases of insanity (Bucknill and Tuke), of about ten per cent, of cases of epilepsy (Gowers), and probably an even greater percentage of cases of hysteria and chorea. Pa- ralysis agitans (Koht), Basedow's disease, hemiplegia, spinal paralysis from myelitis (Koht), rheumatoid arthri- tis, haemoptyses, icterus, amaurosis (R. P. Jones), even gangrene (De la Brousse and Rush), and death (Cazenave, Cotting, Manson, E. Opitz, and others), have been brought on by intense fear. Some authentic cases of alopecia and whitening of the hair have been reported (Fredet fils, Fig. 1148.-Spores and Mycelium of the Achorion Schonleinii, from Favus. X 300 diam. (From Neumann.) structures may be found in the root-sheath, and often in the shaft of the hair. Treatment.-The disease being local, topical treat- ment is to be depended on; but tonics internally are called for in most cases, as the eruption occurs in those of lowered vitality. The hairs must be extracted, when the disease is deep-seated, and a parasiticide applied thor- oughly thereafter. Bichloride of mercury, from one to ten grains to the ounce, oleate of mercury, and sulphurous acid are most to be relied on, and should be kept contin- uously applied ; also iodine, and carbolic acid and naph- thalin are serviceable. Among greasy applications, di- luted citrin and sulphur ointment are most valuable. Prognosis.-This depends greatly upon the patient and the physician ; left to itself the disease terminates in cicatricial baldness ; under careful and sufficiently pro- longed treatment it is curable. L. Duncan Bulkley. FAYETTE SPRINGS. Location and Post-office, Fayette Springs, Fayette County, Pa. Access. -By Baltimore A Ohio Railroad to Union- town, thence by carriage to Springs, eight miles distant. Analysis (Prof. F. A. Genth, 1876).-One gallon (231 cubic inches) contains : Grains. Sulphate of magnesia 0.25472 Sulphate of lime 0.05542 Sulphate of soda ... 0.19965 Sulphate of potash 0.11525 Chloride of sodium 0.08522 Bicarbonate of iron 1.06709 Bicarbonate of magnesia 1.53414 Bicarbonate of manganese 0.04795 Bicarbonate of lime 9.33441 Phosphate of lime 0.04822 Alumina trace Silicic acid 1.19690 Nitrous oxide trace Carbonic acid (free) < 0.38284 Therapeutic Properties.-This is a calcic-chalyb- eate water of attested virtue, and enjoys a well-founded though local repute. These springs issue from the coal formation of the Laurel Mountains, in Southern Pennsylvania. The lo- cality possesses a pure and bracing mountain climate, and the surroundings are rich in objects of picturesque 14.32181 50 Favus. Febricula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tuke). Attacks of purpura haemorrhagica have been brought on by fright. Dr. Hall attributed a case of den- tal caries to the same cause. Dr. Hitchcock reports a case of rupture of the tricuspid valves from fright. Fear may, especially in children, give rise to an ephem- eral fever. It is a general nervous depressant, and from this fact those who suffer from it in times of epidemics are more predisposed to the disease. Authentic evidence of this has been given. A case of acute ascites occurring in a healthy person, as the result of a frightful dream, is reported by Py. Neurasthenia and spinal irritation occur not rarely as the result of the fright and mental shock of railroad and other accidents. It is now admitted, however, that many of the cases of organic spinal disease supposed to be caused by the above class of injuries, are really only func- tional nervous disorders. To fright may often be traced an entire change in the character of the nervous system of an individual, so that women more especially, ever after are irritable and nervous. In very rare and excep- tional instances it is possible that fright may, in pregnant women, cause some mark upon, or developmental arrest of, the foetus. From the foregoing it will be seen that there is hardly a form of disease which may not be excited by fear, and there is not a function of the body which may not be seriously affected by it. Fright, fear, and anxiety are the most injurious emotions to which humanity is sub- ject, and both the social economist and the sanitarian must take into account the fact in trying to prevent dis- ease and promote happiness. But fright is not always an injurious agent-on the contrary, it is sometimes curative, although vastly less so than the opposite emotions of joy and hopeful expecta- tation. Dr. Tuke reports the case of a man suffering from rheumatic fever, who was instantly cured by the shock and fright of a railway accident. Sharp relates a similar history. E. Yost has described a case in which a strangulated hernia was reduced by fright. Hysterical paralyses have been cured by sudden fright, although such occurrences are rarer than is generally supposed. The mental state of fear, anxiety, and dread may be- come fixed and chronic, although no reasonable cause for the same exists. Or the mind may be in such a state that emotions of fear are excited by certain trivial objects or thoughts. The patient is then the victim from a true mental disorder. Thus the hypochondriac suffers from a constant fear or anxiety regarding himself. These states of morbid fear occur often in neurasthenia, and in those of a congenitally psychopathic constitution, and they have received various names. The list, as given by Beard, is as follows : Astrophobia, fear of lightning (Beard); Ago- raphobia, fear of open places (Westphal); Claustrophobia, fear of closed places (Ball); Anthropophobia, fear of man (Beard); Pathophobia, or Hypochondriasis; Monophobia, fear of being alone; Pantaphobia, fear of everything ; Mysophobia, fear of contamination (Hammond). The persons suffering from these morbid fears are aware of their groundless nature, and have no delusions. They cannot be classed as insane, at least from a legal point of view, although there is a true impairment of the men- tal functions. The disorder appears to be generally the evidence of psychical degeneration, an undeveloped form of primary monomania, or in the milder cases, simply of chronic cerebral exhaustion. It may as well be stated here that the attempts which have been made to classify certain of these morbid fears (e.g., agoraphobia, claustro- phobia) as forms of vertigo, are quite needless and barren. Even if agoraphobia, for example, were " a form of ver- tigo," which it is not, we should know no more about its pathology. Some ridicule has been thrown upon the at- tempts to give names and descriptions to these various mor- bid fears. This could only be done by persons who have not seen examples of the morbid symptoms in question, and noted their striking clinical distinctness. I have my- self met with well-marked cases of anthropophobia, myso- phobia, agoraphobia, claustrophobia, and what might be called pyrophobia, or fear of fire. In all these cases the morbid apprehension was the most salient feature in the history. It is easy to see that morbid fears are closely connected with such conditions as the grubelsucht, of Griesinger, and the folie du doute, of Le Grand du Saulle. In the latter disorders, the patients are in a constant state of worriment, dread, and anxiety over numberless trifling things, such as the arrangement of their room, their clothes, their food, and all the details of their domestic life and daily work. In a word, morbid fear is only one of a sisterhood of symptoms that are implanted upon degenerated or exhausted brains. For a consideration of the peculiar sleep-disorder known as night-horrors or pavor nocturnus, the reader is referred to that subject. The prevention of the bad results of fear and fright in- volves the avoidance, as much as possible, of exposure to these depressing emotions, and the strengthening of the nervous system, from childhood up, by all possible hygi- enic and educational measures. Children should never be frightened in sport, or by being forced to sleep in dark and lonely rooms, ot by nurses' tales. Frail, neurotic, or pregnant women should be carefully guarded against fright. Men who suffer from unreasonable fears should be dealt with more heroically. I can recommend the ex- ample of Peter the Great, who is said to have overcome his fear of water by throwing himself headlong into the sea. Those who are strong enough of will to follow such a course are sure to get well. John Hunter used to over- come his fear of public speaking by taking a dose of laudanum before each lecture. Opium, alcohol, and all narcotics and stimulants temporarily remove the sense of fear, but their final effects are injurious rather than cura- tive. The treatment of the morbid fears, properly speaking, is the treatment of the underlying cause. The patients require tonics, mental discipline, diver- sion, freedom from all depressing agencies, everything in fact which will help to give better nutrition to the brain, and greater dominance to the will. On the whole, the prognosis in these cases is not bad. Many patients re- cover, and often those who suffer from morbid fears and hypochondriasis in the first half of life are more comfort- able, if not well, in their declining years. Charles L. Dana. FEBRICULA (diminutive of Febris, fever). Syno- nyms : Simple fever, simple continued fever. Febricula is a convenient term which finds its justifica- tion in ignorance rather than in knowledge. A pyretic state lasting from one (ephemera) to ten days, in which the temperature probably does not rise above 102° F. except temporarily, nor the pulse usually above 100 to 120, accompanied by a white, furred tongue, constipation, loss of appetite, by headache which may be sharp ; but without other derangement of the bowels than constipation, without any exanthem, without any dis- tinguishable internal or external local lesion, inflamma- tory or otherwise ; ending in sudden resolution and rapid, easy recovery-this is febricula, and we agree to call this general condition, whatever may be the cause, by that name for want of a better, and because it requires some designation. Febricula has no pathology, because it always ends in re- covery. Febricula ending in death takes ou another name. Abortive typhoid, typhus, or relapsing fever ; scarlet fever or measles without their rash ; tonsillitis with an in- appreciable tonsillar affection ; acute rheumatism or ery- sipelas without localization, may all conceal themselves under the term febricula. On the other hand, the same symptoms-as shown in a mild or short continued fever-may result from exposure to extremes of temperature, from exhaustion, from di- gestive disturbances, from derangements of the nervous centres. The febris ardens of the tropics, various degrees of which are encountered in the United States during the occasional hot ' ' waves " of our summer months, belongs more appropriately under insolation, or heat, or sun- fever. The diagnosis of febricula can only be reached by ex- 51 Febricula. Fees, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. elusion, and should only be made subject to ready revi- sion. The treatment is simple and consists of a saline laxative, diuretics, diaphoretics, or refrigerants, as indicated in the particular case. George B. Shattuck. be kept up until the -whole " meal " has been given. Dr. Gallagher, in the New York Medical Journal for 1879, suggests the use of a syringe holding from two to four drachms, the nozzle of which is to be inserted in the nos- tril and the contents injected ; the process to be repeated as above described. Dr. Hamilton, in the Journal of Insanity for January, 1857, states that the following recipe proved useful: two or three eggs, half an ounce of sugar, half an ounce of olive-oil, one pint of milk or of beef-tea ; the whole to be strained through a coarse linen cloth. The patient should be made to lie on the back, the head being inclined backward and the chin slightly elevated. Various special forms of apparatus have been invented for forcible feeding through the nose ; some of them are quite complicated, and are no better practically than an ordinary small tin or crockery vessel fitted with a spout ; to this spout a piece of rubber tubing is attached ; the rubber tubing is passed the requisite distance into the nostril, and the cup raised so that sufficient fluid (two to four drachms) may run into the nostrils. The cup should then be lowered, in order that deglutition and respiration may take place. Dr. Clement Dukes, in The Lancet, 1876, says that a piece of rubber tubing may be placed in an ordinary bottle, in which the nutritive fluid is placed (as a soda- water bottle), and the tubing passed into the nostril to the pharynx, when a syphon-action may be set up ; this is probably started by the involuntary action of swallow- ing. An apparatus designed by Mr. T. Newington is de- scribed in The Lancet, 1879. It consists of a small rub- ber cup with an opening in the bottom, to which is fitted a rubber tube of rather large calibre ; to this tube are attached two smaller tubes, which are passed into the nostrils. The passage of the fluid can be easily inter- rupted by pinching the tube, or more surely by using an ordinary "spring-catch." The principal danger in this method of feeding is the passing of substances into the larynx and trachea, and the consequent suffocation ; this may be guarded against by passing the tube well toward the back of the throat, and some distance into the oesophagus; as a rule the tube should be about two feet long, as plenty of it should re- main outside the nostril to allow for struggling and in- voluntary motions. Dr. William Hamilton (Journal of Insanity, 1857) ad- vises the use of an elastic tube tw'enty-four inches long, the first two inches having a curve which prevents its impinging on the posterior wall of the pharynx or on the epiglottis; the curve may be maintained by inserting a piece of silver wire, which has been bent on itself. The results of the use of this method of feeding have in many instances proved quite satisfactory. In a case of refusal to take food, in a female insane patient (Journal of Insanity, vol. xxv.), forcible feeding was performed with the stomach-pump twice a day for three months; milk, eggs, beef-tea, brandy, and cod-liver oil were ad- ministered ; the natural method was gradually resumed, it being necessary to continue the use of the artificial method in the mornings for some time afterward. Dr. Hamilton (Journal of Insanity, 1857) gives the re- sults of three cases: in one case the patient was nour- ished by nasal feeding for twenty days, at which time death ensued; another case was nourished in the same manner from June 21st to November 6th, during which time but two natural meals were taken ; in the third case this method was kept up from July 24th until November 11th, and was followed by recovery. Dr. Thomas Hammond (Lancet, 1880) reports a case in which the administration of beaf-tea, thickened with "pea-flour, milk, and corn-flour," by the stomach-pump, was kept up, twice daily, from March 9th until April 3d. being gradually given up. Dr. Regis (Ann. Med. Psych., January, 1881) advises that the acid contents of the stomach be first removed, and that the stomach be w ashed out with a solution of bi- carbonate of soda, or Vichy water, by the stomach-pump before the nutritious substances are injected. This can FECAMP, a prominent and fashionable bathing-place on the northern coast of France. The temperature of the North Sea, at this point, during the months of bath- ing (from the middle of July to September), ranges be- tween 60° and 68° F. The winds are variable. J. M. F. FEEDING, FORCIBLE. By the term forcible feeding is signified the administration of aliments to such patients as are opposed to taking food in the natural manner ; this opposition generally occurring in the insane, or in those who are determined to commit suicide. Nourishment may be forcibly introduced into the sys- tem in various ways : by the mouth and oesophagus (by the stomach-pump); by the naso-pharynx ; by the rec- tum (see article on Alimentation, Rectal), and subcuta- neously. Such a forcible method of sustaining life does not ap- pear to have been in use for more than fifty years, if one is to judge by the date of reported instances of its use in the journals. One of the earliest articles on this subject appeared in a French medical journal in 1856-57. In all cases, before resorting to this method of feeding, every effort should be made to induce the patient to take food in a natural manner, and this should be repeated at each time of feeding. As far as possible the " forcible" part is to be avoided, the dangers of the methods being sufficiently great to make it desirable to dispense with them if possible. No doubt, in many cases, a patient hav- ing been once subjected to any of the methods about to be described, will consent to take nourishment naturally ; but, on the other hand, if the process be attended with great discomfort, the patient, while not consenting to natural feeding, will be apt to struggle all the harder upon each repetition of the operation. The first method employed for the artificial introduc- tion of food was the stomach-pump ; the tube was passed down to the stomach, and the nutritive fluid pumped in (the reverse of the usual process). The same dangers which attend the use of the stomach-pump, when used to wash out the stomach, are present under these circum- stances. Thus, for example, the tube may be passed into the larynx, or particles of food may be injected into it; or the (esophagus may be lacerated, and the instrument may penetrate the adjacent parts. In four cases, cited by Dr. F. Needham (in Journal of Mental Science, vol. xxv.), it was found necessary in three of them to give up feeding by the stomach-pump, on account of the symptoms of impending suffocation. A modification of this method has been used, in which a tube is simply passed into the (esophagus, but not to the stomach (Dr. Moxey, in The Lancet, 1873). ■ The question of the comparative advantages of the meth- ods in which the aliments are yitroduced through the mouth and of the methods in which the naso-pharyngeal passages are used, has given rise to great discussion. At present the latter method is generally employed. This method consists in passing a soft-rubber tube through the nostril into the pharynx ; it may be passed within or beyond the grasp of the constrictor muscles, or it may not descend so far as to be grasped by them. In some cases the aliments may simply be poured into the nostril by means of a small funnel, no tube being used. The nutriment administered must always be in a fluid or semi-solid state, as milk, eggs, beef-tea, brandy, or cod-liver oil. The substance should be lukewarm, as it is less apt to cause irritation to the naso-pharyngeal pas- sages than when it is cold. Dr. Moxey says a pint should be administered two or three times a day, when the pa- tient declines all food. From two to four drachms should be administered at a time, and then there should be an interval for deglutition and respiration, after which this amount may be again administered ; this process should 52 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Febrieula. Fees. all be accomplished, of course, with but one introduction of the tube. The question of nourishing through, or under, the skin in cases in which forcible feeding is necessary, has re- ceived some attention ; many experiments have been performed on the lower animals, and some on human beings. Frequently good results have been attained by repeated inunctions of cod-liver oil, but such nourishing has only been supplementary to other methods, natural and arti- ficial. In the case of an insane man, fifty-seven years old, who refused food, and had been nourished by the stomach- pump for twenty-seven months, it became necessary to give up this method, owing to the cough and partial suf- focation which it produced. Accordingly, the following process was carried on for twenty days: from ten to twenty cubic centimetres of olive-oil were injected sub- cutaneously twice a day ; this, when injected slowly, gave rise to no pain or inflammation; the white and yolk of an egg beaten together, however, produced an abscess when injected similarly. Each injection took from half an hour to an hour to become completely absorbed. The process of transfusion might be resorted to in cases necessitating forcible feeding (see article on Trans- fusion). William H. Murray. action to recover fees will lie unless the medical man is a regular registered physician. In the United States, the fiction that a physician is lowering himself by asking payment for his services never had any foothold at all, and in every case proper compensation has been allowed, according to the facts proven. There is the same restriction in most of the States that there is in England as to registration, and an unlicensed physician cannot recover for his services. In some of the States it would seem that the fact of license or non-license does not affect the right to recover. If the services were worth anything, the practitioner can enforce payment. The statutes requiring a license state in such cases the penalty for a violation. The usual rule is, however, that if a license is necessary for lawful practice as a physician, no suit can be maintained for ser- vices by one who has not observed the law. The burden of showing that the practitioner is unlicensed is upon the defendant. It has been very concisely stated that the es- sential pre-requisites to a recovery for fees are: 1, Em- ployment ; 2, ordinary skill ; 3, services rendered ; 4, usual charges. And, in considering these points, it may be said that the first three are conditions precedent to any recovery, and the fourth concerns the extent of the compensation. In regard to the employment, it may be briefly said that a person is of course liable who requests medical services for himself. He is also liable for services rendered for his family, and it is not always necessary to prove that he ordered such services. If a person orders medical ser- vices for another, he is usually considered as an agent merely, and cannot be made responsible for the physi- cian's compensation. If a person expressly promises to pay and the services are rendered on this account solely, he is liable and not the patient. If a person receives medical services without having ordered them, there is not now the presumption that they are gratuitous, but the law raises an implied promise to pay a reasonable sum for services which are accepted. The right to re- cover compensation does not depend upon success, un- less the practitioner has expressly made a contract to that effect. It has been said that " if a surgeon has performed an operation which might have been useful but has merely failed in the event, he is, nevertheless, entitled to charge; but if it could not have been useful in any event he will have no claim upon the patient. A medi- cal man who has made a patient undergo a course of treatment which plainly could be of no service cannot make it the subject of charge. If the physician has em- ployed the ordinary degree of skill required of one in his profession, and has applied remedies fitted to the com- plaint, and calculated to do good in general, he is entitled to his fees, although he may have failed in this particu- lar instance, such failure then being attributable to some vice or peculiarity in the constitution of the patient, for which the medical man is not responsible." When the surgical instruments used in the amputation of an arm were rough and unusual, such as a large butcher knife and a carpenter's sash-saw, the court charged the jury that, if the operation was of service and the patient did well and recovered, the surgeon was entitled to com- pensation. Malpractice, of course, always prevents the collection of compensation, for the rule is, that unless some good has been done by the practitioner he cannot enforce payment. If the good has been less than was properly expected, or than it ought to have been, it will affect the extent of the compensation. In one case it has been held that an action for fees where no defence of malpractice is set up, will be a bar to a subsequent direct action for damages on account of mal- practice. A change of treatment, even when it is entire, and when it is made without notice or consultation with the patient, if prompt action on the part of the practitioner is requisite, will not prevent a recovery for fees. The communication of an infectious disease, like small- pox, by the medical attendant will prevent a recovery for services rendered necessary by his lack of care, and the physician may be responsible himself in damages. FEES, LEGAL RULES GOVERNING THE COLLEC- TION OF. Until a comparatively recent period, it was not possible to enforce by legal process the collection of the fees of a medical practitioner. Under the Roman law the service rendered by a physician or other profes- sional man, such as a lawyer, was regarded as gratuitous, and the idea of a fee or salary which could be enforced legally was repudiated. Compensation, when made, was called an honorarium. It seemed to be the feeling that the insistance upon a fee made the service mercenary and derogatory to the position of a member of the learned and liberal profes- sions. In fact, in the case of lawyers pleading for their clients in the Roman courts, a law was once passed absolutely forbidding the acceptance of any remuneration. This was a regulation not likely to be regarded favorably, and was in fact soon repealed by a law permitting any re- ward up to ten thousand sesterces ($400). While there was this ethical rule which forbade the medical man from enforcing a claim for compensation, it seemed to apply strictly to cases where there was an em- ployment without any stipulation as to compensation. When there was an express promise to pay a certain sum, the Roman law permitted an action for its recovery. It would seem, therefore, that even under this code the physicians would usually receive compensation, for it» would be natural for them to ask for a promise of pay- ment. In the Continental countries of Europe, where the Roman law held sway, the same rules were in force as to the collection of fees, until changed by legislative enact- ment. In England there was a corresponding feeling that a physician's services ought to be gratuitous, but here, as in Rome, an express promise to pay a fee could be enforced. Surgeons originally had a much lower grade in the profession than physicians, and there was no pro- hibition in regard to them. It did not appear derogatory to the standing of a surgeon to ask and receive compensa- tion. In one case the physician was a surgeon as well, and the careful distinction was drawn that he might en- force payment for what he had done as a surgeon, but not for what he had done as a physician. This prohibition of the courts gradually came to be re- garded as artificial and unjust, and by the Medical Act of 1858 the whole fabric of rules preventing the physi- cian from recovering compensation was swept away. The services of a medical man are now on the same foot- ing with all other services, and a recovery is allowed in each case, according to the justice of the particular de- mand; the only exception being that, in Great Britain, no 53 Fees. Feet. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. A contract to cure is held to be unprofessional and vicious, as it warrants a result which never can be abso- lutely sure in any case. When, however, a contract of this kind is made it must be carried out, or there can be no recovery. In regard to the extent of the recovery it may be said, in general, that there is no limit except that it must be reasonable. In deciding what compensation is reasonable, attention may be paid to the professional standing of the medical man, the delicacy and difficulty of the case or operation, the time and care expended, and the wealth of the patient. A practitioner highly distinguished in the profession nat- urally expects larger compensation than a comparatively unknown man, and the courts recognize this proper rule. The difficulty of an operation, or a course of treatment requiring unusual care, also affects the extent of the re- covery. The wealth of a patient is an element to be given some consideration, but if a person is a millionnaire that is no reason why the bill should be extortionate. The juries are the judges as to the extent of the recov- ery, and their verdicts are as diverse and irreconcilable as is possible. The only thing that can be said is that juries usually render reasonable verdicts, and when they are not they may be set aside by the court. In some communities fee bills are common and the rates specified are known to the public. In such cases the practitioner will be bound by the list of charges which he has assented to. In some cases, also, fees are pre- scribed by law. The charges made must be specific and state the times and amounts. A round sum for medical services is not a proper charge to make. For instance, a charge of "thirteen dollars for medicine and attendance on one of the gen- eral's daughters in curing the whooping-cough" has been held by a South Carolina court to be too vague to base a recovery on. Physicians can recover for services rendered by their assistants, even when the latter are unlicensed. A separate charge may be made for medicines furnished to a patient, as these are not necessarily essential to the treatment; but it has been thought that a surgeon's splints, bandages, etc., are a necessary part of his treat- ment, and are covered in a charge for services. This distinction is, however, very technical, and does not seem to be well founded. The existence of an epidemic does not warrant a phy- sician in largely increasing his charges. When a doctor's bill is not paid on presentation or with- in a reasonable time, he is not limited by it, but may re- cover whatever the services are reasonably worth. A bill once presented will, however, be usually taken as the phy- sician's opinion of the value of his services, and an in- crease is not favored by juries. Where witnesses vary as to the value of services, the tendency of courts and juries is to take the lowest estimate. The patient, and not the attending physician, must pay the consulting practitioner. Even if the attending phy- sician promises to pay his professional brother, the latter is not bound by this, but may sue the patient. The con- sulting physician may in such cases have a choice of remedies, but he cannot enforce his claim against both parties. Where what are called consultations are very numer- ous, the courts may consider them ordinary calls, and give the compensation usual to such services. When physicians appear as ordinary witnesses on the trial of actions they receive only the usual fees. In cases of expert testimony, very few of the States re- quire witnesses to accept the pittance paid to ordinary witnesses. Alabama and Texas are, perhaps, the only exceptions to this statement. The general rule is that no one is obliged to testify as an expert against his will, nor unless he is compensated reasonably. The demand for payment must, however, be made be- fore the witness is sworn, or at all events before the tes- timony is begun. Expert witnesses are called because of their supposed superior knowledge, and it would be un- just to require them to accept the ordinary fees. Another reason is that expert witnesses are often required to study up a case thoroughly, to be present during the whole trial, and to listen attentively to the evidence, so as to qualify them to give opinions concerning it. A fee of live hundred dollars in one case was held to be reasonable, considering the attention and study demanded of the wit- ness. In rendering services to the poor of a city, county, or township, compensation is often regulated by law. It is necessary to show, in suits for compensation, that the per- sons ordering the medical services are the proper officials, otherwise there will be no claim against the city or other political organization. Henry A. Riley. FEET, CARE OF THE. The social usages and ma- terial necessities that render imperative the covering of the lower extremities, necessitate in the United States alone the annual manufacture of hundreds of millions of boots and shoes-not to mention stockings-the value and importance of which far exceed the principal industries, and are second only to agriculture. Of the millions that are obliged to wear these coverings for the feet, but few escape their inconveniences, nearly every one being more or less subjected to the deformity and discomfort occasioned thereby. This infliction seri- ously modifies the anatomy of the foot and its vasculo- nervous supply, and there results from this far-reaching cause a special pathology and an appropriate hygiene which offer a vast field for meditation and practical re- form. The modest but seasonable maxim regarding the abso- lute necessity of taking care of one's feet enunciates a proposition of personal and even social hygiene, the cor- rectness and propriety of which are admitted by all, not- withstanding the fact that the practice of most persons is totally at variance with the wisdom and requirement of the precept. References to feet and shoes are found in the Script- ures, in classical medical works, and in literature since the times of the Attic writers. Indeed, Balduinus1 states in his curious and learned work that the invention of foot-coverings goes back to Adam. Primitive tribes in the extreme North are warmly shod, and it is only among those of a low grade of intelligence, as the Fuegans, that one finds the feet and legs absolutely naked. The sub- ject, though apparently lacking in both epic and senti- mental interest, has become a vital question in strategy with military men. The wisest of writers exclaims in the Canticles, " How beautiful are thy feet with shoes, () princess! " Our great dramatist has occasionally expressed himself in the same feeling manner ; and among the writers of gynographs, Restif has shown the most singu- lar aesthetic taste in Le pied de Fanchette. On the other hand, foot-coverings have come in for legal prohibition and ecclesiastical denunciation, and St. Chrysostom re- garded all ornamental shoes as an invention of the Evil One. Aside from the writings of celebrated shoemakers who have gone beyond their lasts in order to add to the bibliography of the subject, one must seek the remedy for a martyrdom of which nearly everybody complains in the recent writings of medical men, who, more than others, have occasion to see and judge seriously a great number of maladies of the feet. The hard prison of leather in which the foot has so long been incarcerated, has caused the disappearance of the natural foot, and one is obliged to study in infants, in savages, or in statues, the primordial lines and propor- tions of a part of the body which has, more than any other, been subjected to the tyranny of fashion, and the cruelty of constraint. The healthy inspiration of nature is not to be found in the distorted feet of the pedaneous crowd that frequents the sidewalks, where one's medico- aesthetic sense is equally shocked in observing the clouted shoes of the tramp, and the feet of silly women who try to conquer the absence of the conventional at- traction that nature has denied them in this respect by 54 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fees. Feet. squeezing the feet into small, ill-shaped shoes, that re- spect neither the form nor the mechanism of the foot. The deformity in the configuration of the parts is more noticeable in women, whose badly-constructed, high- heeled boots reunite all the conditions of deformity and discomfort, and drive the foot more and more to the front, producing a kind of walking-down-hill effect. This is, however, being remedied to some extent by the better classes in our large towns, wdio have incurred the Philistine reproach of Anglomania. Such a thing as a natural female foot no longer exists except in a transcendental sense, and the artist or the anatomist may look in vain for the great width of instep ; the well-marked great toe; the longer second toe projecting a little beyond the great toe ; and the very small, or, in some cases, almost suppressed little toe, that characterize the per- fect female foot of the human spe- cies. Many artists have reproduced the deformed foot. This is notice- able in the foot of Mars, by Paul Veronese, to be seen in the collection at Frankfort-on-the-Main, and in one of Benedetto Gennare's pictures in the Dresden Museum. On turn- ing over the pages of some of the monographic works on anthropot- omy, it will be seen that the most distinguished anatomists have badly drawn the foot. This is noticeable in Quain, Froriep, and others. Med- ical museums are, moreover, want- ing in illustrative specimens touch- ing the hygiene of the human foot; while they abound in specimens of the smallest details relating to the care of the feet of oxen, asses, and horses, concerning which volumes have been written. No feature of the human stature presents a more marked anatomical interest than the foot, and it is the special development of the great toe that enables man to stand erect. In the perfect adult foot the long axis of this toe when continued backward should converge on the heel as seen in Fig. 1149. Its only joint is drawn downward by a strong flexor tendon, which tends to shorten the foot. In fact, the action of the flexor muscles on the arch of the foot has a sort of bow- string effect, according to Ellis, and these muscles actually shorten the foot in walking, instead of lengthening it, as the older anatomists supposed. This shortening of the foot in propulsion of the body may be further seen on running bare- footed in the wet sand of a sea- beach, and it may be demon- strated by instantaneous pho- tography. Instead of the natural foot, the student has to deal with artificial types of an infinite variety that the ignorance of the shoemaker and the vanity of the wearers of shoes have succeeded in producing. The type most common, when ob- served from its plantar surface, is seen to be made up of two truncated triangles opposed base to base, and this double base rests on a curve which separates the toes from the rest of the foot. The axis of the great toe, instead of passing through the middle of the heel when extended backward, takes a very erratic inward course, as seen in Fig. 1150, which represents a foot only moderately deformed. The symptoms following defective covering of the feet constitute a painful picture of petty misery almost too well known to require mention. Forced deviation of the toes, bunions, corns, ingrowing nails, painful bursae, and the like, are some of the inconveniences and disad- vantages of so-called elegant shoes. Muscular alterations, pains, inflammation, and contracture of the peronei mus- cles, accompanied by considerable paresis, have also been noticed in girls addicted to high heels. Another result- ing inconvenience arises from the intimate relation with the general state, particularly that of menstruation, for it is common to find difficulty in this function and con- gestion of the ovaries directly traceable to this cause. Diminished volume of the foot, consequent upon com- pression of its vessels, may also retard the development of the bones of the leg, the thigh, and pelvis, thereby ad- ding to the difficulty and danger of parturition. Besides, the atrophy of the nerves leads to some of the phenomena that are observed in persons who have had limbs ampu- tated-the spinal cord may become affected, and the vulva, by way of compensation, may take on an inverse de- velopment. Sympathetic bubo also may result from the irritation of a corn on the toe, which often causes long- continued or incurable lameness, and even death. The writer knows of two recent cases of phlegmon of the en- tire limb, following the interference of a chiropodist, and of two instances within the last year, in which useful men died of gangrene following the application of a nostrum to a soft corn. Nor is the influence of bad shoes confined to the physical domain ; for it may also repro- duce itself in the moral feelings. Who does not know of the lowr spirits, bad humor, chagrin, loss of serenity, and general misery arising from badly fitting shoes ? In military life this apparently trivial detail often be- comes a question of grave interest. High authority as- serts that a soldier without shoes is no longer a man ; * that in w'ar military virtue cannot replace good shoes; and that victory may depend on this detail so little epic in appearance. The reigning king of Prussia, in 1769, having noticed by daily observation the accidents that may result from the fatigue of marches, caused inspec- tion of the feet of his soldiers. Marshal Saxe says the whole of tactics is in the legs, and that the nation who shall have given to its troops the best shoes will have over its enemies the immense advantage of keeping its men always ready for marching. Napoleon said that he made wTar not with the arms but with the legs of his soldiers ; and Wellington, who regarded two things especially ne- cessary to the soldier, namely, a pair of good shoes on the feet, and a pair of good shoes in the knapsack, noti- fied his government, during the Peninsular campaign, that his army could not march unless they had shoes. The shoes did not come, and in the meantime the enemy marched away. Marshal Niel, in a speech to the Corps Legislatif, in 1868, said, " Shoes have for infantry the im- portance that horses have for cavalry." Army statistics show that from tw7enty-five to thirty per cent, of the effective force are more or less crippled in the feet in the first day's march, and that ten per cent, require the care of the surgeon. In the army of the Po- tomac whole brigades were often incapacitated from this cause. With a viewr to remedy this absurd state of things, the more progressive members of equipment boards have recommended a shoe more in accordance with the shape of the foot than the one now worn, and the Quartermaster's department has caused to be translated for distribution the prize essay " On the Military Shoe," by Major Salquin, of the Swiss* infantry. Unhappily, many of these excellent suggestions meet with the same spirit of resistance that opposed the introduction of percussion caps, and after- ward of breech-loading arms, into the army ; and w ith the a b Fig. 1149.-Plantar Sur- face of Normal Foot. Fig. 1150.-Plantar Surface of a moderately Deformed Foot. 6 * On the other hand, Dr. Phoebus says that the softest, the least pain- ful, and the most appropriate shoe for the infantryman is air.-Zur Fuss-Cultur beim Soldaten, Berl. Klin. Woch., 1886, No. 31. 55 Feet. Feet. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. thoughts provoked by dental instruments, or the middle age appliances of the Inquisition. With scarcely an ex- ception these lasts are wanting in even the rudimentary curves of the foot. The bottom is curved from before backward as if the foot were a rigid immovable rocker; toward the toe it is wedge- shaped, and so constructed that a shoe made upon it gives the foot the appear- ance of having a section of nearly an inch in width sliced from the long curve on the outer margin ; the instep is pressed downward and backward, and the high ridge of the last is along the middle line instead of being on the inner margin. To illustrate the latter essential points, and at the same time to emphasize the de- naturalization, especially in its transverse dimensions and the form of the anterior extremity, the writer presents the accom- panying diagrams of sections through a frozen foot, which are compared with similar sections of a last obtained from a fashionable shoemaker. In both instances the sections were made through what shoemakers call the ball, the exception of some few improvements, the shape, style, and make-up of the soldier's shoe still await a practical Fig. 1151.-Transverse Section through " Ball " of a Frozen Foot compared with a Section of Shoemaker's Last. and definite solution-lie being still shod with a view to satisfy administrative neeessities rather than the de- mands of hygiene and well-being. This is all the more astonishing when it is remem- bered that the operations of war and the wonders accomplished in a campaign depend more or less on rapid marching and timely arrivals. In civil, as well as in. military life, the ad- vantages to be derived from comfortable feet are of equal importance. The first care neces- sary for their preservation is not to hinder the circulation by too tight coverings, and this prophylactic indication cannot be carried out effectively unless the shoes have been properly constructed on a last having the curves and proportions of the natural foot, in the me- chanical construction of which there is no primitive difference, all normal feet being per- fectly alike, except as regards length and width ; and any differences are only altera- tions of form produced by shoes. Yet this fundamental principle is almost totally ignored in the construction of lasts and shoes. To look at the lasts in any shoemaker's shop af- fords ground for a sad commentary on the artistic taste and intelligence of the age that offends one to the heart. These outward and visible signs of deformity and discomfort are totally at variance with correct principles and aesthetic taste. The same may be said generally of the collection of lasts and shoes in the United States Patent Fig. 1153.-Transverse Section of Frozen Foot through Instep compared with similar Section of Shoemaker's Last. waist, and the instep. The drawings are mathematically exact, being traced from the sections themselves. The dotted outline is that from the last. The importance of having the highest vertical part of the last on the inner mar- gin, especially above the ball of the great toe, and not by its side, is the more urgent for the reason that the foot in the act of propulsion undergoes a rising almost en- tirely on the inner side, owing to the pow- erful action of the long flexors, which ac- tion, as before remarked, shortens rather than lengthens this organ. To secure the free action of the flexor muscles is an ad- ditional reason why the sole of the last, and consequently the shoe, should be flat to the end ; for if the sole is turned up and stiff, these muscles cannot act with full effect. Moreover, when acting to their full extent they also approximate the inner side of the foot to a straight line ; hence the inner margin of the boot should be straight or nearly so, to pre- serve this special feature. The sole should also conform to the natural outline of the foot, the outer margin of which is a long curve, Office, which suggests a teratological cabinet, or the carv- ings of primitive tribes, and fills one's mind with the Fig. 1152.-Frozen Section through "Waist" of Foot. 56 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Feet. Feet. Most shoemakers, however, leave an unoccupied an gular space around the little toe, which is contrary to nature, and is neither useful nor ornamental. Shoes with a rounded point are therefore to be preferred, provided the point is not in the middle, and the internal side approaches a straight line. High heels interfere seriously with the regular form of the foot, as well as efficacious stability, and con- sequently prevent a graceful walk; and they may cause flattening of the foot. In addition to a broad, low heel, and a flexible sole, the upper of the boots should be of flexible leather without the unyielding canvas lining which prevents the leather from stretching, and consequently interferes with the suppleness and elasticity of the foot. The eminently vicious system of measurement followed by most shoe- makers allows nothing for the enlarge- ment that the foot undergoes toward evening, and more especially with the weight of the body. These Procrus- tean measurements are taken in a sit- ting position, with the foot elevated and the great toe everted and drawn up ; a vicious and exaggerated direc- tion that is further involuntarily main- tained by the stocking. In order to obtain the form and division of the sole, the internal extremity of which ought to offer a slightly rounded obtuse angle for the easy lodgement of the great toe, the measure should be taken on the naked foot. For this purpose it has been recommended that a vertical line be traced on a leaf of paper, the two naked feet being placed by it in such a manner that the metatarso-phalangeal ar- ticulation and the internal part of the heels shall be flush with the line, when a pencil tracing is made of the inter- mediary ellipse, and two other lines parallel to the first are drawn tangentially to the salient part of the fifth metatarsals. Taking the measure of the foot from the outline of the sole and making the shoes very large, as is done by so-called anatomical shoemakers, who for the most part are the veriest frauds and humbugs, fails to ease the foot or prevent the evils to which it is subject. Shoes made after such exaggerated and abnormal proportions fail to fulfil the desired conditions, "because, not being modelled after the curves and propor- tions of the natural foot, they do not hold the great toe in its normal posi- tion. The use of shoes made after the model proposed in the foregoing re- marks will be found highly advanta- geous to children; and adults, whose feet are without exception, more or less de- formed by the present style of shoe, will experience renewed strength and comfort in the feet, which will gradu- ally recover their natural form. Nor is the proposed form open to aesthetic ob- jections. Shoes corresponding to the plan just pointed out require only the technical art of a good workman in order to fit as neatly as a kid-glove, and have absolutely true beauty; while the same cannot be said of the compressed and unnat- ural pedal extremities which convention, habit, and prejudice have accepted in opposition to all the canons of loveliness. guard against the effects of uncleanliness is an injunction respecting the hygiene of the foot which equals in im portance the fabrication of the shoe. The normal phe- nomena of the foot are sensibly modified by the mode of life which is inflicted upon it, and this modification is particularly noticeable in the vitality of the skin, which, in this region, is rich in voluminous sudoriparous glands, and is subject to abundant epidermic desquamation. This excretive waste, being confined by the coverings of the foot, softens the skin and renders it sensitive, unless strict attention be paid to cleanliness both of the feet and stockings. In fact, the neglect of these small attentions, especially in warm weather, is a prolific source of irrita- tion that often develops into a traumatism. In persons of rheumatic or eczematous diathesis there is often an exaggerated sensibility of the feet which is increased by want of cleanliness ; and in many persons with delicate skins local irritation is produced by woollen or by dyed stockings. The physiological relations of the feet, the pelvic vis- cera, and even of the brain are matters of medical knowl- edge, though constantly overlooked. The feet must act according to cerebro-spinal impulse, and if the action be interfered with, it requires no great neurological knowl- edge to foretell the result. Pains in the feet often precede an attack of rheumatism or of eczema ; cold applied to these members may develop an inflammation in some other region of the body ; and the fact of its producing a desire to urinate has been taken advantage of by persons suffering from atony of the bladder, who have only to walk or to stand barefoot on a cold surface in order to produce the desired effect. All physicians know the de- rivative effect of a warm pediluvium, also of the cutane- ous revulsive action of Ju nod's boot in cerebral, spinal, and pulmonary hypertemias, and everyone knows of in- somnia from cold feet. The shape and condition of the stockings contribute much toward maintaining freshness and efficiency of the feet. As a matter of necessity they should be kept per- fectly clean, and should correspond to the natural shape of the foot by having a straight inner line, so as to avoid outward diversion of the big toe, and the consequent bringing of its culminating point in the middle line of the foot. A separate stall for the great toe is to be recommended when this .digit has undergone great dis- tortion. The form of clothing for the feet is of great importance in relation to frost-bites and chilblains of these members. In the way that people are generally shod these acci- dents occur from cold of even a moderate degree, but with proper foot-gear they should be rare during the coldest weather. Frost-bites are unusual among Eskimo and among Arctic travellers, who adopt the mode of protecting the feet with reindeer stockings and seal-skin boots, in the bottom of which is placed a layer of dried grass or straw. The personal experience of two polar ex- peditions convinces the writer that no other form of foot covering at present known affords greater protection from extreme cold. It seems almost superfluous to reiterate the necessity of frequent foot-baths, and the advice is thrown away on many persons who do not wash any part of the body, not even the feet. Washing does not make the skin tender, as many erroneously suppose ; on the contrary, by pro- moting nutrition it prevents, in a measure, the incon- venience of bad-fitting shoes and the formation of corns and callosities. When one is foot-sore after a day's fa- tigue, the immersion of the feet in a cold bath relieves the sensation of burning, and at the same time has a soothing and reviving effect. Nothing is to be feared from the supposed imprudence of this method of relief. It may cause fear in Continental Europeans, who are gen- erally averse to cold water, but daily experiences of mod- ern hydrotherapeutics have proved that this fear is with out foundation. Promotion of the general health is an additional advantage that accrues from frequent bathing of the feet. It also lessens the tendency to contract cold and pulmonary affections. Sir Astley Cooper, who passed thirty consecutive years without a cold, attributed this Fig. 1154.-Cor- rect Outline of Sole. Fig. 1155. - Cor- rect Outline of Sole. The next object of solicitude in regard to preserving the feet in good condition is perfect cleanliness. To 57 Feet. Feigned Diseases. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. immunity to the daily habit of bathing not only his feet, but the entire body, with cold water. It is, moreover, re- lated that he wore thin silk stockings in midwinter, and generally went without an overcoat. The best time to bathe the feet is just before going to bed, and delicate or elderly persons, afraid of the effects of cold, will find an excellent preventive in the habit of taking first a very hot foot-bath, which is to be followed by plunging the feet in cold water. Ointments, lotions, and the like, all of which have been used to preserve the feet, are useless and need be men- tioned only to be condemned, since the use of proper shoes with cleanliness excels all other attentions, hygienic or medical, that the feet require. The minor operations of the pedicure hardly come within the present scope. Indeed, the guiding principle of the foregoing plea for the much abused foot is the doing away with the neces- sity for the existence of such things ; and it is believed that popularizing the order of ideas just advanced, regard- ing the hygiene of the foot, will answer to the present as well as to future wants. For further details see Nystrom (Le Dr. A.): " Du pied et de la Forme Hygienique des Chaussures," Paris, 1870 ; Rohmer (J.): " Les variations de forme normales et pa- thologiques de la plante du pied etudiees par la methode graphique," Nancy, 1879; also Starcke (Dr. Paul): " Der Naturgemasse Stiefel," Berlin, 1881. Irving C. Rosse. able. Not only are the more ordinary methods of cun- ning, mimicry, and falsehood employed, but even such material devices as spectacles, trusses, bandages, eschar- otics, blood, dyes, and even cutting instruments are oc- casionally resorted to. The affections that are feigned belong to every depart- ment of medicine. The physician meets with all sorts of aches and pains, neuralgic or rheumatic, acute or chronic, fevers, diarrhoea, dysentery, incontinence of urine, chorea, epilepsy, hysteria, catalepsy, haemorrhages, apoplexy, imbecility, insanity, coma, and even death. But fre- quently such a varied array of symptoms is presented as to scarcely suggest any known affection. The surgeon meets with simulated fractures, dislocations, sprains, anchyloses, ruptures, strictures, ulcers, tumors, etc. Near-sightedness, photophobia, cataract, blindness, otor- rhoea, and deafness, as well as a number of artificially produced lesions of the eye and ear have been recorded by the specialists in these departments. Phantom tumors, pregnancy, abortions, prolapsus of the uterus or vagina, and many minor ailments are encountered in practice among women. Means of Detection.-The greatest source of error in the diagnosis of feigned diseases lies in the hasty and incomplete examination of cases so common in private practice, and even in hospitals, the statements of the malingerer being taken at face-value, and treatment im- mediately prescribed. While it would be highly im- proper to examine every patient as though he were an impostor, the physician should at all times remain open to suspicion; and, while still holding every man inno- cent until he has been convicted, he should investigate every indication of deception, with the same care as he would an indication of disease, at the same time carefully guarding against the more serious error of an unjust con- viction. The discovery of any probable cause for decep- tion, as a desire for a change of climate or associates, a month's recreation, etc., is often of great value. Fort- unately, the very methods upon which the impostor reposes the greatest confidence are frequently those which first arouse the suspicion of the examiner. It may be that the train of symptoms is narrated with an ease and familiarity that at once suggests study ; an undue degree of anxiety may be manifested for the impression that is being made as the case is portrayed, or insignificant symptoms are emphasized to the exclusion of others of more real importance. No matter how carefully the pre- tender may have studied his case, he is sure to omit some important detail. The origin, exciting cause, and course of the malady should, therefore, in all cases be inquired into. The asking of contradictory and irrelevant ques- tions will generally lead to confused and contradictory answers. In many instances, too, where a decision can- not be reached at the first interview, all doubt will be dispelled by subsequent examination, or by secret ob- servation after the impostor has begun to relax his prim- itive vigilance. An unexpected visit will sometimes find the bed-ridden or paralytic impostor up, and enjoying the luxuries of health. Bandages, splints, trusses, and other apparatuses should not be regarded ; and anchyloses and spasmodic affections often disappear under the adminis- tration of an anaesthetic. Haemorrhages are usually feigned by the use of colored fluids, or the blood of ani- mals, which may be revealed by microscopic examina- tion ; but occasionally the individual obtains blood from existing lesions, or from self-inflicted wounds, which should be searched for. Defective sight and hearing, although among the most difficult of simulation, are among the most frequently selected for the purpose. The deception is generally de- tected without difficulty. The aimless stare and the rest- less eyelids of the blind are seldom well imitated, and the application of glasses will soon confound the pretended myope, while the ophthalmoscope will disclose a normal condition of the eye. The feigning deaf man exaggerates his efforts to hear, and is usually without much difficulty confused by remarks uttered in a low tone in the midst of a loud conversation. The best general rule for the detection of a majority of 1 Calceus Antiquus et Mysticus : Paris, 1615. FEIGNED DISEASE. The wilful simulation of dis- ease or injury, through malice or for the purpose of at- taining a desired end. The semblance of diseased conditions of mind or body has always been a favorite method with all classes of people, for securing betterment of condition, or relief from oppressive duty, to escape punishment, or merely to attract notice and sympathy. In a broad use of the term, feigned diseases include all those affections which, although purely imaginary, and having their origin in some deranged psychical function, are as real to the pa- tient as though they arose from pronounced bodily lesions. These, however, receive appropriate considera- tion under the titles Hysteria, Hypochondriasis, etc., the present article referring only to those cases in which the individual deliberately and studiously endeavors to de- ceive. Not only is simulation free from limitation to any par- ticular class or race of individuals, but it is practised about equally by both sexes, and at every period of life : from childhood, with its pretended aches and pains, to old age, with its exaggeration of infirmities. By far the most persistent efforts at deception are those which occur in times of war, when men seek in this manner to evade the draft, or to escape duty in battle. Probably the most frequent attempts at deception in times of peace are made by the idle poor and vagrants, for the purpose of gaining admittance to our asylums and hospitals ; but the boards of pension examiners and the medical officers of all char- itable institutions are burdened with the appeals of ma- lingerers, and the private practitioner is by no means infrequently confronted with imposture. The means em- ployed, and the persistency with which they are practised, are determined for the most part by the individual's ex- perience with disease ; the success of the attempt, as also the skill with which it is executed, naturally depends upon his knowledge of symptoms, and the degree of nat- ural cunning which he possesses. The disease that is imitated is usually one with the symptoms of which the pretender believes himself perfectly familiar. In this regard, however, he is generally greatly in error, and the imitation is rude, and easy of detection. But when those who have had abundant opportunity of observing the phenomena of disease attempt the deception, their sim- ulation is likely to be more accurate. The resources of the malingerer are the most varied, and at times there is displayed an amount of ingenuity worthy of a better cause, and the inconvenience and act- ual suffering that is endured is sometimes truly remark- 58 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Feet. Feigned Diseases. the cases that come before the physician, is the careful study of the differential diagnosis of the affection that is feigned. Treatment.-The judgment of the attendant is at times more severely taxed with the treatment of his case than with the diagnosis of it. Not infrequently, when he is brought to realize at once the evil that is intended to others, and the degree to which his own professional dignity is compromised, it is with difficulty that he can refrain from resenting the insult and exposing the decep- tion. Should he be acting in an official capacity, this is in fact his only course ; but in private practice it is fre- quently more prudent to attend the case as one of real illness, guarding against the danger of appearing parti- ceps criminis by the giving from time to time of such ad- vice as shall frustrate the evil design of the impostor. • If medicinal treatment is employed at all, it should be done with caution, and should be directed against some real ailment, however trifling. Occasionally the pretender, recognizing the failure of his efforts to deceive the med- ical attendant, will appeal to him for aid in the accom- plishment of his deception ; it is, then, in most instances, advisable to dissolve all relation to the case. James AI. French. the peculiar ash-colored, goose-tlesh-like surface to be seen in tinea tonsurans. Microscopic examination of the short hairs will, as in the case of favus, show the char- acter of the disease. Scabies may be simulated by careful tearing up of small portions of skin by the aid of a tine needle. The absence of the peculiar and characteristic burrow of the itch in- sect, and the impossibility of demonstrating the presence of the acarus, make it an easy matter to detect a fraud of this sort. Bromidrosis.-Among the means resorted to in France to avoid conscription, the production of fetid odors ap- pearing to proceed from the sweat-glands finds a place. Alt hough this mode of malingering has not gained a place in this country, it is worth mention-the inunction of the axillae with Dippel's animal oil, grease mal-odorized by asafoetida, decayed fish or cheese. Frauds of this sort are easily detected if the suspected person can be cleansed thoroughly and placed under surveillance for a short time. Carbonate of sodium and permanganate of potassium can be used for disinfection. An additional mode of detec- tion is the examination of the soles, which in true bromi- drosis present a macerated appearance. After thorough cleansing, if the supposed malingerer is caused to sweat violently, the perspiration freshly secreted will show whether or no true bromidrosis is present. Hamatidrosis is in fact a haemorrhage which occurs over a smaller or greater area of unbroken skin. In many cases it is to be considered as one of the nervous symp- toms of hysteria in the young, particularly in young fe- males, and though sometimes genuine, is not infrequently simulated. Careful surveillance, with examination to make sure that the blood of some animal be not substi- tuted, or some minute punctures practised, will alone suffice to make the diagnosis plain. (See Haematidrosis.) Chromidrosis has frequently been simulated, and in fact, the existence of some forms as genuine diseases was denied for a considerable time. Black chromidrosis, in particular, was held in great suspicion. But the careful investigations of several experts, particularly in France, have placed the existence of the disease beyond question. Plumbago, soot, indigo, pure or mixed with talc, have been employed to imitate the peculiar blue-black of some varieties of chromidrosis. To discover a fraud, the part should be carefully washed, examined with a lens, and kept under careful observation, or covered and sealed. Microscopic examination of the substance appearing on the surface will sometimes throw light on the materials composing it, and thus lead to a discovery of the gen- uineness or falsity of the supposed chromidrosis. Black chromidrosis is the only form which has been simulated. For the description of this, as well as the other forms of chromidrosis, reference may be made to the article on that subject. Vesicular and Pustular Eruptions (dermatitis, eczema, etc.).-1. Imitated Eruptions.-Croton-oil and other irri- tants are used by malingering soldiers and others to pro- duce pustular eruptions, and sulphur, turpentine, pitch plasters, mercurial ointment, are also employed for the same purpose. All these substances give rise to con- fluent vesicles becoming rapidly purulent, or to vesico- pustules covered with a thick crust. Mechanical irritation may be employed, with the result of giving rise to eruptions resembling dermatitis. Sangster described the case of a young girl, first as " abortive herpes," and later as " neurotic excoriation," where pain- ful erythematous patches were succeeded by exudation on the surface of serum and sero-pus, each patch termi- nating in desquamation, and running its course in ten to fourteen days. There was no vesiculation or loss of sub- stance. The longest interval during which the patient had been free from the lesions was three months. The case was under observation at intervals for three years, but finally Sangster was able to satisfy himself that the lesions were produced purposely by forcibly tearing with the nails. Stelwagon has described the case of a girl of nineteen, pale, nervous, and suffering from hysterical aphonia, who applied for relief for an eruption which had per- FEIGNED DISEASES OF THE SKIN. These are often very difficult of diagnosis. On the one hand, care must be taken not to mistake professional eruptions as bakers', bricklayers', sugar-boilers', bartenders' eczema, or the eruptions produced by the ingestion of drugs (see Derma- titis Medicamentosa) or of certain edibles for factitious eruptions ; and, on the other hand, it must be remem- bered that various skin diseases may be closely simulated by artificial means, and that such deception may be kept up for months. In the case of soldiers and prisoners, where fraud may be suspected, such measures as bandag- ing, surveillance, etc., may be practised ; but among hys- terical females of the better classes the difficulties of diag- nosis are heightened by the fact that factitious eruptions may be caused by a sort of automatic mental impulse, and without any perceptible object. Also, in these latter cases, the betrayal of any suspicion on the physician's part that he has to deal with an artificial eruption will be received with extreme indignation, not only by the patient, but by her friends, and the opportunity of relieving the case will probably be lost if a frank avowal of his suspicions should be made by the physician in attendance. Laugier (" Diet, de Med. et de Chir. Pratiques," article Maladies Simul6es) gives a classified description of the various affections of the skin commonly simulated. Sy- cosis has been imitated with greater or less success by means of applications of tartar emetic ointment, which produces umbilicated pustules followed by thick crusts. Oil of cade produces a similar eruption. Sequestration of the patients beyond the reach of irritating substances is followed by a rapid cure. Even close observation of individual lesions for a few days will show the presence of the artificial eruptions, as the lesions run a rapid course, while those of sycosis are much more persistent. Favus is imitated by dropping nitric acid on circum- scribed areas of the scalp, protecting the neighboring parts by a circle of grease or ointment. This produces lesions resembling the yellow cups of favus, but to be distinguished certainly by microscopic examination, which in the case of favus infallibly shows the presence of fungus. Favus is such a rare disease in this country that it is not likely to be simulated often. As its presence permitted the French conscript to avoid service in the army, simulation of favus was formerly not uncommon in that country. Alopecia areata may be simulated by plucking the hairs over a circumscribed area, but a close examination will show traces of this rather violent operation, and surveil- lance even for a few days will permit the growth of new hairs to be perceived by the eye before they grow long enough to allow of a fresh epilation. Tinea tonsurans is simulated by the partial destruction of the hair by means of depilatories. These, however, give rise to an irritation of the skin quite different from 59 Feigned Diseases. Fermentation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sisted almost uninterruptedly for three months, and which consisted in groups of two or more parallel, elongated, crusted lesions, situated on the flexor and extensor sur- faces of the forearms and on the tibial surfaces of the legs, with eczema form patches in the flexure of one elbow and on one instep. The crusts resembled those of impe- tigo contagiosa. The patient, who had been for some time unsuccessfully treated, was soon suspected of simulation, and finally confessed having produced the lesions by con- stant rubbing with the finger-ends. The sensation thus given was an agreeable one, and it was this, she asserted, and not the desire to gain sympathy, which was her ob- ject. The writer has observed several similar cases occurring in young women, where, however, no clew could be gained as to the cause of the eruption. In one case ery- thematous patches of irregular shape, soon yielding to slight exudation and crusting, or occasionally to denuda- tion of the skin, occurred on the face, backs of the hands, forearms, and occasionally the legs. The eruption usually occurred about the menstrual period. The erup- tion seemed to be a dermatitis. It was accompanied at first by a burning sensation, but gave no trouble after- ward. The eruption seemed to be a source of great shame and annoyance to the patient. Although it was suspected of being factitious, no proof of this could be obtained. Under the name "so-called erythema gangrenosum," Dr. T. C. Fox has described two cases, in one of which large rounded or oval patches of gangrenous inflamma- tion of the skin of the neck and arms appeared succes- sively or at intervals for several years, leaving in some cases faint scars, in an hysterical woman of forty-five; while in the other case, a girl of seventeen, there existed erythematous areas of a severe type, like scalds, running into vesiculation and drying up without scars. The lo- calities affected in the latter case were the mammae, fore- arms, thighs, and legs. In order to make a diagnosis in cases of feigned eczema or dermatitis, regard must be had to the general condi- tion of the patient, mental and physical; the objects of simulation, should these exist, must be inquired into, and the appearance and distribution of the eruption carefully examined. It will almost invariably be found that there is something lacking to complete the picture of the dis- ease. Either it is too abundant or too scanty, or it oc- curs in unusual localities, or the component parts of the eruption-the vesicles, pustules, crusts, etc.-are unusual in appearance and development. It must be remembered, in connection with the locali- ties affected by feigned eruptions, that these occur upon easily accessible parts of the body, such as the face, breast, forearms, and legs. 2. Sustained or Aggravated Eruptions.-The diagnosis in these cases must be made, not as to the nature of the eruption, originally a spontaneous one, but as to the cause of its persistence. Such cases not infrequently occur in large hospitals, when the soothing applications made dur- ing the day by the physician are replaced at night by ir- ritants. Hermetic occlusion of the affected spot or local- ities, with surveillance, will unmask the fraud. Pemphigoid Eruptions.-Bazin has reported a case in which a young girl succeeded in producing an eruption of bullae by introducing cantharides powder under the epidermis. Duhring saw a case under the care of the late Dr. Fagge, of London, in which a young girl caused an eruption of bullae resembling those of pemphigus, by the application of nitric acid to the skin. A careful study of the course pursued by the eruption, together with an ex- amination of the buccal and pharyngeal mucous mem- branes, and a consideration of the patient's general health, will throw light on the character of the eruption. Rupia(ulcero-crustaceous syphiloderm ?) is said to have been imitated by the ingenuity of French malingerers, but as this eruption is usually accompanied by profound cachexia and other signs of malignant syphilis, it is not difficult to distinguish the true from the false eruption. Papular Eruptions, particularly urticaria, are occa- sionally simulated by the application of nettles, etc., or by the ingestion of substances known to produce the eruption. As these eruptions are transitory, the subjects of them must usually be hysterical persons, as malinger- ers would hardly be likely to take the trouble for nothing. The absence of concomitant general symptoms must be relied upon to establish a diagnosis, in connection with the precautions mentioned above, e.g., surveillance, etc. Ulcers.-The factitious production of ulcers has been a practice of malingerers and deceivers of all ages. Va- rious animal, vegetable, and mineral substances have been employed to cause such a destruction of tissue as shall simulate a true ulcer. Oil of cashew nut, cantharides, the clematis vitalba or common virgin's bower (a former remedy for scabies), the ranunculus sceleratus, a species of crowfoot, the anemone pulsatilla, the euphorbia lathy- ris, bryony root, savin, nitric acid, potassa caustica, and frequently caustic lime. This list, given by Laugier, is inserted to aid the diagnosis in doubtful cases, but com- monly there are certain features of the factitious ulcer which will serve to distinguish it from other affections with which it is liable to be confounded. Thus the ap- pearance of the sore and its surrounding parts, the condi- tion of the" patient, and the probability or not of any ad- vantage to be gained by simulation. In the lower limbs the presence or absence of varices, dermatitis, eczema, previous gummatous swellings, etc., should all be taken into account. See also the description, in other parts of this work, of diseases apt to give rise to ulceration, e.g., cancer, epithelioma, scorbutus, scrofula, syphiloderma, ulcers, dermatitis medicamentosa, etc. In the case of genuine ulcers kept up by stimulant or irritating sub- stances, hermetically sealing the part and surveillance are required. Erysipelas is occasionally simulated by the application of irritants. Thapsia is employed for this purpose in Eu- rope. The artificial dermatitis thus produced does not, except to the most superficial view, resemble erysipelas; there is little or no fever, no general symptoms of any kind, in fact, and the affected surface commonly shows minute phlyctenulae or numerous minute vesicles. Phlegmon or abscess is occasionally produced by exces- sive stimulation of the surface, or by the introduction of foreign objects under the skin. The malingerer or simu- lator must, in these cases, not only possess unusual forti- tude to induce painful lesions of this sort, but must also be sufficiently alive to the pathological necessities of the case to put his sticks and thorns, or what not, in places where such objects would be apt to become imbedded. Such simulations are not always without danger. Hut- chinson gives a case in which amputation had to be per- formed as the result. Laugier. Maurice: Simuldes (Maladies), Nouveau Dictionnaire de Med. et de Chir. Pratiques, 1882, vol. xxxiii. Bazin: Lemons Theoriques et Pratiques sur les Affections cutanees ar- tificielles. Paris, 1862. Le Roy de Mericourt: Memoire sur la coloration partielle en noir ou en bleu de la peau chez les femmes, Arch. Gen. de Med., Novembre, 1857, 5e Serie, t. x., page 340. Fox, Tilbury : Feigned Erythema Gangrenosum, Lancet, October 30, 1875. Fox, T. Colcott: Notes on two cases of so-called Erythema Gangrenosum, Jour. Cutaneous and Venereal Dis., 1884, vol. ii., p. 9. Stelwagon : A Case of Feigned Eruption, Archives of Dermatology, 1882, vol. viii., p. 236. Bulkley: Remarkable Case of Feigned Eruption, Archives of Dermatol- ogy. 1880, vol. vi., p. 256. The Manufacture of Stigmata, British Med. Jour., 1876, vol. i., p. 204. Fox, T. Colcott: On two cases of Chromidrosis in which a blue-black pigment exuded from the skin of the circumorbital regions, Clinical Society Transactions, vol. xiv., p. 211, 1882. Report of the Committee on a case of Doubtful Chromidrosis, etc., ib., p. 255. Fox. T. Colcott : A Case of Feigned Skin Disease (excoriation), Lancet, 1882, vol. ii., p. 1109. Murrell: Feigned Skin Diseases (excoriation), Lancet, 1883, vol. ii., p. 477. Startin, Jas. : Feigned Hysterical Diseases of the Skin, Brit. Med. Jour,, 1870, vol. i., p. 25. Fagge-Birkett: Notes on Some Feigned Cutaneous Affections, ib., p. 157. Roberts, W. : Cases of Motiveless Simulation of Disease, ib., p. 307, Flower, T. : Feigned or Hysterical Diseases of the Skin (excoriation), ib., p. 307. Fortner, I. B. : Feigned Skin Diseases (excoriation), Lancet, August 25, 1883. Squire, B. : Simulated Alopecia (areata?), Brit. Med. Jour., 1873, vol. ii., p. 398. Bibliography. 60 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Feigned Diseases. Fermentation. Sangster: A Case of Abortive Herpes, Clinical Soc. Transactions, 1878, vol. xi., p. 212. Ib., A Case of Supposed Neurotic Excoriation (supplementary to the above), Archives of Dermatology, 1882. vol. viii., p. 46. Foote, Pavilly : Simulated Black Sweat, Dublin Jour. Med. Sci., 1869, vol. xlviii., p. 79. (See also Lancet, 1861, vol. ii., p. 364 ; Med. Times and Gaz., 1861, vol. ii., p. 152.) Wilson,'Geo. : Feigned Diseases, Edinburgh Med. Jour., 1871, vol. ii., p. 530. Mackintosh : Attempted Simulation of Disease, Black Spots, etc., Can- ada Med. Jour , 1870, vol. vi., p. 529. Mattei: Maladies Simuldes; Hemorrhagies spontanees par les doigts; erysipelas, etc., Rev. Med., 1850. vol. viii., p. 370. Tufnell: Simulation of Venereal Ulcers, Dublin Hosp. Gaz., 1859, N. S., vol. vi., p. 24. Arthur Van Harlingen. consumed as a flavor in cordials, as a spice, and in vet- erinary practice. Dose, the same as anise. Allied Plants and Drugs.-See Anise. IF. P. Bolles. FENUGREEK (Semen Fenugraci, Ph. G. ; Fenugrec, Codex Med.). The seeds of Trigonella Foenum-gracum Linn. Order Leguminosce (Papilionea). An annual, in- digenous to Southern Europe, etc., but cultivated for centuries both there and in India. It is an erect, branch- ing herb, with white flowers, and long, slender, pointed and curved, several-seeded pods. The seeds are about one-eighth of an inch long, oblong, shrivelled or compressed, and brownish-yellow; taste, bean-like; odor, fragrant, resembling cumarin. They contain a little fetid fat, some resin, mucilage, and albu- minous substances. The odorous principle is not yet isolated. Fenugreek is at present only used in this country in veterinary medicine, but is largely consumed in India and other parts of Asia, in various ways. It has no partic- ular physiological action. Allied Plants.-For the Order see Senna. W. P. Bolles. FELLATHALQUELLEN, or Vellach, in Karnsten, Aus- tria, near the railroad station Kiihnsdorf, is noted for its pure alkaline springs. These exude from the base of the northern slope of the Alps, at an altitude of 2,750 feet above the level of the sea. Their waters are rich in so- dium carbonate, potassium carbonate, and sodium sul- phate, with an abundance of free carbonic acid. The temperature of the water at its source is 48° F. It may be drunk plain or with wine, and is now exported in large quantities, chiefly to surrounding provinces. Every comfort is afforded residents at the springs. The chief indication for the administration of the water of Fellathalquellen is found in the catarrhal states of the urinary passages. It is recommended also in catarrhs of the respiratory organs, and favorable results have fol- lowed its administration in dyspepsia and gastric catarrh. J. M. F. FERMANAGH. A county in the northwest of Ireland in which are situated about twenty mineral springs and wells. These are divided into two classes, characterized respectively by the presence of iron or sulphuretted hy- drogen. In the first class belong the waters of Churchill, Killinshan Valley, and several others, each containing a small amount of iron. Among the second class are Ash- wood, Kesh, Lisbleak, etc. Little importance is now at- tached to these springs, however, both on account of the inaccessibility of the region in which they are situ- ated, and because they possess no virtues which are not shared or surpassed by many other - waters. The spring at Ashwood is well suited as a resort , both because of the beauties of its environment and its proximity to Ennis- killen. Its water, in addition to free sulphuretted hydro- gen, contains some soda and lime, traces of iron and car- bonates, with chlorides and sulphates in small amount. J. M. F. FELSENQUELLE. A spring situated at the extremity of the Muhlbrunn Colonnade, on the left bank of the Tepel, at Carlsbad, Germany. Although enclosed since 1844, it has never attained the repute of either the Spru- del, the Schlossbrunn, or the Muhlbrunn ; yet it is con- sumed in considerable quantities. Its temperature is 138° F.; chemically it differs little from the more promi- nent springs in its vicinity. (See Carlsbad.) J. M. F. FENNEL (Faniculum, U. S. Ph. ; Fomiculi Fructus, Br. Ph. ; Fructus Faniculi, G. Ph. ; Fenouil Doux, Co- dex Med.). The fruit of F&niculum Capillaceum Gillib. (F. vulgare Gaertn.). Order, Umbelliferce. This is a perennial or biennial herb with a tall, smooth, green, branching stem, and pinnate, skeleton-like leaves, the latter consisting of but little more than straggling, branching midribs and veins, arising from broad concave, half-sheathing petioles. Umbels compound, naked, many- flowered. Flowers yellow, fruit oblong or ovate. Fennel is a native of Southern Europe, Western and Southern Asia, etc.; it exists in several varieties, and has been long and extensively cultivated. The mericarps are slightly adherent and occasionally attached to each other, but may be easily separated by rubbing. The entire fruits are oblong or ovoid, terete, from one-half to one centimetre (£ to 5 inch) in length, greenish-brown in color, and smooth. Each mericarp is slightly curved, with three blunt dorsal and two more prominent lateral ribs. Vittae six, four dorsal and two ventral. Odor characteristic, anise-like, agreeable. Taste aromatic, sweet; in some varieties bitter. There are three principal varieties of fennel in the mar- ket : Sweet, or Roman, with very large, long, light-col- ored, pale greenish fruits, and a particularly pleasant odor and taste, from cultivated plants in the south of France ; German, or Saxon, with shorter and propor- tionately thicker fruits, cultivated in Germany ; and com- mon Wild, or Bitter Fennel, from wild plants growing in the south of France. The flrst-named is much the most valuable of the three. Fennel contains about three and a half per cent, of an essential oil very much like that of anise, being composed of a large proportion of anethol and a smaller one of a hydrocarbon of the terpene series. Action and Use.-Fennel is a mild aromatic of ex- actly the same medicinal qualities as anise. It is, how- ever, less used in medicine than that, but is considerably FERMENTATION (from fervere, to boil) is a term- originally applied to almost every occult chemical phe- nomenon, particularly if accompanied by a bubbling or effervescence-which has become familiar through long usage in connection with the making of alcoholic drinks. It stands for a series of events in which certain sub- stances are made to undergo changes in their chemical composition by the action of peculiar bodies called " fer- ments." For example, the "alcoholic" fermentation is the result of the action of a peculiar body, yeast, upon certain sugary substances, leading under proper condi- tions to the disintegration of the sugary bodies with the concomitant appearance of new compounds, prominent among which are alcohol and carbon dioxide. The sub- ject has become, of late, of special interest to the student of medical science, because it is now very generally be- lieved that certain diseases are essentially peculiar fer- mentations taking place in the living organism (see Germ Theory of Disease). Very many observers had noticed the outward appear- ances of fermentations, and not a few, like Stahl and Becher, had speculated upon the nature of the hidden causes of these phenomena even before the time of La- voisier, the founder of quantitative chemistry, whose brilliant career was brought to a sudden and melancholy end by the guillotine in 1794. But before Lavoisier, measurements of the successive phases of fermentations were inexact, if not impossible. By his use of the balance Lavoisier paved the way in this subject, as in all, for his famous successors in the chemistry of fermentation, viz., Gay-Lussac, Liebig, and Pasteur. It is worthy of notice, however, that before Gay-Lussac had instituted his classi- cal researches, with which the work of the nineteenth century upon fermentation properly begins, several ob- 61 Fermentation. Fermentation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. servations of great importance in this connection had been made and recorded. These were as follows : 1. The Discovery of Yeast by Leeuwenhoeck.-In 1680 the Dutch scientist of this name saw in yeast glob- ules which he has described and figured in his Opera. But his figures are so inaccurate as to be grotesque, and he himself believed that he was observing starch grains of a peculiar sort, instead of the well-known oval yeast- cells of to-day, which bud so freely and thus give rise to " colonies." 2. A Method of Preserving Fruits by "Can- ning."-Precisely who was the first to preserve perish- able fruits in this way is not known, though the art seems to have been understood and practised by Wren in 1666. But in the early part of this century it was brought to a high degree of usefulness by Appert, and became well known. Appert's method was almost ex- actly the same as that in vogue to-day in the common art of " canning." The fruits to be kept were put into bot- tles, which were then tightly corked. The bottles were at once heated to the temperature of boiling water, and kept at this temperature for a long time; after which treatment it was found that the contents would resist putrefaction for a very long period. 3. The Discovery' of Oxygen in 1774.-This had an important influence, in all probability, in suggesting to Gay-Lussac his famous researches shortly to be men- tioned. 4. Lavoisier's Study' of the Quantitative Chem- istry' of Alcoholic Fermentation.-Lavoisier was the first to investigate quantitatively the relations of the sugar undergoing alcoholic fermentation to the products formed. But, owing to the imperfections of his appa- ratus, it became necessary for Gay-Lussac, some years later, to correct the results, which he did by analyses that still stand unquestioned by the majority of chemists. Pasteur, however, maintains that Gay-Lussac's equation representing the reaction, viz., C8H12O8 = 2COa + 2CaH8O Sugar. Carbonic acid. Alcohol. is not strictly correct, since other products, especially succinic acid and glycerine, occur in small quantities in the alcoholic fermentation. We shall refer to this fur- ther on. From reflection and experiment upon Appert's method, Gay-Lussac, in seeking for the ultimate causes of fermen- tation, was led to believe that oxygen, at that time still a new and wonderful substance, was the hidden agent at the bottom of the whole affair. For so long as the ordi- nary air was excluded in Appert's process, no fermenta- tion took place ; but if the stoppers of his bottles were removed and the contents thereby exposed to the air, fer- mentation speedily ensued. Accordingly, Gay-Lussac devised his celebrated experiment of sending up through the column of mercury in a barometer into the Torri- cellian vacuum above, clean, ripe grapes, which were then readily broken open by agitating the mercury. In these cases no fermentation took place. But if, after- ward, a bubble of air were allowed to pass up into the space above the mercury, fermentation usually ensued. By experiments of this sort, Gay-Lussac seemed to have established the fact that when air is present, fermentation occurs ; when it is absent, no fermentation takes place ; and the deduction was made that it is the oxygen of the air which causes fermentation. These views prevailed till Schultze (1836) and Schwann (1837) separately and conclusively proved that, although there is assuredly some- thing in the air which provokes fermentations, neverthe- less that something cannot be the oxygen of the air. Schultze arrived at this important conclusion by allowing only air which had passed through strong sulphuric acid to come in contact with a fermentible solution at first boiled, while this air was coming in, and afterward al- lowed to cool with the access of the purified air only. Schwann admitted to a similar solution only air which had been passed through and " calcined " in bent glass tubing heated in a flame; and in both cases, though it was known that the oxygen was unchanged by the acid or the flame, no fermentation took place. Schroeder and Dusch, in 1854, went a step further, and showed that air passed through cotton-wool plugs is impotent as regards the pro- voking of fermentation; and Pasteur at last completely demolished the theory of Gay-Lussac, by omitting even the cotton plugs and employing instead a flask with a bent neck, so arranged as to allow of the deposit of dust, etc., before reaching the fermentible materials. It will be noticed in passing that the experiments just mentioned, though disproving the efficacy of oxygen as an agent of fermentation, serve to establish beyond doubt the pres- ence of an agent of some sort in the ordinary air. The labors of Pasteur and others have since demonstrated the fact that bits of living matter, in the shape of "spores," "germs," or "corpuscles" are tolerably abundant, espe- cially in the agitated air of cities, dwelling-houses, etc. Nevertheless, notwithstanding the labors of Schultze and Schwann, of Schroeder and Dusch, and others, which were perfectly conclusive in regard to the negative im- portance of oxygen; in spite of the suggestions of Schwann and others, that organized bodies must be the real cause; in spite, too, of the discovery (or rediscovery) of yeast by Cagniard de Latour and Schwann, indepen- dently of one another, about 1837, almost no progress toward the establishment of the true theory was made until 1860 or thereabouts, when Pasteur began his mas- terly researches. The reason for this astonishing delay at a time when progress was in the air, and all other branches of science were marching swiftly forward, lies chiefly in the fact that Liebig, who had been a student of Gay-Lussac, chose to maintain an attitude of opposition, and even of contemptuous scorn, to the theory modestly put forward by Schwann. The latter and Cagniard de Latour agreed in describing yeast, as we now know it, as a budding vegetal organism, always present in the alco- holic fermentation. Turpin, a botanist of the day, classi- fied the new plant among the TotuIcb, and named it Tomia cerevisia. This classification has since been corrected by Meyen, to whom we owe the name which belongs to it at present, viz., Saccharoniyces cererisia. Schwann and his followers regarded yeast as the cause of alcoholic fermen- tation, and fermentation as a consequence of the vital activity of yeast. This theory Liebig denied in toto, and instead of it proposed a theory of his own, in substance not unlike that which Stahl offered long before this time. Liebig's theory of fermentation regarded the phenom- enon as due to the instability of complex molecules, such as albuminous compounds, which he held to be con- stantly breaking down in a fermentation or putrefaction into simpler compounds. If, perchance, sugar or other unstable molecules be present, they are infected with the decomposition and made to fall to pieces in a similar manner. Upon this theory yeast may be present and even thriving; but if so, it is a pure incident, a mere aside. Causal relation to the act it has none, unless, by excreting albuminous matters, or by death and conse- quent decomposition, it supplies unstable (albuminous) molecules calculated to fall to pieces and to drag down sugar molecules into their own ruin. But Liebig went further than this, and openly ridiculed the idea of a liv- ing organism at the bottom of the phenomenon, and he was doubtless the author of an anonymous communica- tion, written in a tone of mock gravity, which Huxley has well pronounced " the most surprising paper that ever made its appearance in a grave scientific journal." (Liebig's Annalen, 1839: Das entrdthselte Geheimniss der'geistigen Gahrung ; vorldufige briefliche Mittheilung.) So powerful was the influence of Liebig that his younger contemporaries were infected with his opposition to the vital theory, and pronounced, according to a modern chemical historian, in most exuberant terms upon the "pregnant idea" of Liebig's theory, which they des- ignated as "a grand principle at the very root of chemistry." Nor was it in Germany only that Liebig's influence was felt. In France, Fremy and Boutron sought to extend Liebig's ideas to the acetic fermenta tion, and the fame of Liebig completely eclipsed the labors of Cagniard de Latour. In short, as Helmholtz has remarked, " most of the facts upon which the theory 62 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fermentation. Fermentation. is based, that the decomposition of fermentible mixtures is only a consequence of the vital processes of lower organ- isms, were ignored by many of our greatest chemists, and considered to be mere physiological phantasies. They rejected the idea of the vegetable nature of yeast, basing their beliefs upon the observation of Ehrenberg, that in- organic, lifeless precipitates may sometimes arrange them- selves in beaded or branched figures." One reason for this attitude, doubtless, was the impor- tant fact that the alcoholic fermentation seemed, upon the vital theory, to be only a special, possibly even an excep- tional case, for in fermentations other than this no living ferment playing the part of yeast had ever been discov- ered. But in 1857, while the "mechanical" theory of Liebig was at its height, and was rivalled rather by the " catalytic " theory of Mitscherlich and Berzelius, than by any vital theory whatsoever, Pasteur suddenly an- nounced his discovery of a living ferment always to be found in lactic fermentations. (Mem. sur la fermentation appelee lactiqae.-Ann. de Chimieet de Physique (3), lit, p. 407.) He was fresh from the field of molecular physics, in which, by his industry and experimental skill, he had al- ready achieved success. But having been recently appointed Dean of the Faculty of Sciences at Lille, a neighborhood in which the making of alcohol from beet- root sugar was a prominent industry, and having also been brought face to face with certain changes of molec- ular constitution effected in the paratartrates by fermen- tations, Pasteur, partly from motives of policy, and partly in pursuit of studies already begun, happily decided to attack this subject, He was admirably equipped for the work, bringing to it exactly what it most demanded, extraordinary skill in experimentation, long discipline in exact methods, unbounded enthusiasm, and a pertinacity which served to maintain in the face of opposition what- ever ground was once gained. The first fruits of his new labors, announced in 1857, explained the wrell-knowrn conversion of lactose, or milk-sugar in milk, into lactic acid, as due to a living ferment, analogous to the yeast found in an alcoholic fermentation, but much smaller and more difficult to observe. Methods were outlined for securing this lactic ferment in a tolerably pure state, and its microscopic characters were fully described. From the lactic, Pasteur proceeded to the butyric fer- mentation, and here also discovered and described a liv- ing organism or ferment, which provokes the so-called butyric fermentation. His next step was a bold one. He reaffirmed the old theory that all putrefactions are really fermentations caused by living ferments, only specifically different from those of other fermentations, except in the materials fermented and in the products formed-the lat- ter having in putrefactions an evil smell. This had indeed been a favorite idea with some of the earliest chemists ; e.g., Becher and Stahl, but with them it had been by necessity chiefly guess-work. Pasteur, however, exam- ined putrefying infusions writh the microscope and found them swarming with micro-organisms of the same gen- eral nature as those found in the various fermentations. The acetic fermentation, or the conversion of alcohol into acetic acid, which had been supposed to be a phenom- enon of oxidation by catalysis or contact, also yielded micro-organisms wThich Pasteur claimed to be the special ferments at work. In this way, by the brilliant labors of Pasteur, which have since been fully confirmed, it has been finally settled that many fermentations, such as the alco- holic, the acetic, the butyric, and the lactic are caused by the vital activity of special ferments, i.e., by living or- ganisms, and that putrefactions are only bad-smelling fermentations. More important still is the fact, which is now very gen- erally admitted, that certain diseases likewise owe their specific characters to the activity of specific ferments or " germs," which are in reality living micro-organisms. This view' is known as the " germ" theory of disease (see Germ Theory). Liebig died in 1873, still clinging to a modification of his original theory and refusing to accept the vitalistic theory of Pasteur. But at the end hew'asa solitary figure, defending a shattered theory. Living Ferments and Lifeless Ferments.-Up to this point the fermentations which have been considered are those now known to be produced by the activity of living micro-organisms. Death of the organism in these cases always means cessation of the fermentation, which appears therefore to be a concomitant of vital activity. Ferments of this kind are accordingly known as "living" or " organized." But there is another group of obscure chemical phe- nomena known as fermentations, produced by certain life- less or unorganized substances, which are therefore called the " lifeless," " unorganized," "soluble," or "chemi- cal " ferments. These are capable of enduring relatively high temperatures, though they are destroyed if moist at about 100° C., and they are believed to produce results out of all ordinary proportion to their own gain or loss in the process, if indeed any occurs ; so that a small amount of the ferment may convert into new compounds a very large amount of material. This does not mean that work is done without a due expenditure of energy, but only that the energy expended is so little that it is not easily discoverable alongside of the very conspicuous results. Analogies for actions of this sort are very nu- merous, as witness, e. g., the insignificance of the energy expended in a spark compared with that in the explosion of a magazine of gunpowder to which the spark is ap- plied. Perhaps the most comprehensible of these ferments are the different mineral acids, such as sulphuric or hydro- chloric, which are capable, as are even some of the or- ganic acids, under certain circumstances, of decomposing starch, cane-sugar, and some other organic substances into new compounds, without undergoing themselves any ap- preciable change whatsoever. Thus, cane-sugar, or sac- charose, is "inverted," i.e., turned into dextrose and levulose as follows: C12H22O11 + H2O=C6H12O6 + C6HI2O6 Saccharose. Water. Dextrose. Levulose. This process is plainly one of hydration, and the acid appears by its mere presence either to provoke or to fa- cilitate the fixing of water with a simultaneous decompo- sition. In like manner starch takes on water, and is converted into dextrine and dextrose as follows : C2.i 1 Lq02o + 3H2O = Ce H i oO 5 + SCglL AL Starch. Water. Dextrine. Dextrose. Prominent among the lifeless ferments are also those concerned in digestion, e.g., pepsin, ptyalin, and trypsin, while still others are more or less familiar, such as the diastase of malt, the emulsine of sweet and bitter al- monds, and the ferment of yeast-solutions, 'which inverts cane-sugar, and yet is incapable of producing alcoholic fermentation. This last example is of special interest, as it furnishes material for a comparison of the living ferment, yeast, whose function is to convert grape-sugar into al- cohol, etc., with the lifeless ferment of yeast-solutions, whose function is to convert cane-sugar into grape- sugar. Berthelot was the first to show that the con- version of cane-sugar into grape-sugar by yeast, ob- served by Dubrunfant in 1832, is done, not directly by yeast itself, but indirectly by a soluble ferment which may be extracted from the yeast, and will still act in its absence. In fact, yeast itself cannot utilize cane- sugar, but must first get it changed to grape-sugar by this soluble ferment, so that the conversion of saccharose or cane-sugar into alcohol, etc., is a double event, and re- quires, first, the action of a lifeless ferment to turn the cane-sugar into the more hydrated grape-sugar and sec- ond, a living ferment, yeast, to turn the grape-sugar into alcohol, etc. Reflection upon cases of this kind has led numerous observers to believe that the phenomena of all fermenta- tions are at bottom identical. For if yeast can secrete, as it does, a soluble, lifeless substance which inverts sugar, may it not be that it repeats the process, substantially, in changing inverted sugar into alcohol ? Berthelot and others maintain the affirmative, because of its inherent 63 Fermentation. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plausibility. But to suppose that the alcohol-bearing fer- ment is analogous to the " inverting" ferment, we must assume either that it is present in extremely small quan- tity ; or else, that it is transitory and destroyed as soon as it is made. At any rate, it has never yet been extracted by the methods employed for extracting other lifeless fer- ments. Accordingly, plausible though the theory is, that living ferments are merely the sources or factories of life- less ferments, and that all fermentation is only one and the same process, it must be remembered that it is a theory only, and at the best involves grave difficulties. If, however, this theory be ever established, the final explanation of the phenomena of fermentation must be sought in molecular physics, a domain in which Pasteur has already landed us with his " respiratory " theory. He was led to this by careful quantitative studies of the al- coholic fermentation, and especially by his discovery that the equation of Gay-Lussac (see above) cannot be re- garded as correct, even if it be changed according to the suggestions made by Dumas, Boullay, etc. For in ad- dition to the alcohol and carbon dioxide, known to Gay- Lussac, Pasteur found always present small though vary- ing quantities of glycerine and succinic acid. But even with the addition of these to the alcohol and carbon di- oxide, it appeared from his analyses that about one per cent, of the sugar fermented had disappeared. Out of one hundred parts of cane-sugar, about ninety-five parts are obtained as alcohol and carbon dioxide, three or four parts as glycerine and succinic acid (the former being consider- ably more abundant than the latter), while one part has disappeared. It is upon the loss of this one per cent, of the weight of the sugar that Pasteur's "respiratory the- ory " of fermentation is based ; for he reminds us that the yeast which does the work ought to profit by the opera- tion. It gains in weight and grows, and Pasteur con- siders that it does so at the expense of the one per cent, missing from the sugar. He also maintains that in doing this it is really breathing, and that in its hunger for oxy- gen, yeast attacks the sugar molecule and robs it of a portion of its oxygen, thereby causing it to break up into alcohol, carbon dioxide, glycerine, etc. He recalls the general fact of the respiratory needs of plants, points out that the habit of life of yeast is such as to make it difficult for it to get free oxygen, and shows by experiment that a given weight of yeast decomposes more sugar in the ab- sence of oxygen. He even goes so far as to divide the micro-organisms into two great classes : 1. Those which thrive only with free oxygen ; these he calls aerobes. 2. Those which do not require oxygen, but can get it from complex albu- minous or sugary compounds ; these he calls anaerobes. Now, although it was at first emphatically denied by Sachs and Brefeld that yeast can live and do work with- out free oxygen, their view has since been shown to be erroneous. It cannot any longer be denied that yeast may live and cause fermentation without free oxygen diffused through the liquid. Nor can it be denied that yeast has a great avidity for oxygen, for one of the best ways in which to make a fluid oxygen free is to charge it with yeast. On the other hand, the presence of abundant free oxy- gen does not forbid the occurrence of all fermentation, and the growth and health of yeast is best promoted by abundant oxygen. It is, moreover, very questionable whether Pasteur's measure of the energy of a ferment as the ratio of the sugar decomposed to the yeast formed, is a true one. But into this matter we need not go further. Enough has been said to indicate why Pasteur's plausible theory has had wide circulation, and has met with very general acceptance in the popular mind. But many chemists, physicists, and biologists have hesitated to adopt it, and serious objections to it have been raised by Schiitzenberger, Berthelot, Traube, Fitz, Nageli, and others. In order to make it of general importance, it be- comes necessary to suppose that other ferments act in the same way; and a certain amount of evidence exists in favor of this view. But it needs far more evidence than we now possess to make it likely that all fermentations depend upon the respiratory wants, alone, of micro-organ- isms. It is more probable that these effect the changes known as "fermentation" as events, perhaps sometimes simple but more often complex, connected with their in- trinsic metabolic processes ; so that the phenomena of fer- mentation will not be understood till the phenomena of metabolism-both anabolic and katabolic-are better com- prehended than at present. The occurrence of lifeless ferments in plants and animals lends color to the idea that all fermentations are essentially identical, and that some of the more intrinsic are transitory and too unstable to be readily obtained ; but this theory, though perhaps as good as any, lacks the necessary basis of proof. The whole subject, indeed, needs further elucidation. Literature.-P. Schiitzenberger : " On Fermenta- tion." D. Appleton & Co., New York (International Scientific Series), 1879. Adolf Mayer: " Lehrbuch der Gahrungschemie," Heidelberg, 1879. Both of these are excellent general works, ami give full references to the older literature, including the papers of Liebig and those of Pasteur upon fermentation. L. Pasteur : " Etudes sur la Biere, Paris, 1876. Published also in an English translation, made by Faulkner and Robb, under the title "Studies in Fermentation," London, 1879. C. Nageli: " Theone der Gahrung," 1879. W. Watson Cheyne: "Antiseptic Surgery," London, 1882, gives a rather full account of fermentations in their medical bearing, as does also E. Duclaux : " Ferments ct Maladies," Paris, 1882. William T. Sedgwick. FERN, MALE (Aspidium, U. S. Ph.; Filix mas, Br. Ph.; Rhizoma Filicis, Ph. G.; Fougere male, Codex Med.), the rhizome of Aspidium Filix mas, order, Filices (Poly- podiacea). This is a large, robust, handsome, and in many parts of the world an exceedingly abundant fern. It arises from a horizontal or decumbent rhizome one or two decimetres long, and one or two centimetres in di- ameter, but apparently much thicker on account of the persistent bases of the fronds, which are as closely im- bricated over its surface as the scales of a iir-cone. The living fronds arise near the apex of the rhizome, and form a fine plume from a half to one metre in height (two to three feet). They are erect or gracefully curved back- ward, on stiff, channelled, pale-brown, chaffy stipes, and once or twice pinnate. Their general outline is oblong- ovate and taper-pointed. The pinnae are either pinnate or more or less deeply pinnately lobed. The ultimate divisions are blunt, slightly serrated. Sori attached to the backs of the veins about half way from the midrib to the margin, each covered with a nearly circular but notched indusium, whose point of attachment is at the angle of the notch. Sporangia rather numerous, dehis- cing transversely, spores minute brown. Male Fern is one of the commonest ferns of the cooler parts of Europe. It grows also in abundance in the tem- perate parts of Asia, in the northern and southern ex- tremes of Africa, and in both North and South America. It is not found in the eastern United States, but occurs in British America and in the Northwestern States. Its medical employment is of great antiquity, as it is men- tioned by some of the earliest writers upon medicine. Like many other substances, its use, or at least the records of it, disappeared for a time during the dark ages, and made its appearance again after several centuries in more modern practice. The introduction of the "oleo-resin" (ethereal extract) dates from the recommendation of an apothecary of Geneva named Peschier, in 1825 (Fliick- iger). Description.-The portion used is the rhizome usually covered with the bases of the fronds as above mentioned. It is, with these appendages, from four to eight centime- tres thick, of a rusty brown color, and very rough surface. When the " scales" (stalks) are broken or cut off, the rhi- zome proper is about as thick as the finger, fleshy, of a .yellowish-green color, a sweetish astringent taste, and a rather disagreeable odor. Woody bundles in the sec- tion about ten. From their size and succulent character these rhizomes retain their vitality and greenness a long time. The U. S. Pharmacopoeia directs that only those parts which have retained this color should be used. 64 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fermentation. Fever. Fliickiger, on the other hand, directs that the rhizomes should be "divested of the dead portions, split open, dried with a gentle heat, reduced to coarse powder, and at once exhausted with ether." It is generally conceded that it is a very perishable drug, and should be used soon after collection. Composition.-The most characteristic ingredient of Male Fern is filicic acid, a white crystalline powder of slight taste and odor, and acid reaction, insoluble in water or diluted alcohol, soluble in absolute alcohol, and Action and Use.-The physiological action of this substance upon man is not very definite, and as it is never given with this in view, has not been very closely investi- gated. In the ordinary medicinal doses it often has no ef- fect upon the system ; sometimes, however, it causes vomit- ing and other symptoms of gastro-intestinal disturbance ; in very large doses it is an irritant to the bowels. Its ac- tion upon the several species of tape-worm, however, is well marked and fatal, and makes it one of the most cer- tain agents for their destruction. For other intestinal worms, although sometimes used, it is less valuable. Administration.-In sub- stance, it is now never used ; from five to eight grams are given as the dose by Hager. Of the oleo-resin, from two to five grams is the usual dose, to be repeated in a few hours. One of the most important points in its administration is the dietetic preparation of the patient. For ten or twelve hours before the first dose he should eat no solid food what- ever, and the bowels if full should be emptied by a ca- thartic. Milk may be taken freely, or soup; then about four grams of the oleo-resin should be given at one dose; after several hours a second dose may be given, followed by a cathartic, if needed. The discharges should always be carefully examined for the head and upper portions of the worm. Unless these are passed the cure cannot be con- sidered as certain, and the treatment may be required to be repeated. Allied Plants.-Aspidium marginale Willd., a very nearly related American fern, grow- ing abundantly in the Eastern States, where the other is want- ing, and distinguished by hav- ing its sori nearer the margin of the frond, is also recognized in the United States as a source of "Aspidium." Its rhizome may be distinguished from that of the preceding by having only six woody bundles instead of nine or ten. Its value can scarcely be said to be fully es- tablished, but its composition and properties appear to re- semble those of A. Filix mas very closely. No other ferns are at present used as medi- cines. For other cryptogams see Ergot. Allied Drugs.-See Koos- so for anthelmintics. IE P. Bolles. Fig. 1156.-Male Fern. Frond about one-third natural size, also a lobule enlarged about four times, show- ing the round-reniform indusia covering the sori. (Luerssen.) in ether. It also contains a peculiar tannin, coloring mat- ter, fattg oil, resin, etc. All the ingredients of medicinal value are contained in the ethereal extract {Oleoresina As- pidii, U. S. Ph.), obtained by percolating the root with stronger ether, and evaporating off the menstruum; it is a thick, oily, dark-green liquid, with a nauseous, bitter, dis- agreeable taste, and the odor of the drug. Crystals of impure fllicic acid form in it upon standing. The yield of this preparation is about eight per cent., and it con- sists, besides the acid just mentioned, chiefly of the fatty oil of the fern (filixolin). FETTQUELLE. A mineral spring of Baden-Baden, which is pronounced the richest in lithium, Bunsen hav- ing found 2.3 grains of the chloride of that salt in each pint of the water. The hopes which were at one time entertained for its curative action in gout and lithiasis have not been realized. J. M. F. FEVER (Febris, from ferveo, I am hot, or, possibly, from febreo, I purify). Synonyms: pyrexia; Germ., Fieber ; Fr., fievre. Definition.-1. An abnormal elevation , of the tem- 65 Fever, Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. perature of the body. 2. A diseased state of the system, the most prominent symptom of which is an elevation of the temperature, as typhoid fever, scarlet fever, etc. In order that an elevation of the temperature shall con- stitute fever, it is generally conceded that it must con- tinue for several hours at least above the normal, that it be more or less continuous or repeated at certain inter- vals, that it be not the result of excessive external heat or violent muscular exercise, and that it pursue a somewhat definite course. History.-No symptom of disease was more generally recognized among the ancients than fever. The term was employed in almost the same manner as at the pres- ent time, and as a basis of prognosis, high temperature had the same import with Hippocrates as with us. Heat with the ancients was a manifestation of the element fire, and the burning of a fever was compared to the consum- ing of a flame. the temperature range in either case. In the first in- stance this range is constant, not being characterized by distinct paroxysms. A remittent fever is distinguished by the occurrence of paroxysms between which there is a partial decline of the temperature. In intermittent fever the decline falls to the normal grade with an inter- val of apparent health. Fever is further classified as dynamic or sthenic, ady- namic or asthenic, and hypersthenic, according to the prominence of the symptoms on the part of the heart and nervous system. Sthenic fever is characterized by a full, bounding pulse, flushed skin, muscular tremor, and fre- quently by restlessness and active delirium. The disease attended by it usually runs a rapid, frequently a fatal course. When it terminates favorably the crisis is short and well defined. The term hypersthenic is occasionally employed to denote a most violent form or case of the dynamic type, generally terminating in death. In the as- thenic form the pulse is feeble and compressible, though rapid, the skin is pale and moist, respiration is more or less labored ; if delirium develops, it is of the low, mut- tering kind, and there are present all the general symp- toms of great prostration. The disease terminates by a feeble effort at a crisis or by a prolonged lysis, which not infrequently leaves the patient too debilitated to un- dergo a favorable convalescence. Relapsing is a term limited to a special form of disease distinguished by a recurrence of fever after unusually long periods of apyrexia. Description.-The chief characteristic of the febrile state is an elevation of the temperature. In addition to this fact, there is a more or less pronounced functional derangement of all the organs. This derangement is in part a result of the elevation of the temperature and in part a coeffect of the cause producing such elevation. In mild cases of fever, which on the whole constitute the majority, the temperature ranges between 38° C. and 40° C. (100° F. and 104° F.). As the temperature rises above 40° C. the gravity of the disease rapidly increases ; yet the height of 41° C. (106° F.) is not infrequently reached in cases of malarial infection without serious re- sult, and even 42.5° C. (108.5° F.) of short duration, as in relapsing fever, has been followed by recovery. The term hyperpyrexia has been applied to temperatures ranging above 42° C. (107.6° F.), but aside from the gravity of the symptoms there is nothing to distinguish the condition thus designated from the ordinary febrile state. In certain affections of the nervous system, as in tetanus and hydrophobia, and rarely in connection with other diseases, the temperature reaches the height of from 43° C. to 45° C. (110° F. to 113' F.), and in a few re- ported cases this measure has been exceeded; but the maximum in these cases usually precedes death by a very short interval. Such elevations are known as prc- agonic. The degree to which the temperature rises in the febrile state is, however, a less important characteristic, as regards either diagnosis or prognosis, than its varying tendency to persist and to run a more or less definite course, independent, to a great extent, of all physical influences brought to bear upon it. In this regard its behavior resembles that of the normal temperature ; for we find that, however much the heat may have been reduced by artificial means, it speedily regains its former elevation upon the removal of such influences. Further, there is observed in fever a morning remission and an evening exacerbation corresponding to the diurnal fluctuation of the normal temperature. Any consideration of the importance of a close observa- tion of the temperature range during the progress of a disease is now quite superfluous. The introduction of thermometry is universally recognized as one of the most important advances that have been made, and no clinical history is even justifiably accurate without a complete record of the diurnal range of the temperature. The record should be made to correspond as nearly as may be to the interior or blood heat, which is best secured by introducing the thermometer into one of the cavities of the body, preferably into the rectum. The tempera- " Even through the bowels runs the scalding plague And wastes the flesh with floods of eddying fire." -West's "Lucian." The source of this heat-production was variously lo- cated. Galen and Aristotle ' placed it in t.he heart. The rate of the pulse was considered an important indication of fever by Galen, and later, in the time of the Ptolemies, became a symptom more relied upon in diagnosis than the temperature of the body. With Erasistratus2 body- heat lost its prognostic value. To him excessive heat was but the indication of morbid action in the vascular, sys- tem iu the region of the heart, the forcing of blood over from its normal abode in the veins into the arteries, where it came in contact with the pneuma, or vital spirit. Thus the origin of heat, whether normal or febrile, re- mained a matter of conjecture throughout the dark ages. Even the Renaissance failed to produce a more correct theory than that of Galen. Mondini,3 for example, ac- counts for the pyramidal form of the heart by the fact that the pyramid is the special figure belonging to a flame. The heart remained the centre of heat production until long after the discovery of the circulation of the blood, and fever was due to an excessive production of heat in the heart, to obstruction to the flow of the vital spirit, to the action of evil spirits or humors, or to other equally vague and mysterious influences. Finally, after the discovery of the chemical nature of the respiratory process by Lavoisier, and its analysis by Magnus, a new origin was sought for heat. Then, as so often happens in the history of the medical sciences, an effort was made to employ the theory of greatest promi- nence in explanation of all that was obscure, and the lungs became the centre of warmth. It was the gradual recognition of the general process of oxidation which finally dispelled all local theories. Later investigation demonstrated the universality of this process, so that in our day the source of heat is no longer limited to any one organ or region, but is referred to the organism at large. With the application of thermometry to the investiga- tion of disease, a most important advance was made in the study of fever. To Boerhaave, in the earty part of the last century, is due the credit of its introduction ; and his pupil, De Haen, in 1760, was able to detect with the thermometer an internal temperature of 40° C. during a rigor. But so modest were these investigators in the declaration of their discovery, and of so little importance was the discovery considered, that no practical applica- tion was made of it, and it was soon forgotten. It then remained for Gavarret, in 1839, to introduce thermom- etry as a new method for the diagnostication of fever. But still a period of twenty years elapsed before the regu- lar observation of the temperature of fever patients, advised by Zimmerman, and a few years later by Traube and Jochmann, and more especially by Wunderlich, was adopted by the profession. Among the more recent investigators of the febrile process may be mentioned Liebermeister, Naunyn, Sam- uel, Wood, and Rosenthal. Classification.--Fevers are classified as continued, remittent, or intermittent, according to the character of 66 REFERENCE HANDBOOK' OF THE MEDICAL SCIENCES. Fever. Fever. ture thus obtained averages about 0.2° C. (nearly 0.4° F.) higher than that of the axilla, but it is more constant and less liable to be erroneously estimated. Etiology.-Our first positive knowledge of the man- ner in which the organism is incited to the morbid ac- tions that result in fever dates from the observation by Nannyn, Billroth, and Weber that a febrile elevation of the temperature may be experimentally produced by the introduction of septic matter into the circulation. It has since been shown, however, that the same result follows the introduction of aseptic matter, whether particulate or diffusible. Even the injection of the blood of another animal or of water into the veins of a dog sufficed to ele- vate its temperature. With the discovery in these so-called septic matters of minute living organisms, which are now generally recognized as the causative elements in the infection, new light has been shed upon a previously obscure subject, and the study of fever has received a new impetus. There is no special pyrogenic substance, but the ma- terials capable of exciting fever are many. In the acute infections, as for example scarlet fever, small-pox, and cerebro-spinal meningitis, the febrile temperature is be- lieved to be caused either by the direct action of micro- organisms upon the nerve-centres, to which they are car- ried by the blood, or by the action of a poison which they develop within the body. That such minute organisms are capable of producing fever, is inferred from the fact of their existence in large numbers in anthrax, pyaemia, relapsing fever, and from the elevation of temperature occurring in trichiniasis. In many other febrile states, as in those resulting from injury, the elevation of temperature may be referred either to the entrance of minute organisms, or to the di- rect impression on the nervous system. Billroth6 consid- ers the occurrence of fever in a wounded person proof that decomposition is going on in the wound, and that its products have passed into the blood ; but Volkmann6 be- lieves the symptoms in either case to be sufficiently dis- tinct to be called septic and aseptic fever, according to its probable mycotic or irritative origin. The septic variety arises, it is believed, from the action of the bacteria of decomposition, and includes septicaemia and pyaemia; while the aseptic variety is characterized by only a slight elevation of the temperature, without other pronounced accompaniments of the febrile state. Examples of this fever are the slight elevations of the temperature follow- ing surgical operations or natural labor, and the second- ary fever of such affections as variola. The temperature which is caused by the action of micro-organisms is be- lieved to correspond in degree to the extent and rapidity of their development. It is thus that we account for the peculiarities of onset and range that are observed in the different diseases. Pathology.-The production of febrile heat furnishes an example of the close engrafting of a morbid upon a physiological process, for it consists essentially in the de- rangement of certain normal functions rather than in the establishment of a new process. The production of bod- ily heat within certain limits is a necessity to the proper functional activity of all the vital organs. The leading view that is now maintained in regard to the origin of this heat, and the origin of febrile heat, refers them to the same cause, viz., to the oxidation of blood and tissue- elements in the various parts of the organism. Any con- siderable modification, either of the circulation or of nu- trition, by increasing this oxidation, is responded to, in a measure, by a similar modification of heat-production. Thus, a free diet of animal food and violent muscular ex- ercise increase the production of heat, while a reduced diet, or a diet of nitrogenized food and muscular inactiv- ity decrease it. The temperature of the body may be ele- vated by exposure to excessive external heat, or depressed by exposure to excessive cold, but such elevation or de- pression is not always compensated by an equivalent in- crease or diminution of heat-production. Heat, when formed in excess, is removed from the body chiefly by means of the cutaneous circulation. The temperature of the interior of the body (the aorta, muscles, etc.) has been found from 1.3° C. to 1.7° C. higher than that of the sub- cutaneous cellular tissue. The heated blood coming from the interior contributes some of its warmth to the cooler cellular tissue and skin, whence it is removed by radia- tion and convection into the cooler surrounding media. The amount to which the blood is thus cooled depends, for the most part, on the rapidity of the cutaneous circu- lation and the calibre of the vessels. So accurate is the ad- justment between the processes concerned in the evolution of heat on the one hand, and those concerned in its removal from the body on the other, that in health the temperature remains almost constant at 37.2° C. (98.4° F.), independent to a great degree of the temperature of surrounding me- dia. The capability of the body to resist sudden changes of surrounding temperature depends, in all probability, more upon variations in the amount of heat dissipated than upon variations in heat-production, although it has been shown that the latter process also varies with the demand for heat. So close an adjustment of forces naturally suggests a dependence on the nervous system, and the belief in such a connection has led to not a little original investigation. With the discovery by Bernard of the influence of the sympathetic system of nerves on the capillary circulation, the regulation of heat-production was attributed to the vaso-motor branches of this system. The cerebral centre of these nerves has been experimentally located in the lower portion of the floor of the fourth ventricle, near the point of the calamus scriptorius. The importance of this centre has been called in question of late, chiefly by H. C. Wood,7 who, after carefully conducted experiments on dogs, arrived at the conclusion that there is a special heat-centre located either in or above the pons, probably in the first cerebral convolution, posterior to the sulcus cruciatus. This centre he regards as inhibitory in its ac- tion, for heat-production is diminished when it is stimu- lated, and increased when it is destroyed. The normal stimulus of this centre is the same as that of the vaso- motor apparatus regulating the peripheral circulation, namely, an elevation of the temperature of the body. Tscheschichin suggests that the action of this centre is to cause a retardation of the chemical changes which pro- duce heat, but Rosenthal believes that the phenomena re- ferred by Wood to a special centre may still be accounted for as due simply to modifications of the circulation. Traube attributes the elevation of temperature to the contraction of the cutaneous capillaries with the conse- quent reduction of heat-elimination in the first stage of fever. Again, it has been suggested that nerve-force is itself directly convertible into animal heat, and is therefore one of the sources of abnormal temperature. A pyrexia of purely neurotic origin has also been described. Still other features of the febrile state may be cited as supporting the view that the nervous system presides over heat-pro- duction and dissipation more directly than merely through its action on the circulation. Chief among these are the regular range of the temperature, generally characteristic of the malady to which it belongs ; the morning remission and evening exacerbation, and probably also the sub- normal temperature accompanying abscesses of the brain substance, which gives place to an elevation of tempera- ture upon the involvement of the membranes. That the proximate cause of the febrile increase of heat-production is an increased oxidation of blood and tissue elements is shown chiefly by the increase of the waste-products found in the excretions and exhalations from the body. The amount of carbonic acid in the ex- pired air is markedly increased, particularly in the stage of invasion, before the temperature has reached its maxi- mum and heat-production has ceased to increase. The amount of urea and other waste-products in the urine and cutaneous transpiration is also increased. The existence of fever does not of necessity imply an increased production of heat, although this is generally an element in its formation. On the contrary, less heat is sometimes produced during pyrexia than at other times when the temperature remains normal. The same is true also of the elimination of heat, and no rule can be applied 67 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to the relation that exists between these processes further than that which is so well expressed by Wood 8 when he writes : " Owing to its depressed, benumbed state, the inhibitory centre does not exert its normal influence upon the system, and consequently tissue change goes on at a rate which results in the production of more heat than normal. ... At the same time the vaso-motor and other heat-dissipation centres are so benumbed that they are not called into action by their normal stimulus." Symptoms.-In the febrile state there are three more or less distinct stages, known respectively as the invasion, the fastigium, and the decline or defervescence. The first of these is generally preceded by a period of incuba- tion. These stages may vary in duration from a few hours to a week, or more, and they may be equal or un- equal in the same disease. The temperature, as measured by the thermometer, is the index to the character and duration of each stage. The symptoms which accom- pany the elevation of the temperature are in part its effect and in part coeffects of its cause. 1. The initial stage is usually announced by the occur- rence of chilly sensations and shivering, or a pronounced rigor. In children this rigor is frequently represented by single or repeated convulsions. The surface of the body is cold to the touch, especially the nose, ears, and ex- tremities, owing to a spasmodic contraction of the capil- laries, which may continue as long as two hours ; but the thermometer reveals an elevation of the general tempera- ture amounting to a degree or more. "The outer parts freeze, while the inner burn " (Virchow). This rise of (Celsius). In the continuous fevers an exacerbation of the symptoms occurs at night, and a remission in the morning, the fluctuation usually amounting to about a degree of the centigrade scale. The pulse and respiration also increase with the ad- vance of the second stage of the disease. Greater im- portance was, however, attached formerly to these altera- tions, especially of the pulse, than at present; and a long list of peculiarities belonging to the rate, rhythm, volume, and tension of the pulse have been tabulated. The pulse- rate usually coincides pretty closely with the elevation of the temperature, and averages an increase of eight beats per minute for each degree (Celsius) of febrile elevation (about four per minute for each degree Fahrenheit). So numerous are the influences which modify the heart's action, however, that this relation is frequently disturbed. The following table, prepared from that of Liebermeister, shows the relation of pulse to temperature in broad limits : Temperature: Centigrade .... 37.0° 38.0° 39.0° 40.0° 41.0° 42.0' Fahrenheit.... 1'uise: 98.6° 100.4° 102.2° 104.0° 1U5.8® 107.6° Maximum 124.0 148.0 160.0 158.0 160.0 1C8.0 Minimum 45.0 44.0 52.0 64.0 66.0 88.0 Average 78.6 88.1 97.2 105.3 109.6 121.7 The volume and tension of the pulse are of much greater practical value, however, than the mere number of its pulsations. There is further observed in the fastigium an increase of the thirst, the anorexia, the lassi- tude, and all other symptoms of the invasion. The mind frequently be- comes much clouded, and various nervous phenomena may appear; sometimes delirium supervenes. The secretions in general are reduced in quantity, owing chiefly to a diminu- tion of their fluid constituents, the solids remaining in normal quantity or being increased. The second stage terminates by crisis or lysis. In the former in- stance the temperature falls in the course of from twenty-four to thirty- six hours to the normal, the other symptoms undergoing a similar de- cline. The pulse may decrease as many as one hundred beats per minute, and the respirations may be reduced ten to fifteen in number within a few hours, while the secretions usually more slowly return to their normal standard. Such sudden decline is usually at- tended by the occurrence of a critical sweat, haemorrhage, or other evacuation. The best examples of crisis are ob- served in croupous pneumonia and relapsing fever. When the decline is by lysis, several days are generally occupied in the process, the morning remissions growing gradually greater, the evening exacerbations less, until finally the normal standard is reached. This mode of ter- mination is well illustrated in scarlet and typhoid fevers. In fatal cases of disease accompanied by fever the tem- perature frequently rises several degrees shortly before death. Sometimes, however, as a result of shock, as, for example, in the perforation of the intestinal ulcers of typhoid fever, the temperature falls abruptly to or below the normal, the decline being accompanied by great de- pression, restlessness, cold sweat, occasionally by deli- rium or coma, though this collapse is often marked by a delusive clearing up of the previously clouded brain. Death may occur at any stage of a fever, being due in the earlier stages to blood-poisoning, or later it may be to the effects of elevation of temperature pur et simple. For the special symptoms of particular fevers the reader is referred to the articles on Typhus, Typhoid, Small-pox, Measles, Scarlet Fever, Intermittent Fever, etc. Results.-Certain lesions are always likely to result from a prolonged pyrexia, especially in the acute infec- Fig. 1157.-Chart Illustrating the range of temperature in a typical case of Typhoid Fever of mod- erate severity. temperature actually precedes the rigor ; it may be sud- den or gradual, continuous or remittent. When the in- vasion is gradual, extending over several days, an even- ing exacerbation and morning remission are observed, similar to those which occur in the later periods of the disease. This is best illustrated in such diseases as ty- phoid fever (Fig. 1157), small-pox, and measles. When the initial elevation is more sudden, it is usually more continuous in its rise. These symptoms, which properly belong to the pyrexia, are generally accompanied by a small, frequent pulse, accelerated respiration, thirst, anorexia, and sometimes vomiting. The tongue is more or less heavily furred, the bowels as a rule constipated. These, however, as also such symptoms as muscular pains, coryza, vertigo, epistaxis, etc., depend rather upon the nature of the dis- ease to which the fever belongs, upon the severity of the attack, or upon idiosyncrasies of the individual. 2. The stage of invasion merges into the fastigium, or stage of progress, either by sudden, well-marked changes in the symptoms, or by gradual, hardly appreciable tran- sitions, usually corresponding to a brief or prolonged period of invasion. In either instance the sensation of cold gives place to that of heat, the capillary circulation of the skin undergoes a reaction, and the surface becomes red and hot. The temperature remains elevated and may continue to rise ; but in certain diseases, owing to the occurrence of an eruption, or a critical discharge, it not infrequently falls for a time to the extent of a degree 68 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. tions ; lesions which may or may not disappear during convalescence. Either the parenchyma or the intersti- tial tissues of the various organs may be involved. The parenchyma is usually affected by granular fatty degeneration of its cellular elements ; the interstitial substance by a sclerotic change. An albuminoid de- generation of the parenchyma has also been described. These degenerations are almost universal in their dis- tribution among the organs, and their importance therefore varies with the organ affected. In the heart they cause great debility, and often thrombosis ; in the nervous system, paralyses, etc.; in the liver, spleen, and other glands various disturbances of assimilation and nutrition, resulting in anaemia and emaciation. The vol- untary muscles, in addition to these degenerations, are liable, especially from the high temperature of typhoid fever and acute miliary tuberculosis, to undergo a waxy metamorphosis which has been designated, from the name of its discoverer, Zenker's degeneration, whereby the muscular fibres lose their transverse striations and be- come converted into homogeneous vitreous masses. It is now pretty generally believed that the high tem- perature attending the acute infections and some other diseases is not wholly evil. Since it has been demon- strated that the growth of the tubercle bacillus ceases at a temperature above 41° C. (105.8° F.), and that the spir- illa of relapsing fever disappear at the close of each paroxysm, when the temperature reaches 42° C. (107.6° F.), it is inferred that a similar destructive influence may be exerted by excessive heat on the germs of other diseases. The spores being, however, more tenacious of life, continue to develop and prolong for a variable time the duration of the disease. Prognosis.-In estimating the gravity of a case at- tended with fever, the average temperature should be considered, as well as the height of a single elevation. Thus, the prognosis is more unfavorable when the even- ing temperature is high and the morning remission but slight. It may be said, therefore, that a high morning temperature is indicative of greater gravity than a high evening temperature; yet a high evening temperature, although accompanied by considerable morning remis- sions, should always be looked upon as an indication of danger. If the evening temperature does not exceed 40° C. (104° F.), the prognosis is generally favorable; from 40° C. to 41.5° C. (107° F.) the prognosis becomes rapidly more grave as the latter limit is approached, and the majority of the cases in which a temperature of 42° C. (107.6° F.) is reached terminate fatally, except in those cases of remittent type already referred to. Remissions and intermissions, whether pertaining to the disease or the result of treatment, greatly diminish the risk arising from the preceding high elevation of temperature ; hence the favorable prognosis in intermit- tent and relapsing fevers, notwithstanding the extreme degree of fever. Yet a decline of temperature, if unat- tended by a slowing of the pulse, in no way mitigates the danger. A rapid rise of temperature, especially in the stage of defervescence, is indicative of danger, owing to its dependence as a rule on complications, and if follow- ing close on a crisis, is generally followed by death. So a decided rise of temperature at the expected time of a crisis should occasion fear of the development of com- plications. But, on the other hand, a rapid and decided decline is not always free from danger, as it is frequently a symptom of collapse. But so numerous are the in- fluences peculiar to particular diseases or to the individual case, as to greatly modify any rules of prognosis that can be formulated ; and the great reduction of the danger at- tendant upon high temperature that has been attained as a result of the present advanced methods of treatment gives fair promise of still further improvement. Treatment.-The first indication in the treatment of fever is to discover and remove, if possible, the cause of the pyrexia. Very often, as where this is due to the presence of foreign bodies, excremeutitious matter or pus, the removal of such matter will of itself suffice for a re- lief of the symptoms. But it is not always possible to recognize and meet the causal indications ; although it is probable that the remedies which have become most noted for their antipyretic action, as a result of continued em- pirical use, owe their efficacy in a great measure to a specific action which they exert upon the cause of the dis- ease, in many instances not yet discovered. Various antipyretics have been adopted for the relief of the febrile state. First among these, and often the most important, is the judicious use of cold water and other fluids. Hydrotherapy includes both the internal administration of water and its application to the exterior. The great thirst and the diminished secretion of fluids demand the introduction of water. This may be given plain or acid- ulated. Pleasant beverages may be made by adding to water a few drops of hydrochloric, sulphuric, or phos- phoric acid, or one of the mucilaginous or farinaceous sub- stances prepared for the purpose. Lemonade is one of the best drinks for the fever patient in most cases; but an occa- sional draught of plain cold water, or hot water, if cold be contra-indicated, is grateful to the patient. The plen- tiful administration of milk answers in part this indica- tion as well as the demand for nourishment. Fluids should be administered in moderate quantities, at stated intervals, varied to correspond to the degree of pyrexia, and to some extent independent of the wishes of the pa- tient, particularly if he be in a typhoid state or other- wise incapable of expressing his needs. Care should be exercised, further, as to the time and quantity of their administration, that the appetite for food and the power of digestion be not impaired by them. This method of treatment may frequently be varied by the occasional ad- ministration of ice. The application of water to the exterior of the body is secured by, 1, the cold bath; 2, the graduated bath ; 3, the cold pack; 4, cold affusions ; 5, cold sponging ; 6, cold compresses, or, 7, by frictions with ice. But one mode of action belongs to all these, however, namely, the abstracting of heat from the fevered body. Their rela- tive value is to be estimated by the extent to which they are capable of accomplishing this end ; but their relative applicability depends in great measure on the age and strength of the patient, as well as on the character of his disease. The cold bath, which is the most effective, should be of a temperature not lower than 20° C. (68° F.) and of about ten minutes' duration, or until chilliness is complained of. The entire body should be immersed, but with as little inconvenience to the patient as possible. A glass of brandy or wine should always be administered directly before the bath to patients exhibiting signs of feebleness, and may be employed in any case of exhausting disease, in order to combat the depression which is likely to follow. When taken from the bath the patient should be wrapped in a dry blanket or sheet without drying, and returned to his bed. Should he still complain of chilliness, friction should be applied to the extremities, and bottles filled with hot water may be put to the feet. The bath should be re- peated at sufficiently frequent intervals to prevent the return of excessive heat, rarely oftener than once in three hours ; or, what is still better, it may be substituted by one of the milder methods of hydrotherapy. After a cold bath the surface temperature is reduced to or below the normal, but the general temperature subsides gradu- ally for half an hour or more, when it again begins to ascend. The cold bath should rarely or never be given to children or the aged, and is contra-indicated by debility of the heart. The graduated bath should at first be of a temperature about 5° C. (nearly 10° F.) lower than that of the body, and should be of fifteen or twenty minutes' duration. After the body has been immersed the temperature of the bath is gradually reduced to about 20° C. (72° F.) by the addition of cold water. The graduated bath is less prompt in its action than the cold bath, but the sensation it con- veys is so much more agreeable to the patient that it is generally to be preferred, except in cases in which the stimulating effect of the cold bath upon the psychical centres is demanded. It should always be chosen for children and the aged, or individuals of highly excitable 69 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nervous constitution. The rules for its repetition and the contra-indications to its use are the same in character as those of the cold bath. The cold pack exerts, to a considerable degree, the action of the cold bath upon the psychical centres, but is less prompt and less severe in its action ; it is, therefore, pref- erable in many cases. The patient is wrapped in a suc- cession of wet sheets for about twenty minutes. Four such treatments are required, according to Liebermeister and Braun, to produce the effect of one cold bath. Cold affusions are seldom employed in this country, owing to their objectionable features, which almost equal those of the cold bath. Cold compresses and cold sponging are of feeble efficacy, but may be employed to aid other methods. Frequent sponging of the body of fever patients with tepid water is almost imperative, however, for its refreshing effect. Frictions with ice, although powerfully antipyretic, are objectionable because of their severity, and are seldom resorted to. Medicinal Treatment.-The chief medicinal agents for the reduction of elevated temperature are quinia, sali- cylic acid, kairin, and antipyrin. The relative value of these preparations varies with the character of the dis- ease in which they are employed. Quinia is preferred for all malarial affections, and sali- cylic acid for acute articular rheumatism, because in these affections their action is in either case specific in char- acter ; but either remedy is applicable to the reduction of temperature from a great variety of other causes. Quinia should be given in the dose of 70 centigrammes (10 grains) every half-hour or hour, until two or three grammes (30 to 45 grains) have been given. It may be given either in solution or in capsules or pills, followed by a few drops of diluted hydrochloric acid. Salicylic acid and the salicylates should be administered in the quantity of 1 to 1.25 gramme (15 to 20 grains), repeated every hour or two until the full physiological effects of this remedy are produced, then in smaller and less fre- quent doses. Kairin, although efficient for the reduction of high temperatures of almost any origin, has fallen into disfa- vor on account of the evil effects which frequently follow its use. It is administered in gramme (15-grain) doses every hour until four or five doses have been taken. Antipyrin is the most certain, as well as the most pow- erful, of the antipyretics yet introduced, and promises fairly to supplant, in great measure, all other medicinal agents, and even the cold bath. It is administered in the dose of one gramme (15 grains) every hour for three or four hours. A reduction of about 1° F. is usually ob- tained from each dose, the decline commencing within an hour after the first administration. The remedy is usually attended by no evil effects, except in some cases by a profuse sweating, which may be modified by com- bining with it a half-centigram (-^ grain) of agaricine, or one milligram (/^ grain) of atropia. Its applicability is almost unlimited. Its action is rapid, and continues for several (five) hours, and its free solubility admits of its being administered hypodermatically, for which purpose half the usual quantity is requisite. The other remedies which have in turn attracted notice for their antipyretic properties require no consideration here. The most prominent of them are resorcine and chinoline. But, although they possess unquestionable antipyretic powers, their administration is productive of such unpleasant phenomena as to prevent their coming into general favor. Little need be said in this connection of the further care of the fever patient, as this subject will be more fully considered in the articles on the diseases attended by fever. In general, the diet of the patient should be limited to unirritating and easily-digested articles of a fluid or semi-fluid consistence, and in moderate quantity. In many cases a diet of milk, rendered more easy of di- gestion by the addition of lime-water, is sufficient during the greater part of the febrile state. In most cases the addition to milk of certain farinaceous substances pre- pared for the purpose, and the administration of soups, broths, and teas, is admissible and acceptable to the pa- tient. Alcohol, in the form of wine or brandy, is an excellent food in prolonged fevers, and exerts, in a moderate de- gree, an antipyretic action. The character of the pulse is the best index to its administration, as it is a powerful cardiac stimulant in these cases. Digitalis is also antipyretic in this sense, but veratrum viride, antimony, and like remedies, whose whole anti- pyretic effect is due to paralysis of the heart, no longer merit mention in the list. James M. French. 1 Aristotle: Opera Omnia, V., iii. p. 669. 2 Galen : Opera Omnia, V., xi., p. 152. 3 Mundinus: De omnibus humani corporis interioris membris Anatho- mia. Chap. De Anathomia cordis. 4 Boerhaave : Aphorism i de cognoscendis et curandis morbis. 5 Billroth : General Surgical Pathology, Amer. ed.. 1880, p. 93. 6 Volkmann : Beitnige zur Chirurgie. Leipzig, 1875. 7 Wood : Fever-A Study in Morbid and Normal Physiology. 1880. 8 Wood; Op. cit., p. 255. References. FEVERS, CONTINUED: RELAPSING FEVER. Syno- nyms.-Febris recidiva; typhus recurrens ; famine fever ; bilious typhoid; spirillum fever ; epidemic remittent fever; remitting icteric fever ; fievre a rechute; fievre recurrente ; typhus a rechute ; Hungerpest ; Riickfalls Fieber ; Wiederkehrendes Fieber ; Armentyphus ; tifo re- cidivo, etc. Definition.-A specific, contagious fever, which may prevail as an epidemic among the destitute, and espe- cially among those who live in overcrowded tenements, during seasons of unusual scarcity of food; hence the name famine fever. It is characterized by the presence of a mobile spiral filament in the blood-a spirillum or spirochaete (S. Obermeieri)-which is found during the relapses as well as during the initial paroxysm, but is ab- sent during the apyretic intervals. The first febrile par- oxysm lasts from five to seven, or even nine days, and is terminated abruptly in profuse perspiration ; after an apyretic interval of a week or more a relapse commonly occurs, which is similar to the initial paroxysm, but of shorter duration ; in some instances a second, a third, or even a fourth relapse occurs. History.-The attempt has been made (Spittai, 1844) to show that some of the fevers described by Hippocrates correspond with relapsing fever. This view is consid- ered by Hirsch to be quite erroneous. He says : "It is clear that Hippocrates speaks there of bilious remittent malarial fever." The first notice of the occurrence of relapsing fever in Europe is found in the writings of the Scotch and Irish physicians of the early part of the last century. Hirsch says : " I have searched in vain, in the descriptions which the physicians of the sixteenth and seventeenth centuries have given of the fever epidemics observed by them, for any indications of relapsing fever that would be in some measure precise." The fact that the disease was not recognized, and differentiated from other specific febrile affections, cannot, however, be taken as evidence that it did not exist prior to the date of the first clearly-recorded epidemic in Ireland (1739). An ac- count of this epidemic has been given by Rutty, who wrote in 1770. The earliest accounts of the disease in Scotland date from 1741 (Hirsch). But the literature re- lating to relapsing fever belongs for the most part to the present century. It prevailed in Ireland and in Scotland during the years 1799-1800, 1817-1819, 1826-1827, 1842- 1848, and in the latter year (1848) it invaded several of the larger towns of England. In 1868-70 it again pre- vailed in England and Scotland, and cases are reported to have occurred in London as recently as the year 1873. On the Continent the first accounts we have come from Russia-Odessa, in 1833; Moscow, 1840-41. In the autumn of 1863 the disease reappeared in Odessa ; the following year it became epidemic over extensive areas in Russia, and extended to Livonia and Finland (1865), to Siberia (1866), and to Poland (1868). According to Hirsch, the disease continued to prevail in Russia over extensive areas during subsequent years, and was ob- served among the Russian troops as late as 1878-79. In 70 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. Germany an extensive epidemic broke out in 1868, as a result of importation from Russia (Hirsch). A second, more restricted, epidemic occurred in 1871-72, and a third in 1878-79. In the west and southwest of Europe- Switzerland, France, Italy, Spain-the disease is as yet unknown. In India relapsing fever has, no doubt, pre- vailed for many years, but the differential diagnosis be- tween it and remittent fever, or the specific continued fevers which prevail there so largely, was not clearly made out by the earlier observers. During the last thirty years, however, numerous outbreaks of this disease in various parts of India have been recorded, and Carter has demonstrated that the disease, as it occurs in that coun- try, is identical, as regards its clinical history, with relaps- ing fever, as described by recent European authorities, and also, that it is characterized by the constant presence of the spirillum discovered by Obermeier in blood drawn during a febrile paroxysm. Relapsing fever has several times been imported to the United States, but its preva- lence has been limited to restricted areas in our largest sea-port cities. In 1844 fifteen cases were received into the Philadelphia Hospital from an emigrant ship sailing from Liverpool; in 1848 a few cases arrived in New York, and in 1850-51 Dr. Austin Flint saw a number of cases, among recently arrived Irish emigrants, received into the Buffalo City Hospital ; but no epidemic resulted from these importations, and it was not until some years later (1869-70) that the disease became epidemic in cer- tain sections of the cities of New York and Philadelphia. Parry, who made a careful investigation with reference to the origin of the first cases in Philadelphia, was un- able to trace it to importation ; but this can scarcely be questioned in view of what is known of the history and etiology of the disease, and in consideration of the fact that Philadelphia is a sea-port city which has constant communication with ports on the other side of the Atlan- tic which at that time were known to be infected. Parry and Pepper have given us admirable accounts of this epi- demic in Philadelphia. We quote from a recent article by the last-named author the following statement, relating to its progress and extent. "In Philadelphia, of 1,176 cases in which the date of occurrence is known, there oc- curred in September (1869), 4 cases ; December, 6 cases ; January (1870), 5 cases ; February, 13 cases ; March, 124 cases ; April, 209 cases ; May, 325 cases ; June, 293 cases; July, 115 cases ; August, 19cases; September, 28 cases ; October, 15 cases ; November, 1 case ; December, 2 cases; January (1871), 2 cases ; February, 1 case; March, 2 cases ; May, 7 cases ; June, 2 cases ; September, ? cases ; October, 2 cases. The coincidence of relapsing fever and typhus has been noted in many of the epidemics which have occurred in Europe, but the history of this coincidence does not jus- tify the supposition that there is any etiological relation between these diseases other than that furnished by com- mon predisposing causes, viz., the depressing effects of overcrowding, insufficient food, and filthy surroundings. This view is supported by the fact that either disease may occur alone, and the circumstance that sometimes one and sometimes the other has the precedence in time in those epidemics in which coincidence has been observed. Etiology.-The discovery by Obermeier, in 1873, of a minute vegetable parasite-Spirochate Obenneieri-in the blood of patients suffering from relapsing fever, and the subsequent demonstration, by numerous observers in vari- ous parts of the world, that this micro-organism is con- stantly present in the blood of relapsing fever patients during the febrile paroxysms, has thrown a flood of light upon the etiology of this disease, and is one of the most significant facts with reference to the etiology of the in- fectious diseases in general which has been brought to light by modern microscopical researches. Conservatism suggests the possibility that the parasite may be simply an accompaniment of the disease, and not directly con- cerned in its etiology as the essential and specific cause. This hypothesis seems to us to be hardly tenable, in view of what is now known of the pathogenic action of certain other micro-parasites of the same class, and of the follow- ing facts; (a) The parasite is constantly present in the blood during the febrile paroxysms, and in smaller num bers during the latter part of the period of incubation, and is absent during the apyretic intervals, (b) This para- sitic organism is peculiar to the disease under considera tion, i.e., repeated researches by competent microscopists have failed to demonstrate the presence of a similar or- ganism in any other disease, (c) The parasite is present in the blood in such numbers that its pathogenic power can scarcely be questioned. Carter says: "During spe- cific fever several organisms (e.g., five to ten) are visible in the field at one time ; not seldom they are too numer- ous to count, and occasionally they are present in swarms, being apparently nearly half as common as the red disks themselves." (d) The disease may be communicated to man (Motschutkoffsky) and to the monkey (experiments of Koch and of Carter) by inoculations With blood con- taining the spirillum, and the parasite is found in great numbers in the blood of the inoculated individuals dur- ing the febrile paroxysm which results-after an incuba- tion period of three or four days (Carter)-from such in- oculations. The morphology of the relapsing fever "germ" is shown in Fig. 11.58, which is copied" from a photo-micrograph by Koch. The spiral filaments are exceedingly slender, their di- ameter being not more than 1 (0.001 mm., Le- bert), or, accord- ing to Carter, COUCHT to roooTT of an inch. The length varies from two to six times the diameter of a red blood disk (Carter). The mo- tion of these spiral filaments, in blood recently drawn, is very lively, "ro- tary, twisting, and rapidly progressive, but soon ceases under the ordinary conditions of microscopic examina- tion " (Lebert). According to Carter, the movements may continue from a few' hours to one or twm days or longer. A good objective and a certain amount of skill in the use of the microscope is required for the detection of the spirillum in fresh blood. This is shown by the fact that Obermeier himself failed to recognize the presence of the parasite in the microscopic researches made by him some years prior to the date of his discovery ; and by the fail- ure reported by some of those who have since attempted to verify his observations. Carter says: "That, as re- gards the examination of fresh blood, obstacles do exist, is proved by the fact of the organism being originally found only after long-repeated scrutinies; and at Bom- bay I have met with observers, not unaccustomed to the use of the microscope, who could never clearly see the filaments." The demonstration is more readily made when a thin film of dried blood attached to a cover-glass is stained, secundum artem, with one of the aniline colors -an aqueous solution of methyl violet, or of Bismarck brown, or fuchsin. It is not yet certain whether the spirillum of relapsing fever is reproduced by spores as well as by " spontaneous fission," but it seems extremely probable that this is the case. Carter supposes that certain short filaments which he has observed in the blood are germinating spores, and remarks that ' ' the practical facts of contagion require the presence of fertile spores, since spiral filaments are absent in the secreta and excreta of the body, and propa- gation by blood-inoculation is obviously not the rule in common life." The same author gives several instances in which an attack is supposed to have been due to acci- dental inoculation while making an autopsy. . Other cases are ascribed to simple contact with the dea'd body, independently of any wound. That the disease may be Fig. 1158. 71 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. transmitted from individual to individual by direct con- tagion, or indirectly through fomites, is demonstrated by a multitude of observations ; and, indeed, we have no sat- isfactory evidence that it is transmitted in any other way, or that the specific infective agent-spirillum-is capable of multiplication in an external nidus, and thus of giving rise to an epidemic independently of direct contagion, as is undoubtedly the case in certain other diseases, e.g., typhoid fever, cholera, yellow fever. On the other hand, the evidence on record shows that in well-ventilated apartments and hospital wards the attendants upon the sick and patients suffering from other diseases are not very liable to contract the disease. Where, however, the sick are massed together in insufficiently-ventilated hos- pitals, or when cases occur in the overcrowded tene- ments of the poor, the transmission of the disease to attendants and others exposed to contagion is far more frequent. Up to the present time, attempts to reproduce the spi- rillum of relapsing fever in a series of cultures have not been successful. Carter has, however, observed a growth of the spirilla in length, and the development of a tangled network of long filaments in a culture-cell containing aqueous humor, kept in a warm chamber at a tempera- ture of 40.5° C. (105° F.). Predisposing Causes.-There is no evidence that cli- mate or season has any marked influence upon the preva- lence of relapsing fever; the disease has prevailed in Siberia as well as in India, and its preference for certain localities is quite independent of climatic conditions, re- lating rather to circumstances connected with the mode of life and hygienic surroundings of the population. No age is exempt, and sex has no apparent influence; but children are more subject to be attacked than adults, and susceptibility seems to diminish to some extent with ad- vancing age. According to Murchison, only 195 out of 2,111 cases received into the London Fever Hospital, in twenty-three years, were over fifty years of age. To ap- preciate the value of these figures it would evidently be necessary to know how large a proportion of the exposed population were over fifty years of age. Insufficient food is generally recognized by medical writers as a potent predisposing cause, and epidemics have so frequently been observed to coincide with peri- ods of unusual scarcity that the name "famine fever" has been applied to the disease. Some authors have even gone so far as to ascribe to starvation and its accompani- ments, overcrowding, and filthy surroundings, an essen- tial role in the development of the disease. But, as in the case of other specific contagious diseases, there seems to be very little foundation for the idea that relapsing fever may be developed de novo in times of famine, and its epidemic prevalence at such times is to be ascribed rather to increased vulnerability, on the part of the starving population, to the action of the specific exciting cause of the disease. We know that under favorable hygienic conditions the disease has but little disposition to spread, and that in the severest epidemics it finds its victims almost exclusively among the destitute. On the other hand, in the numerous instances in which ship- wrecked mariners, Arctic explorers, etc., have been sub- jected to absolute starvation, we have no account of the development of any such disease as relapsing fever. Overcrowding is considered by Parry to be a more potent predisposing cause than starvation, and his careful study of the circumstances of those who were taken sick during the prevalence of the disease in Philadelphia (1870), seems to justify this conclusion-which is, moreover, supported by the observations of Muirhead, Bennett, Lebert, and others. One attack of relapsing fever does not protect the indi- vidual from subsequent attacks, and second, or even third, attacks during the same epidemic have been noted. Carter's experiments upon the monkey have led him to the conclusion that "the human virus becomes intensi- fied in its passage through this animal." It is noticeable that, with one or two exceptions, there was but a single febrile paroxysm in the numerous successful inoculation experiments made by the author quoted. This does not invalidate the value of the evidence furnished by his ex- periments, as to the identity of the disease produced in the monkey with the specific infectious disease of man known as relapsing fever, for this single paroxysm was characteristic in its origin, duration, and termination, and in the constant presence of the blood-parasite which is peculiar to this disease. Moreover, in man the relapse is not an essential feature of the disease, Thus Carter, out of a total of 411 cases, found that in 98 (23.8 per cent.) there was but a single febrile paroxysm. Pepper has recorded the fact that in 10 out of 181 cases observed in Philadelphia there was no relapse ; and Murchison, in a series of 2,425 cases collected from various sources, found that there was but a single paroxysm in thirty per cent. Clinical History.-As a rule, the primary febrile paroxysm begins abruptly, without noticeable prodromata. In certain cases, however, the patient experiences a certain amount of malaise, loss of appetite and headache, for a day or two prior to the sudden access of fever. The period of incubation has usually a duration of from five to seven days (five tQ nine days-Murchison), but instances of a lon- ger or shorter incubation are not infrequent. In several cases of accidental inoculation, at autopsies, which came under the observation of Carter, the period of incubation' was from three and a half to seven days ; and in the suc- cessful inoculations in the monkey, made by the same au- thor, the mean duration of this period was about ninety hours. Speaking of these experiments, the author referred to says : " My experiments showed conclusively, that prior to the onset of the fever there always occurs a more or less prolonged period of visible blood-contamination ; and hence that the interval between infection and fever is divisible into two parts, viz., an earlier and usually longer non-spirillar stage, and a final stage of spirillar manifestation during which the body heat, so far from be- ing augmented, is often rather depressed." The initial paroxysm of fever is commonly inaugurated by a decided chill, or at least by slight chilly sensations, accompanied by headache, pain in the back and limbs, and a feeling of weakness, with indisposition to exertion. The tongue is coated ; nausea and vomiting are of com- mon occurrence ; and there is usually a certain amount of tenderness on pressure in the epigastric region. En- largement of the spleen occurs early in the attack, and usually a certain amount of enlargement of the liver may also be detected after the second or third day. Jaundice is of frequent occurrence in certain epidemics, and in others is quite rare. The abrupt seizure usually occurs during the daytime, and is marked by a rapid rise of tem- perature and a correspondingly rapid pulse. The pyret- ic movement exhibits a somewhat remittent character, the evening temperature being one or two degrees higher than the morning temperature, and attaining a maximum of 103.5° to 105° F. during the first twenty-four hours-a maximum which may be exceeded by a degree or two during subsequent evening exacerbations. The distinc- tive character of the pyrexia is its sudden termination by crisis, as a rule on the fifth, or seventh day-more rarely as early as the third or as late as the twelfth day. This sudden termination of the febrile paroxysm is commonly attended with profuse perspiration, and occasionally by a critical diarrhoea, or haemorrhage from the nose, rectum, or vagina. The temperature frequently falls, during this termination of the paroxysm by crisis, as much as ten or twelve degrees F. in a few hours, and as a rule, a subnor- mal temperature is quickly reached, and may persist at the morning observation for two or three days. Deferves- cence may occur at any time during the twenty-four hours, but the observations of Carter indicate that in a majority of the cases (66.6 per cent.) it happens between the hours of 4 p.m. and 7 a.m., or, in other words, that it is most likely to occur during the night. It is attended by a complete relief of the distressing symptoms which marked the febrile paroxysm, and with the exception of a feeling of lassitude the patient has nothing to complain of, his tongue cleans up, his appetite returns, and within three or four days-he might be considered convalescent, were it not for the known tendency of the disease to re- 72 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. febrile paroxysm and subsequent subnormal depression of temperature in yellow fever. In relapsing fever it is not perhaps so common, but is sufficiently so to have at- tracted the notice of Carter, who speaks of it as the " rebound " or " secondary fever," and states that it was observed in about one out of six of his cases. "Its duration is brief, and the blood-spirillum is invariably absent." The pulse in relapsing fever presents no distinctive character. During the pyretic movement it is very fre- quent, and at the outset is commonly full and tense ; but with defervescence there is a rapid reduction in its fre- quency, and during the first portion of the apyretic in- tervals, when the temperature is subnormal, and the patient is in a state of partial collapse, it becomes small and feeble, and occasionally extremely slow-as slow even as in the corresponding stage in cases of yellow fever. Thus, Obermeier has seen it as low as 44, and other observers have seen it even lower than this-Muir- head 34, Stille 30. While, in general, the rapidity of the pulse corresponds with the pyretic movement, yet this is not an invariable rule, and according to Murchi- son is less true as regards the relapse than in the initial paroxysm ; thus, he has seen a pulse of 90 when the temperature was 106°. On the other hand, Carter has noted that in the Bombay epidemic the sudden fall in temperature marking the crisis was not attended with a corresponding de- cline in the frequency of the pulse. During ■ the height of the fever the number of pulsations per minute, in adults, may be stated as from 110 to 140, while in children it often reaches 160 or even 170. After the crisis, an irregular or dicrotic pulse is not infrequent, and as a rule it is feeble and compressible. At this time there is danger of sudden death from syn- cope. A soft systolic mur- mur heard over the base of the heart and along the large vessels is fre- quently discovered, both during the primary paroxysm and during the relapse. Pain in the back and limbs is complained of during the first days of the primary attack, and to a less extent dur- ing the relapse. Articular pains, unaccompanied by swelling, may also persist during the apyretic interval. But the most distressing pain is felt in the head. Head- ache is usually frontal; it is an early and often very per- sistent symptom, disappearing only with the crisis, and recurring with less severity with the relapse. Other symptoms referable to the nervous system are : Vertigo, induced by assuming an erect position; especially com- mon at the outset of the attack, and often persisting throughout the paroxysm; Delirium, usually of an hys- terical character, and most common among the victims of chronic alcoholism ; or the low muttering delirium which accompanies suppression of urine, and which, in the ab- sence of relief, passes into stupor and coma ; Convulsions, the result of uremic poisoning or of extreme nervous irri- tation due to severe and protracted pyrexia; Insomnia, due largely to the distressing pains, and not readily con- trolled by hypnotics; Paralysis, limited to single muscles or to groups of muscles-of rare occurrence. Of these symptoms vertigo and insomnia are the only ones which are so common as to constitute a characteristic feature of the disease. The symptoms referable to the digestive system are those common to febrile complaints generally, viz., thirst, loss of appetite, a coated tongue, torpid bowels, and nausea, with vomiting of ingesta and bilious matters. The tongue usually remains moist and is coated with a thick, white lapse after an apyretic interval of about a week. In 190 cases analyzed by Carter the mean duration of the apyret- ic interval was 7.4 days, the extreme range being from three to twelve days. The relapse, occurring commonly on the fourteenth day from the date of seizure, resembles the initial paroxysm in its sudden onset and abrupt termination, but is usually of shorter duration-three to seven days. The temperature not infrequently attains a higher point than during the initial paroxysm, and there is a correspond- ingly rapid pulse, but with the exception of increased de- bility the other symptoms are, for the most part, of a milder character. Defervescence is attended witli profuse perspiration, and, as in the first apyretic interval, a sub- normal temperature is quickly reached. After a second apyretic period, of from six to fourteen days, a second re- lapse of still milder character and briefer duration may occur, and, in exceptional cases, this may be followed by a third or even a fourth relapse. Special Symptoms.-The characteristic features of the pyrexia are shown by the accompanying chart (Fig. 1159) of a case reported by Murchison, which, however, cannot be taken as entirely typical, inasmuch as the initial par- oxysm and the relapse are of about the same duration, whereas the rule is that the relapse is not so protracted, and the date of its occurrence is more commonly the four- teenth rather than the twelfth day, as in this case. Variations from the typical form are, how- ever, the rule rather than the exception, and the most we can say is that there is a tendency to crisis on the seventh day, and to relapse on the four- teenth day. The remit- tent character of the py- retic movement is often more marked than in this case, and especially so in the relapses. We remark, also, that the subnormal temperature which fol- lows crisis and sudden defervescence is less marked than usual in tins case, after the first feb- rile paroxysm, although shown very well in that part of the chart which repre- sents the second apyretic interval. This is a very notice- able feature of the disease, although not peculiar to it, a subnormal temperature being quite common during the ' ' calm stage " of yellow fever. We have the authority of Murchison for the statement that the temperature may fall as much as 14.4° in the course of twelve hours, reach- ing as low a point in certain cases as 94°, 93°, or even 92°. Pepper has observed a fall from 107.2° to 95°, and states that this is as low a point as is commonly reached. The observations of Carter, also, indicate that a fall be- low 95°, in non-fatal cases, must be extremely rare. The acme of temperature is commonly reached dur- ing the twenty-four hours immediately preceding the crisis, and in certain cases a sudden rise of several degrees has been noted to occur just before the abrupt fall which terminates a paroxysm. In a typical series of cases analyzed by Carter the maximum temperature ob- served during the initial paroxysm was 108.°, on the evening of the sixth day; the maximum temperature noted during the relapse in the same series of cases was 106°. Pepper has recorded a temperature of 107.5° as having come under his observation, and in a typical case, of which he gives a chart {op. cit., p. 380), a temperature of 107J was reached at the termination of the initial paroxysm, and also during the relapse. In this chart a slight febrile movement is seen to fol- low the subnormal depression after the relapse. "Re- actionary fever" of this kind, of moderate degree, and irregular in its course, is commonly seen to follow the Fig. 1159. 73 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fur which may become yellowish, or in cases having a typhoid tendency, brown and dry. It is usually some- what swollen and indented at its edges by contact with the teeth. This appearance, together with the frequent absence of coating upon the edges and over a triangular space at the tip, which remains bright and red, has been regarded by some authors as of diagnostic value. Occa- sionally the tongue is red and glazed, and it may become deeply fissured, or in severe and protracted cases dry and brown. The tongue quickly-clears up and appetite re- turns when the febrile paroxysm has terminated by crisis, and when a relapse occurs it again becomes coated and there is a return of anorexia and gastric disturbance. Nau- sea and vomiting are almost constant symptoms at the out- set of the attack, and, less frequently, recur during the relapse. Occasionally a considerable quantity of bile is ejected ; more commonly the vomited matters consist of ingesta or of glairy mucus tinged with bile. ' ' Black vom- it," due to the presence of blood in the vomited matters, has been seen by several observers, and in certain epi- demics seems to have been not very infrequent. It is a symptom of grave import. Three cases out of four in which it was noted by Pepper terminated fatally. This author observes that, "judging from the frequency with which in fatal cases we find ecchymoses of the gastric mucous membrane, with blood-stained mucus in the cav- ity of the stomach, we should expect black vomit to be more often observed than is the case. " More or less ten- derness and pain on pressure in the epigastric region is a common symptom during the early part of the febrile paroxysm ; in this particular, as in several others, there is a noticeable resemblance to yellow fever. The bowels are commonly constipated at the outset of the attack, but later diarrhoea is not infrequent, and this may be profuse and of a critical character, occurring at the close of a febrile paroxysm, and to a greater or less ex- tent taking the place of the usual critical sweating. Enlargement of the liver may usually be demonstrated by careful percussion, and, in some instances, this organ ex- tends to three inches below the margin of the ribs toward the close of the febrile paroxysm. Pressure in the hepat- ic region causes pain, and occasionally hepatic tenderness is quite a constant cause of distress. Jaundice is a prom- inent symptom in certain epidemics, occurring in from twenty to twenty-five per cent, of the cases. At other times it is comparatively rare. It appears toward the close of the primary paroxysm, or in one of the succeed- ing febrile paroxysms, and usually disappears after the crisis. According to the observations of Pepper and of Stille, it is more frequent in the negro than in the white man. Enlargement of the spleen is a constant and early symp- tom, and it is not unusual for this organ to attain from three to four times its normal bulk. It may be detected as early as the second day, projecting below the margin of the ribs, and toward the close of the febrile paroxysm often forms a visible tumefaction on the left side of the abdomen. During the apyretic interval its volume rap- idly diminishes, to again increase during the relapse. The skin is free from any characteristic eruption, but occasionally an eruption of pinkish or rose-colored spots has been observed (Carter), and " true petechise have been quite common in some epidemics" (Pepper). Sudamina and herpetic eruptions about the mouth and nostrils are of common occurrence. Desquamation of the cuticle, especially from the hands and face, is not infrequent. Several observers have noted a peculiar odor, exhaled from the body of the patient, which is said to resemble that given off by " burning straw with a musty odor." The urine is somewhat scanty and high-colored during the febrile paroxysms, and, as is usual in such cases, has a higher specific gravity than normal ; its reaction is usually acid, and it deposits, on standing, a more or less copious sediment of urates, associated sometimes with crystals of oxalate of lime. The amount of urea present is subject to considerable variations, but the general rule seems to be that it is increased during the paroxysms, and decreased at the time of the crisis, to again increase dur- ing the first part of the apyretic interval. In certain cases the critical sweating is replaced by an abundant discharge of light-colored urine of low specific gravity, but under ordinary circumstances the amount of urine is greatly reduced at the time of crisis ; subsequently the quantity is increased and the specific gravity is reduced to a minimum, and this may persist for some time after convalescence is established. Thus, Carter reports a case in which the daily amount, for two weeks after the re- lapse, was 130 oz., while the specific gravity was only 1002.6. Slight albuminuria has been noted by several ob- servers as commonly occurring toward the close of the fe- brile paroxysm, or shortly after its termination. According to Carter, other evidence of acute renal congestion, such as blood-disks and tubular casts, is almost never found. Other observers, however, have reported the presence of tube casts in those cases in which the urine is albumin- ous, and Obermeier has claimed that acute desquamative nephritis is one of the ordinary phenomena of the disease under consideration. Epistaxis is of rather frequent occurrence in relapsing fever, and haemorrhage from the stomach, from the bowels, and from the kidneys, has been noted in rare cases. Pepper reports fifteen cases in which very pro- fuse epistaxis occurred at the crisis, evidently as a critical discharge, replacing to some extent the usual perspiration. Convalescence is usually rapid in the absence of any complication, but after very severe and prolonged at- tacks, a considerable interval must elapse before the emaciated patient regains his usual strength. The aver- age duration of the period included between the date of seizure and complete convalescence is about six weeks (Wilson). Varieties.-At least one relapse, occurring after an apyretic interval, is necessary to constitute a typical case of relapsing fever. But in a certain proportion of the cases occurring during an epidemic, there is but a single febrile paroxysm-abortive form (Carter)-which, how- ever, is undoubtedly due to the same specific cause, as is shown by the constant presence of the spirillum of Ober- meier in blood drawn during the pyrexia. These cases are often mild in character, and in the absence of a mi- croscopic examination of the blood, and demonstration of the presence of the spirillum, the diagnosis would remain uncertain. The form of fever denominated bilious typhoid by Griesinger and other German authors is undoubtedly a variety of relapsing fever. It is characterized by intense jaundice, a tendency to suppression of the urinary secre- tion, to haemorrhages from mucous surfaces, and to those grave symptoms which constitute the typhoid state, viz., great prostration, muttering delirium passing into stu- por and coma, hypostatic congestion of the lungs, a dry and brown tongue, etc. These symptoms may be devel- oped during the primary febrile paroxysm in such a man- ner as to interfere with the termination of this paroxysm by crisis, and to render obscure the apyretic interval which, in typical cases of relapsing fever, distinctly sepa- rates the initial paroxysm from the relapse. Complications.-One of the most frequent and fatal complications of relapsing fever is pneumonia. It com- monly occurs after the crisis of the primary paroxysm, but may also follow the relapse, or may occur as a more remote sequel of the disease-three or four weeks after the close of specific pyrexia. In 97 autopsies Carter found evidence of pneumonia in 27 instances. Out of 23 autopsies, Pepper found the lesions of this complica- tion in 8. It is more frequent in adult males than in fe- males and children. Pleurisy was found by Carter to co- exist with pneumonia 13 times in 21 autopsies, in which inflammation of the lungs was verified. Deaths from pneumonia commonly occur within a week or ten days after the first crisis. The onset of this grave compli- cation is marked by the usual symptoms and physical signs, and by pyrexia, which may be confounded with that of the relapse due to specific blood-contamination. The pyrexia attending this complication is, however, dis- tinguished from that of the preceding or subsequent specific febrile paroxysm by the absence of spirilla from the blood. The same is true of the " secondary " or " reac- tionary " fever, which in severe cases sometimes follows 74 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. the critical defervescence, and which is independent of any recognizable organic complication. Diarrhoea, in certain epidemics, is rather common as a complication or sequel, and may be the immediate cause of death. It occurred in thirty-three per cent, of the cases observed by Pepper in Philadelphia, and in fifty per cent, of the cases in the Konigsberg epidemic. Paro- titis occurred in from two to three per cent, of the cases collected by Carter, and was observed by Pepper in 3 cases out of 185. It may result in resolution, or more commonly in suppuration. As a rule, it is developed during the first apyretic interval. Hiccough is a distress- ing complication which frequently occurs in severe cases, especially in those attended with jaundice. It is most common toward the end of a febrile paroxysm, and usu- ally disappears after the termination of the paroxysm by crisis. Bronchitis of a moderate degree of intensity is a frequent complication which is developed, for the most part, during the febrile paroxysms, as a result of conges- tion of the bronchial mucous membrane, and disappears, or is greatly modified in degree, during the apyretic in- tervals. Acute laryngitis, with oedema, is an occasional complication. Enlargement of the spleen is so constant that it may be considered an essential feature of the dis- ease, rather than a complication. In certain cases the enlargement persists for many weeks, and is attended with marked debility and anaemia. Rupture of the spleen has been reported by several authors, and splenic abscess has been noted in certain rare cases. The former acci- dent is marked by suddenly developed pain and collapse, and is quickly fatal; the latter commonly gives rise to pyaemia, or may induce acute peritonitis or pleurisy, by discharging into the cavity of the abdomen or the left pleural cavity. Other complications which have been noted as events of rare occurrence are: haemorrhage from the stomach ; metastatic abscesses of the lung ; suppura- tion of the mesenteric glands ; general peritonitis ; throm- bosis of veins, and cerebral haemorrhage. When preg- nant women are attacked with relapsing fever, abortion is almost sure to occur ; and in those cases in which men- struation occurs during the attack, it is usually profuse, and sometimes dangerously so. Among the sequelae of the disease, we may mention as most prominent: diar- rhoea, dysentery, anaemia, neuralgic pains, local palsies, keratitis, and inflammation of the deeper tissues of the eyeball, mental hebetude, mania, and in rare instances gangrene of the feet, nose, or ears, as a result of arterial thrombosis (Wilson). Diagnosis.-The early diagnosis of relapsing fever is made easy by the discovery of Obermeier, and the fact, now verified by numerous observers, that the spirillum peculiar to this disease is found in the blood during the entire period of pyrexia-including the relapses-and usually for a short time in advance of the febrile parox- ysms. Without this test the diagnosis must always re- main somewhat uncertain for some days, inasmuch as there are no pathognomonic symptoms marking the out- set of the attack. The sudden termination of the initial paroxysm by crisis, and the relapse after an apyretic in- terval of five to twelve days, will, however, be sufficient to establish the diagnosis in typical cases; but, as in other specific febrile diseases, there are many atypical cases in which the diagnosis might remain uncertain if it depended upon the clinical history alone. This is espe- cially true of the so-called "abortive form," in which there is but a single paroxysm, in that form which has been denominated bilious typhoid, and in cases in which the typical character of the pyrexia is masked by compli- cations of one kind or another. In countries where se- vere forms of malarial fever prevail there can be no doubt that cases of relapsing fever, especially at the out- set of an epidemic, before the prevalence of this disease has been generally recognized, are often ascribed to malarial poisoning, and fall under the denomination ' ' re- mittent fever "-a term which in former years, and in the absence of precise knowledge, has been made to do duty in tabular statements of disease and mortality for more than one specific disease, e.g., typhoid fever, yellow fever, relapsing fever. The investigations of Carter make it .appear probable that relapsing fever is by no means a new disease in India, yet it has only been recognized during recent years, and the available records of an epi demic which prevailed in Bombay so recently as 1863- 64-65 do not permit the author mentioned to decide posi- tively whether the enormous mortality from "fever termed remittent " was in truth due to relapsing fever or to typhus, as was claimed by some of the local practi- tioners, The differential diagnosis between relapsing fever and true malarial remittent presents no serious dif- ficulties, although there are many symptoms-such as headache, vomiting, epigastric tenderness, enlargement of the spleen, and jaundice-which are common to both dis- eases. The character of the pyretic movement, the sud- den termination by crisis, the failure of quinine to favor- ably influence the course of the disease, the protracted apyretic interval, and the relapse, will suffice. But in ad- dition to these facts relating to the clinical history, there are various circumstances relating to the epidemic prev- alence of the disease which will aid greatly in its rec- ognition. Thus, relapsing fever is transmitted from individual to individual by contagion, and is a disease of towns, and especially of the overcrowded portions of such towns where the poorer classes of the population are congregated under unfavorable sanitary conditions; whereas remittent fever is especially a disease of the country, the prevalence of which depends upon circum- stances relating to locality, climate, and season, and not upon personal intercourse and social condition. As a rule, it may be said that a fatal epidemic disease which prevails among the crowded population of a large city is not remittent fever, whatever else it may be. Typhus fever and relapsing fever are often associated as regards their epidemic prevalence, although there is no evidence that they bear any etiological relation other than that due to common predisposing causes. That they are specifically distinct is well established, and the clinical history of each is sufficiently characteristic. The eruption of typhus, the continuous course of the pyretic movement, and the fatal tendency of the disease are all in contrast with relapsing fever. A more detailed account of the clinical points of difference is hardly necessary in view of what has preceded, and of the ready means of establishing the differential diagnosis which is furnished by the microscope. The same may be said as regards enteric fever, which disease is also characterized by a less abrupt onset, and a pyrexia which presents peculiar feat- ures essentially different from that of relapsing fever, together with special symptoms, such as a tendency to delirium, abdominal distention, an eruption of rose-spots, etc. The differential diagnosis in that form of relapsing fever denominated by Griesinger " bilious typhoid" may perhaps present greater difficulties, and before the dis- covery of the spirillum of Obermeier, much uncertainty existed as to the etiological relations of this fatal form of disease. In addition to the presence of the spirillum it is distinguished from enteric fever by its mode of onset, by the early appearance of jaundice, and by the character of the pyrexia, together with a tendency to haemorrhage from mucous surfaces, a more decided enlargement of the spleen, and the absence of rose-colored spots. Bilious typhoid might very easily be mistaken for yel- low fever in countries where this disease prevails, and we have the authority of Murchison for the statement that this mistake has been made by Graves, Stokes, and Cormack. The two diseases have many features in com- mon, but also essential points of difference. Thus, yel- low fever prevails only in certain latitudes and during the summer season, while relapsing fever is quite indepen- dent of climatic conditions. Yellow fever is extremely fatal, and a single attack protects from subsequent at- tacks ; the reverse is true of relapsing fever. Relapsing fever is propagated by direct transmission from individ- ual to individual; yellow fever is not, and its extension depends upon external conditions. The negro has a partial immunity from the effects of the yellow fever poison, but is especially susceptible to relapsing fever. There are also essential differences in the clinical history of the two diseases. In one-yellow fever-the acme of 75 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. temperature is commonly reached during the first twenty- four hours, and defervescence is gradual; in the other defervescence is rapid and accompanied by a critical dis- charge, and the acme of temperature occurs, as a rule, shortly before the crisis. The " stage of calm " in yellow fever is a period of the gravest danger, the urine is scanty and highly albumin- ous, and complete suppression is a common, and almost invariably a fatal, event ; the febrile paroxysm is usually not so protracted as in relapsing fever, and is attended with less distress, but the effects of the specific poison upon the blood, the kidneys, and the mucous membrane of the stomach are of such a nature as to place the life of the patient in the greatest jeopardy. The apyretic inter- val in relapsing fever is, on the other hand, a period of comparative safety and comfort; the urinary secretion is abundant, the appetite returns, and the stomach resumes its functions. This apyretic interval is, however, not so clearly defined in severe cases of bilious typhoid, as death occurs in from thirty to fifty per cent, of these cases, and most frequently during the initial paroxysm, or as a result of complications Avhich interfere with the normal course of the disease ; and as there is jaundice, albuminous urine, and a tendency to haemorrhages from mucous membranes, it is easy to see how mistakes may arise, and the diagnostic value of the microscopic test, demonstrating the presence or absence of the spirillum, becomes apparent. It must be remembered, however, that the spirillum is not found during the reactionary fever which sometimes follows the crisis, or during the pyrexia attending a complication. Prognosis and Mortality.-The mortality from re- lapsing fever, in the absence of complications, is low. Out of 2,115 cases admitted to the London Fever Hos- pital in twenty-three years (1847-70), there were 39 deaths (1.84 per cent.). Murchison, to whom we are in- debted for these figures, has also analyzed the statistics furnished by Scotch physicians. In a series of 6,300 cases the mortality was 4.12 per cent., and in a second series of 10,444 cases it was 4.42 per cent. According to Pepper, the mortality in the Philadelphia epidemic was 14.4 per cent., the total number of cases being 1,174. These figures scarcely sustain the statement that relapsing fever is a comparatively mild disease, and the mortality in the cases in which jaundice was a prominent symp- tom-"bilious typhoid"-which is said to have been not less than fifty per cent., places this form of the disease on a level with yellow fever and typhus, so far as its fatality is concerned. In India, out of 616 cases collected by Carter, there were 111 deaths (18.02 per cent.). It is evident from these figures that it is only by excluding cases complicated by jaundice, pneumonia, etc., that the statement is justified that " the death-rate in relapsing fever is low." Death may occur during the initial par- oxysm, the apyretic interval, the relapse, or subsequent to this. In an analysis of 99 fatal cases Carter ascer- tained that in 48 death occurred during the primary par- oxysm, and of these 37 at or about the apparent acme of fever, and at the stage of defervescence 11; 24 deaths occurred during the first apyretic interval; 6 during first relapse ; 11 during second interval, and 1 in a second re- lapse. The apparent cause of death in these cases is said to have been in 63 cases exhaustion, resulting from the immediate effects of the pyrexia and its attendant symp- toms ; in 17 cases pneumonia as a complication ; in 2 copi- ous gastric haemorrhage ; in 1 femoral thrombosis ; in 7 cerebral hiemorrhage was ascertained by autopsy ; there was acute dysentery in 8 cases, and hepatic abscess in 1. The influence of age upon mortality is shown by the following table, wrhich we copy from Wilson (op. cit.), who obtained it from the statistics of the Loudon Fever Hospital as given by Murchison. Of the 2,115 cases admitted there were : The favorable influence of youth, as shown in this ta- ble-0.37 per cent, for all cases below the age of twenty- is not in correspondence with the data obtained by Carter in India. He says ; "The influence of age was apparent in the greater comparative mortality at both extremes of the scale of years ; thus, the general mean death-rate be- ing about eighteen per cent., the rate was tAventy-seven per cent, up to the age of ten years, and then in the two succeeding decennia declining to eleven per cent. (11 to 20 years), and sixteen per cent. (21 to 30 years), it rose with advancing age above the mean to 24.5 per cent. (31 to 40 years), 29.4 per cent. (41 to 50 years), and 37.5 per cent. (51 to 60 years). The mortality is greatest at the outset of an epidemic, and the proportion of cases complicated with jaundice is larger at this time. Sex has no apparent influence upon the death-rate, when wTe exclude the decided influence of intemperate habits, and take account of the fact that more males than females are attacked. Anatomical Lesions.-Most authors assert that there are no constant anatomical lesions in relapsing fever, but Ponfick, of- Berlin, who has made the most elaborate re- searches yet published, based upon 65 autopsies made dur- ing the epidemic of 1872-73, asserts " that certain changes in the spleen, the marrow of bones, the blood (large gran- ule cells); also of the liver, kidneys, and muscles (espe- cially of the heart), pertain directly to relapsing fever, and taken together are pathognomonic. " The splenic changes are said to be absolutely constant, and this assertion at once disposes of the commonly repeated statement that there are no constant local lesions in relapsing fever. Liver changes, too, were invariable; but some difficulty here arose from the likelihood of prior lesion due to alcoholism. It is evident that the epidemic at Berlin was a severe one, there being seen several examples of typhus biliosus. The following is a summary of Ponfick's results. Liver : The turgescence ensuing during specific pyrexia may be greater than occurs in any other infectious disease ; the individual lobules become enlarged, their outlines indis- tinct, and tint a grayish-red. Microscopically, the in- creased volume is due to cloudy swelling of the hepatic cells (always present), to their peripheral fatty degenera- tion, and lastly, to an infiltration of small cells in the portal canals ; from an anatomical point of view, no dis- tinction here is possible between the mild and severe form of relapsing fever ; jaundice was present 16 times (twenty-four per cent.), and it results from biliary en- gorgement. Kidneys: Changed without exception, and in correspondence with alterations noted in the urine ; they may be doubled in size; parenchyma flabby ; the cortex broad and clouded ; the Malpighian tufts pallid. Or parts alone may be changed, and when dark streaks are visible, then not only is the tubular epithelium more or less fatty, but the lumen of the tubes is occupied by fibrinous or blood-tinged plugs. Such cylinders with red disks have been found in the urine (not at Bombay, H. V. C.). There is also evident, in the extreme degree of swell- ing, a copious small-cell infiltration of the intertubular tissue ; and besides, an amyloid thickening of the vessels, which may be attributed to previous morbus Brightii. Striated muscles: Lesion of the myocardium is very fre- quent, its consistence flabby, tint pale-gray or brownish, wholly or in streaks, where the fibres have undergone fatty degeneration ; such degeneration may be as extreme as in the most virulent kind of infectious disease, or even in poisoning by phosphorus. Dr. Ponfick naturally ap- plies these data in explanation of certain fatal cases of fever, where death occurs by syncope, and no other lesion is found after death. I have above remarked that the like were not witnessed among the temperate natives of West India. Spleen: Changes here are localized or dif fused ; the latter are always present, and induce a swel- ling of the organ, sometimes greater than occurs in leukat- mia. The pulp is then dark, livid, and projecting: the Malpighian bodies much enlarged or even effaced, their tint gray or yellowish ; at a later stage of fever their out- lines become more defined. In cases of unusually rapid turgescence of the spleen, rupture of its capsule may oc- cur, and death, with or without peritonitis ; this change is Cases. Deaths. Per cent. Under 20 years ... 804 3 0.37 Between 20 and 30 years.... ... 562 4 0.71 " 40 and 50 ' " .... ... 322 8 2.48 " 50 and 60 " .... . . 119 9 7.56 " 60 and 70 " .... 66 7 10.60 " 70 and 80 " .... 6 2 33.33 76 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. compared with that taking place in enteric fever. Swell- ing is due to distention of blood-vessels, and to a great increase of the cell-elements, including large multi-nucle- ated forms in near relationship to the cavernous veins. Dr. Ponfick could not find any spirilla among these cells. Numerous pulp-cells were seen containing red blood-disks and pigment; and others filled with bright granules which look like spores, but probably are not such ; these structures are not peculiar to relapsing fever, though found here in relatively larger numbers than in other fevers ; they may be seen in the blood circulating during life, and when very abundant, may be concerned with death of patient. Cases are quoted such as occurred at Bombay. There is also another contamination of the blood which can be demonstrated during life in severe cases, viz., by vascular endothelium-cells in a state of fatty degeneration ; this, too, is not absolutely peculiar. As to localized splenic changes, the chief pertain to the venous system and comprise the so-called ' infarcts,' which were present in forty per cent, of all autopsies ; they re- semble closely embolic infarcts, but arise from a differ- ent cause than arterial obstruction, and hence are pecul- iar to relapsing fever." (Quoted from Carter, op. cit.) Ponfick also describes certain changes in the marrow of bones which he considers peculiar to relapsing fever. " These changes consist in proliferation and subsequent degeneration of the lymphoid cells of the marrow, with multiplication of the nuclei in the walls of the minute vessels and fatty degeneration of their coats. As a result of these changes spots of puriform softening may form, chiefly in the cancellous tissue of the ex- tremities of long bones, with the production of local- ized necrosis, and possibly with extension of inflamma- tion to the neighboring articular cavity." (Quoted from Pepper, op. cit.) In addition to these constant changes, a variety of lesions are found which appertain to the complications which occur in this disease with greater or less frequency. Most prominent among these are the lesions due to pneu- monia. Pepper found evidence of lobar pneumonia in 33 per cent, of his autopsies, Carter in 28 per cent., and Ponfick in 20 per cent. Treatment.-All efforts to cut short an attack of re- lapsing fever by specific medication have thus far proved unsuccessful, and the knowledge that the disease is due to the presence of a minute vegetable parasite in the blood has not resulted in any decided improvement in our therapeutic resources. The evident indication is to destroy or restrain the development of this blood-parasite; but in the list of known therapeutic agents there is not one which can be safely administered in sufficient quantity to accomplish this purpose. Quinine in full doses has been tried again and again, but the testimony of Murchi- son, of Pepper, and of Carter is in accord as to its fail- ure to exercise any specific therapeutic power. The last-named observer says that ' ' the blood-spirillum and the febrile symptoms remain unaffected after quinine given largely to cinchonism, after narcotism by chloral, and the freest exhibition of spirituous liquors ; also after the administration of the carbolates, and very large doses of the salicylates." We have no precise data showing the action of germicidal agents upon the spirillum of Obermeier; but Carter states that he once found that weak neutral solutions of quinine seemed to kill the spirillum ; and Dr. Litten has ascertained that the move- ments of the parasite are arrested by a one-per-cent, solu- tion of carbolic acid. The experiments of Ceri and of the writer (not published) show that the development of schizomycetes is prevented by the presence of muriate of quinine in the proportion of 1 to 800 in a culture solution. The development of certain species is prevented by a considerably smaller amount, but so far as our experi- mental data go the indications are that at least one part in two thousand will be required to prevent the develop- ment of organisms of this class in the blood. This would require the constant presence of something more than a drachm of muriate of quinine in solution in the blood to prevent the multiplication of bacterial parasites present in this fluid. The therapeutic possibilities in the case of carbolic acid are not as favorable as this, and the writer has elsewhere estimated the amount of this agent which would be necessary to restrain the development of patho- genic organisms in the blood to be something more than two drachms. Arsenic was fairly tried by Pepper in the Philadelphia epidemic, and his conclusion is that "there seems to be no reason whatever for any further use of this drug in relapsing fever." Large doses of sodium salicylate have been demonstrated by Unterberger and by Riess to exercise a marked antipyretic effect, but to be impotent for the arrest of the febrile paroxysm or for the destruction of the blood-parasite. " Unterberger has seen the temperature brought down 3° C. (5.4° F.), yet the attack was not apparently cut short, or splenic en- largement prevented, or the active blood-spirillum vis- ibly affected. Dr. L. Riess, after essay on twenty-six cases, thinks that it is possible to cut short or mitigate the symptoms (especially the temperature) of specific re- lapses by very large doses (100 grains or more daily), noting, however, that even when the heat is reduced to normal or below it, the spirillum still persists." (Quoted from Carter.) Another remedy, tried by Pepper in a large number of cases, is the hyposulphite of soda ; his verdict is that "it is certain that it exerted no specific effect upon the disease." In the absence of any knowm specific, our therapeutic resources are reduced to those measures which are best adapted to the control of the most distressing symptoms, and to that wTatchful care and anticipation of complica- tions which enables us so often to tide a patient safely through the critical stages of an infectious disease, and to save many lives, notwithstanding our acknowledged inability to cure these diseases. Although the high pyrexia is not so immediately dangerous to life as is the case in certain other continued fevers, it will always be advisable to keep it within bounds, and the tendency to death toward the close of the febrile paroxysm, primary or secondary, should be borne in mind. The evidence on record is in favor of sodium salicylate, rather than quinine, as an antipyretic medicine; it may be given to the extent of 100 grains, or more, in the twenty-four hours, and is said to be well borne. Its persistent use, however, interferes with the patient's appetite, and it will be best to reserve it for those cases marked by a specially high pyrexia, and to administer it, in full doses, only when the temperature approaches 106° F. For a more moderate elevation of temperature, cold sponging of the surface, and the administration of simplfe febrifuge reme- dies, such as effervescing draught, or solution of spirit of nitric ether, w ill suffice. Aconite, in small and repeated doses, may be given-one drop every two hours-in com- bination with moderate doses of spirit of nitric ether, and if any routine treatment for the fever is considered neces- sary this may be recommended, as less liable to disturb the stomach than certain other drugs which are some- times used in similar conditions, e.g., veratrum viride, digitalis. There is a tendency to constipation, and a mild aperient will commonly be required at the outset of the attack ; a dose of castor-oil, or a simple saline purga- tive, will answer the purpose; later the bowels may be moved, if necessary, by enemata; emetics, as a rule, do more harm than good. Headache is to be combated by cold applications to the head. Insomnia is a marked and distressing feature of the disease ; Carter prefers to ad- minister chloral and bromide of potassium for the relief of this symptom, rather than to give opiates. Pepper, on the contrary, says that ' ' opium and morphia must be regarded as the basis of the rational treatment of relaps- ing fever. It is called for by the insomnia, the severe headache, and the pains in various parts of the body, the nausea and vomiting, and the pyrexia." One-fourth of a grain of morphia, given at intervals of six to twelve hours, was found by the author last mentioned to relieve pain and vomiting, and often to induce refreshing sleep. It is contra-indicated in those cases having a typhoid tendency, as shown by a disposition to stupor and defi- cient urinary secretion. In the experience of Pepper during the Philadelphia epidemic, bromide of potassium in full doses failed to produce sleep or relieve headache, 77 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and chloral, in doses of twenty to forty grains, could not be depended upon, although it sometimes gave relief. In view of the tendency to heart-failure in this disease, the author named very properly points out the possible danger which may attend the administration of chloral. For the relief of excessive tenderness of the liver or spleen, Carter recommends hot fomentations and poultices in preference to cold applications, " which are seldom grate- ful to the patient." To control excessive irritability of the stomach, Pepper advises the use of small doses of calomel, i to | grain every two hours, or grain of ni- trate of silver, dissolved in thin mucilage of acacia, ad- ministered at intervals of three or four hours. Hiccough is a distressing symptom, which often defies all remedial measures. In Pepper's experience, chloroform is the most useful remedy for its relief. As death from heartfailure may occur at the acme of the pyrexia, or during the de- pression, often amounting to collapse, which follows crisis, it will be necessary to watch carefully for the slightest indications of such failure, and to guard against it by the administration of digitalis, or atropia, and the early use of alcoholic stimulants. When the symptoms of collapse are developed, it will be necessary to resort to the subcutaneous injection of ether, or of brandy, and to apply artificial heat to the surface of the body. In this, as in other specific febrile diseases running a protracted course, it is necessary to commence with a sup- porting treatment at an early date. As soon as the stomach will retain it, liquid nourishment should be administered at stated intervals-every two or three hours; meat broths, milk, or gruel may be given if the condition of the stomach admits of their being retained ; if not, kou- miss, chicken-water, or skimmed milk diluted with lime- water, may be given in small quantities and at shorter inter- vals. When the stomach is very irritable, it is probable that iced champagne, or a teaspoonful of good brandy poured upon broken ice in a glass, and taken as cold as ice will make it, will be found the best form of stimulant. Whiskey toddy or milk punch may be given during the apyretic interval, or until convalescence is fairly estab- lished, or a good wine may be substituted for these if the patient prefers. In this disease, as in yellow fever, sudden death is liable to occur from cardiac syncope, as a result of very trifling exertion made when the patient is apparently out of danger. It therefore becomes neces- sary to insist upon absolute quiet and the maintenance of a recumbent position until such time as the strength of the patient is fairly restored. This precaution is espe- cially imperative at the time of crisis, and during the period immediately following it, when there is a sub- normal temperature and other evidence of a state of col- lapse. FEVERS, CONTINUED: REMITTENT MALARIAL FEVER. (Bilious fever, bilious remittent, gastric fever, continued malarial fever.) A fever of malarial origin, marked by remissions instead of intermissions ; some- times terminating in from three days to a week, at other times running a prolonged course of several weeks, ac- companied by grave symptoms ; sometimes supervening on, or terminating in, intermittent fever. The term "bilious" as applied to this fever is badly chosen, because it indicates nothing in the way of etiology and exaggerates the importance of a subordinate symp- tom. The term "malarial" is employed because it is believed that the vast majority of fevers called remittent, the world over, are malarial in origin, not excepting those graver and more prolonged forms which bear a strong resemblance to typhoid fever. The reasons for this belief are as follows : 1. Remittenf fever occurs, as a rule, in those regions where intermittent malarial fever prevails, and the two are most prevalent at the same season of the year. 2. The two forms of fever are mutually convertible. 3. Remittent fever, in addition, often, to lesions not belonging to other malarial disorders, does present the le- sions of malarial intoxication, such as slate-colored liver, enlarged spleen, and the pigmentation of tissues. 4. Quinine has a marked curative effect in the milder forms of the fever. The argument that the graver and more protracted forms of remittent fever are not malarial because their course is not arrested, nor perhaps abridged, by quinine, is not conclusive, for it is notorious that a certain propor- tion of pure intermittent fevers are likewise uninfluenced by this drug. The division of remittent fever, according to Griesinger, into "light, heavier, and highest grades," may not be very scientific, but it is perhaps as well as we can do in the present state of our knowledge. Bartholow (" Treatise on the Practice of Medicine " ) employs the more appro- priate terms mild, severe, and grave, to indicate the same divisions. Sternberg (" Malaria and Malarial Diseases," Wood's Library, 1884), after attempting a fanciful dis- tinction between "continued malarial fever," and "ma- larial continued fever," treats of the former under four headings, viz. : 1. Simple malarial remittent. 2. Ardent malarial fever. 3. Adynamic remittent. 4. Pernicious remittent. But while giving good pictures of these vari- ous forms of the disorder, he so utterly confounds his reader with the ever-present ghost of typhoid fever as to destroy the value of his classification. Professor Flint (" Treatise on the Principles and Prac- tice of Medicine ") speaks of simple remittent, typho- malarial, and pernicious remittent fever. Without enter- ing into the question of whether there is such a thing as a mixture of enteric and malarial fever (which I greatly doubt), I am sure that many, and perhaps most, of the cases of so-called typho-malarial fever are merely grave and protracted cases of malarial remittent fever, in which the patient falls into what is called the " typhoid state," with dry tongue, sordes, mild delirium, and sub- sultus tendinum, without the other characteristic signs of specific typhoid fever. This condition was recognized by competent observers, thoroughly familiar with ty- phoid fever, long before Dr. J. J. Woodward invented the term "typho-malarial." Professor Flint, Dr. Stern- berg, and others virtually claim that specific typhoid fever exists wherever malarial fever exists, thus furnish- ing one of the elements for the compound or hybrid af- fection ; that every remittent fever presenting ulceration of the small intestines must be typhoid ; and that no fever which cannot be arrested or abridged by quinine can be malarial. I do not find any facts presented in de- fence of these three positions, anil I believe they are all contrary to fact. But to return to remittent fever, which we will con- sider under the headings of Simple, Grave, and Perni- cious. The anatomical lesions consist in the presence of pig- ment granules in the blood and in various organs, as the spleen, liver, brain, spinal cord, and kidneys (Hertz, An Account of the Rise, Progress, and Decline of the Fever lately Epi- demic in Ireland, etc. By F. Barker, M.D,, and I. Cheyne, M.D. London and Dublin, 1827. A Treatise on the Continued Fevers of Great Britain. By Charles Mur- chison, M.D., LL.D., F.R.S. Second ed., Lond., 1873. Griesinger: in Virchow's Handbuch, Band xi., Abt. 11 (1864). Observations on Relapsing Fever, as it Occurred in Philadelphia in the Winter of 186!) and 1870. By John S. Parry, M.D. Am. Jour. Med. Sci., Phila., October, 1870. Lebert: Article in Ziemssen's Cyclopaadia, vol. i. (Am. ed., Wm. Wood & Co., New York, 1874). Muirhead: Relapsing Fever in Edinburgh. Edin. Med. Journ., July, 1870. Obcrmeier : Vorkommen feinster eine Eigenbewegung besitzende Faden im Blute von Recurrenskranken. Centralblatt f. d. Med. Wissensch., No. 10, Marz, 1873. Guttman: Zu^ Histologie des Blutes bei Febris Recurrens. Virchow's Archiv, Ixxx., 1880. Spirillum Fever. By H. Vandyke Carter, M.D. London. 1882. Hirsch : Geog. and Hist. Pathology, vol. i. (pp. 593-616, New Syd. Soc. ed., 1883). Motschutkoffsky: in Centralblatt f. d. Med. Wissensch., 1876, No. 11, p. 194. Ponfick : in Virchow's Archiv, Bd. lx., Hft. 2, 1874, p. 162; also in Cen- tralblatt f. d. Med. Wissensch., 1874, p. 25. Mulhauser: in Virchow's Archiv. July 9, 1884. Unterberger: Jahrb. f. Kinderheilk., vol. x., 1876. Riess: Deutsch. Med. Wochensch.. December, 1879. Wilson: The Continued Fevers, pp. 302-343, Wood's Library of Stan- dard Medical Authors, 1881. Pepper: System of Medicine, vol. i., pp. 369-433. Phila., 1885. George Sternberg. Bibliogbaphy, 78 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. " Ziemssen's Cyclopaedia," vol. ii.). This pigmentation or melanosis occurs in the graver forms of remittent fever, as well as in prolonged cases of intermittent and in ma- larial cachexia, and is more abundant in proportion to the gravity of the attack or the length of time the patient has been the subject of malarial infection. In the comatose form of the pernicious fevers, the brain sometimes presents a brownish or slate-colored dis- coloration of its cortical portion, due to the presence of pigment matter. Usually, however, the brain shows only hypersemia and oedema. In the algid and adynamic forms, on the contrary, it is bloodless. The spleen is always enlarged by hyperaemia during a paroxysm of malarial fever, whether intermittent or re- mittent. After repeated attacks, or during a prolonged fever, this enlargement becomes permanent by hyperpla- sia of its cell elements. When the enlargement is recent the organ is soft and loaded with pigment matter, giving it a dark-brown or black hue. The liver is usually enlarged, hypersemic, more or less softened and pigmented, being either bronzed or slate-col- ored. Prof. S. M. Bemiss, of New Orleans, considers the slate-colored liver as characteristic of malarial affec- tions. Stomach and Intestines. " After death from remittent fever more or less congestion and inflammation of the stomach and of the intestines are frequently found. The solitary glands and Peyer's patches may be swollen. The latter often present the shaven-beard appearance." (Flint, op. cit.) " The solitary follicles and Peyer's patches in the small intestine are often greatly swollen and colored with pig- ment matter ; the colon is swollen and highly hypersemic, its follicles are infiltrated and partly suppurating, or the mucous membrane shows extensive dysenteric processes. The mucous membrane of the stomach, too, is often hy- peraemic." (Hertz, op. cit.). " With regard to adynamic remittent fever, it may here be stated that, according to Brown, Stewardson, and oth- ers, the hyperaemia so commonly found in other forms is lacking ; on the contrary, the brain, liver, spleen, heart, and all the voluntary muscles are distinguished by great relaxation and softening-the extreme softness and the case with which the tissue of the heart would tear being noticeable, as well as the watery quality of the blood and its evident deficiency in flbrine." (Hertz.) " The same parenchymatous and pseudo-waxy degen- erations which have been described under typhoid fever may occur." (Flint.) Symptoms.-The onset of remittent fever is usually abrupt, commencing with a chill of moderate intensity. If there are prodromal symptoms they will consist of lassi- tude and general malaise for a day or two, with head- ache and perhaps pains in the limbs and back, loss of appetite, a foul taste in the mouth, and sometimes nau- sea. The chill is not as prolonged nor as violent as in many cases of intermittent, lasting perhaps for half an hour or less, and followed by fever in which the tem- perature will range from 101° to 103°, or even 105°, re- maining at or near the highest point reached for many hours. It is not unusual for bilious vomiting to occur during the chill, and during the first few hours of the fever, and in such cases there is often considerable irrita- bility of the stomach for several days. The fever will continue without any marked remission for twelve, twenty-four, or forty-eight hours. During this time there is complete anorexia, sometimes great restlessness and vigilance with continued headache, sometimes a persist- ence of the vomiting ; but more commonly these symp- toms subside and the patient is drowsy. The remission is marked by an amelioration of the dis- tressing symptoms, if such have existed, and a fall of temperature to about 100°. This may continue for from three to six or twelve hours, occasionally even being pro- longed to twenty-four or thirty-six hours. If the attack is not severe, the patient will declare that he feels quite well, and will wish to get up. His appetite, however, does not return, aud he is far from feeling as well as dur- ing the interval of a quotidian intermittent, for instance. At the appointed time the fever rises again, gradually reaching its former, or a still greater, height. This rise is seldom accompanied by a repetition of the chill. From this time on, if the progress of the disease is not arrested, there will be periodical remissions and ex- acerbations, usually occurring once or twice during the twenty-four hours, but sometimes at more prolonged in- tervals. At the beginning of an attack of remittent fever the tongue will be furred, of a gray or yellowish tint, large, moist, and indented by the pressure of the teeth. Later, it is likely to grow dry, smoother, and brownish in the centre, red at tip and edges, with sordes on the teeth. Nose-bleed is not very uncommon. The stomach may be irritable throughout the attack. The bowels are usually constipated, the urine scanty, high-colored and acid. The pulse, of course, varies greatly in different in- stances. As a rule, it is stronger and more moderate than in other conditions accompanied by the same elevation of temperature. Sometimes, even in young people, it is notably slow, and would entirely mislead the practitioner who depended on it as an indication of fever, to the ex- clusion of the thermometer. I have notes of such a case (see Diagram No. 2) in a youth of nineteen, in whom the fever was high (103° to 105°) during the first ten days, and the pulse never rose above 78, while during the last ten days (temperature running from 98.5° to 101.5°) it varied from 42 to 60 per minute. This, however, is un- usual. ' The skin and the whites of the eyes often show a yel- lowish or jaundiced hue, especially in those persons who have lived long in a malarious region. There is no petechial eruption. It is not unusual to see an outbreak of herpes about the mouth. Delirium is not common in the simple remittent, but in the graver, more protracted form it often occurs, ac- companied with the other symptoms of the typhoid state, such as dry, cracked tongue, sordes, subsultus, etc. The course of the disease varies greatly in different cases. In the most favorable, under vigorous treatment, it is arrested in from three to five days, as per tempera- ture diagram No. 1 (see farther on). In severer cases the course is more protracted, running from two to three or four weeks, or even longer. Such cases present very vary- ing degrees of gravity. In some of them the patient makes very little complaint, does not look very ill, eats and sleeps quite well, while still the temperature remains at from 100° to 102.5°, and the patient grows quite weak. In others, with but a slightly higher range of tempera- ture, there will be great gastric irritability or severe head- ache, great restlessness and vigilance, and many, though not all, of the symptoms of typhoid fever, such as dry, cracked tongue, sordes on teeth and lips, muttering de- lirium, picking at the bedclothes, coma-vigil. This is the " typhoid state," which may also occur in other dis- eases than specific typhoid fever or grave malarial remit- tent fever, and these are the cases which are usually re- ported as " typho-malarial fever." There is, however, no characteristic typhoid fever temperature in the first two weeks, no rose-colored rash, no marked iliac tender- ness or gurgling; as a rule no tympanites or diarrhoea. The simple form, when not arrested by large doses of quinine, as shown in Diagram No. 1, runs its course in from ten days to three weeks without any alarming symp- toms. It is common to speak of this form as having its termination in intermittent fever, because the daily fall of temperature finally reaches the normal line, as shown in Diagram No. 2, and also in No. 5. It is true that this constitutes an intermission, and yet we have a very differ- ent state of things from that presented by a patient with plain quotidian intermittent. In the latter, each daily rise of temperature would be likely to be introduced by a chill and to go off with a sweat ; the patient would feel quite well during the intermission and eat with relish; while during the paroxysm of fever he might again vomit, complain of severe headache, pains in the back and limbs, etc. Nothing of all this takes place in the in- termission or the exacerbation of a remittent fever in the 79 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. third week. Therefore it seems to me a mistake to speak of a remittent which acts in this way as ending in an in- termittent fever, since the picture presented by the one differs greatly from that of the other. The grave form of remittent fever runs a more continu- ous course, as shown in Diagrams Nos. 3 and 4. Marked adynamic symptoms soon appear, though in young men, as in No. 3, the pulse may never be very rapid. There is great thirst, entire loss of appetite, dry tongue, sordes, muttering delirium, picking at the bedclothes, etc. As a rule, the bowels are not loose, though sometimes there is diarrhoea, and even haemorrhage from the bowels. All these symptoms, excepting diarrhoea and haemorrhage, were presented in a marked degree by the patients fur- nishing temperature charts Nos. 3 and 4. Prof. S. M. Bemiss, of New Orleans, gives some good points in the differentiation of malarial remittent and typhoid fever (Pepper's " System of Practical Medicine, by American Authors," vol. i.). He says, among other things, " the facial expression of patients suffering with remittent is sufficiently characteristic to afford some diag- nostic inferences. During the pyrexia, the face is flushed and the eyes injected, but the redness is more vivid and the countenance more animated than in typhoid or yellow fever. It would not be inaccurate to say that, however great may be the flushing or other alterations of the countenance in remittent fever, the natural facial expression is better preserved than in either of the fevers in comparison with it. Sallowness of the skin is an early and almost constant event in remittent fever. . . . The tongue may become dry, brown, cracked, and diffi- cult of protrusion, but seldom showing the tremulousness of a typhoid fever tongue. . . . The bowels are ordinarily costive, and when moved by purgatives the stools contrast strongly with those of typhoid or yellow fever, by presenting evidences of the bile-coloring princi- ples which attend all excretions in malarial fevers. . . Delirium may occur in any stage of the disease, but dif- fers from the delirium of typhoid and yellow fevers in showing a less degree of perversion of the reasoning faculties." My own experience differs from that of Bemiss and some others, who say that when remittent fever termi- nates fatally it is usually at from the fifth to the tenth day. Some of the most severe cases do so, but the ma- jority of the deaths that have occurred in my own prac- tice, and in that of my associates here, have been at the end of the second, third or fourth week. It is impossible to say what proportion of deaths occur in malarial remittent fever, owing to the confusion in classification. Few physicians ever let a patient die without calling it a case of typhoid, or at least typho-ma- larial, fever. I am satisfied that the percentage of deaths from remittent fever reported in the U. S. Volunteer Forces, from 1861 to 1866 (viz., 1.34 per cent, of all cases of remittent fever), is an under-estimate, due to the same causes. Pernicious remittent is less marked in its remissions than the other varieties. Pernicious malarial fever may be distinctly intermittent in form, quotidian or tertian, the patient being seized with a so-called " congestive chill" of the algid or the comatose form, from which he, however, recovers, only to succumb to a second or third repetition of the same. When this algid or comatose form is not marked by an intermission, there is often a more or less distinct remission, in the symptoms. The progress of the disease, however, is as a rule not dis- tinctly checked, and moves steadily to a fatal termination in from twenty-four hours to three or four days. The writer has known of several deaths of this kind, in this city or vicinity, in some of which the symptoms of the seizure were quite like those of apoplexy. lie witnessed the development of the comatose variety in a woman who had been ill, with apparently simple malarial fever, for a week. This woman lay for seventy-two hours in the profoundest coma, from which it was impossible to arouse her in the least. She was "as yellow as gold," pupils moderately dilated and fixed, conjunctiva insensible to touch, breathing slow and stertorous, urine, as drawn with the catheter, scanty and very yellow, bowels not to be moved with enemata, nor with what calomel could be introduced by the mouth. Under the persistent hypo- dermic use of quinine and whiskey this patient rallied and recovered. Treatment.-In remittent fever, as in all other forms of malarial disease, quinine is our sheet-anchor. Its use should be begun early and continued late. No prepara- tory treatment should be allowed to interfere with its early and liberal administration, nor is it usually best to wait for a remission. Ten-grain doses every three hours for the first twelve or twenty-four hours, or fifteen- or twenty- grain doses at intervals of six or eight hours, will often cut short a remittent fever in the first two or three days. Less than ten-grain doses should certainly not be depend- ed on in the adult. The only obstacle to the early use of quinine is the nausea and vomiting that sometimes exist. This can easily be subdued by broken doses of seidlitz powders or some other effervescent mixture, or it may be better to rely on small doses of calomel and subnitrate of bismuth, say half a grain of the former to five of the lat- ter, together with sinapisms to the pit of the stomach. As a rule, I am satisfied that no mercury is demanded in the treatment of these fevers, but, on the contrary, that great harm has been done and convalescence seri- ously delayed by the habitual use of calomel. Often a large dose of quinia, by the stomach or rectum, will cause the " bilious " symptoms to disappear more rapidly than ever is the case under the use of mercury. But some- times I have thought that a few doses of calomel or blue mass cleared the way and facilitated the absorption of the quinia. If the stomach is utterly rebellious, we may try the rec- tum, rubbing up double the quantity of quinine we should use by the mouth with a little yolk of egg and tepid water, and using this as an enema. Should the rectum be irritable and refuse to retain en- emata, the hypodermic method is still open to us. This is indeed the most certain way of using the drug, and should always be employed in grave emergencies, where there is no time to be lost and no chances may be taken as to prompt absorption or otherwise by stomach and bowels. The one objection to it is the liability to produce ab- scesses at the site of puncture. Lente, Bartholow, and others, strongly recommend the following solution: B- Quinia) sulphat gr. 1. (50) Acidi sulphurici diluti lit c. (100) Aquae purse § j. Acidi carbolici liquidi X v. Solve. It will be observed that even this solution only contains six and one-fourth grains to the drachm, or one-half of that in an ordinary hypodermic syringe, and, as from six to eighteen grains must be given at a dose, it is objection- able on that account. I have repeatedly known abscesses to follow its use, but I consider that of no consequence in comparison with the far graver dangers that threaten the patient. The hydrobromate of quinia has been highly vaunted of late years, both for internal and hypodermic use, but as it only dissolves in the proportion of one part to fifteen of water, it is more bulky, though less irritating, than the above acid solution. Professor J. G. Whitaker (Cincinnati Lancet and Clinic, October 9, 1880, as quoted by Stern- berg, op. cit.} says: " I have in practice entirely discarded all vehicles except water, and rely solely upon heat to ob- tain a perfect solution. I have a druggist put into a test- tube twenty grains of the bromide of quinine and add to it two drachms of water. The tube should be corked-not to preserve the substance, for it is £till crystalline in this proportion-but for cleanliness. To use the drug all that is necessary is to heat the tube over a gas or other flame. Two or three minutes suffice to reduce the quinine to a limpid, crystalline fluid in the tube, then it is poured in sufficient quantity into a teaspoon previously warmed, and thence taken up into the syringe, warmed also in the same way, and is ready for use, which must be imme- diate. It may be injected anywhere, but always under, 80 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. and never into, the skin." This solution, it will be ob- served, contains live grains to the half-drachm or ordi- nary syringeful. For some years past it has been my practice to give forty- to eighty-grain doses of bromide of potassium with every dose or every alternate dose of quinia, to quiet nervousness, and control to some degree the unpleasant sensations of cinchonism. I am satisfied that this end can be thus accomplished to the great comfort of the pa- tient. 1 usually give the quinine in capsules or wafers (never in sugar- or gelatine-coated pills, for fear of their remaining undissolved), and the bromide in the form of the elixir. In Dr. Sternberg's "Malaria and Malarial Diseases" (p. 115), I see that the bromide of potassium alone has been successfully used in the treatment of " ague" among the out-patients of Guy's Hos- pital, London, which makes me think that, in using it for its mere tranquillizing effect, 1 have perhaps " builded better than I knew." In some of the more restless patients, who perhaps cannot retain the bromide or are not benefited by it, or in those who complain of excessive pain, it will be necessary to use opium or morphine, by the stomach or hypo- dermically. Other symptomatic treatment, both early and late, will be employed by the intelligent practitioner according to the indications of the case. But the great thing to remember is that no treatment of "biliousness" by mercury, nor of the fever by antiphlogistics or refrigerant mixtures, by cold water, or aconite, or gelsemi- num, or anything else in the wide world, will do any good unless accompanied by large doses of quinine. The next question that natur- ally arises is, supposing that, in the course of a few days, it is evident that the fever cannot be broken up, but is going to run a course of two or three weeks or more, shall we stop the quinine? Most of the authorities say " yes. " Even Professor Bemiss, from the swamps of Louisiana, says, " If the first efforts to break the febrile paroxysms fail, it is better to discontinue the quinia and place the pa- tient under symptoma- tic treatment, and await conditions of the system more favorable for its repetition." I am satisfied that this is a radical error. When I first began to practise in this city, nearly twen- ty years ago, I followed such advice, given by the older practitioners whom I called in con- sultation, and I know that my results were not as good as they are now, when I keep up my quinine, in reduced doses, all the way through. After the first three or four days, when it is evident that the fever cannot be arrested by ten- to thirty- grain doses of quinia, let the patient be put on five grains every six hours and kept there through the course of the disease, until signs of yield- ing begin to show themselves ; then double the dose for a day or two, and you may perhaps turn the scale in his favor. I am convinced that of two sets of patients, one of which shall be treated as I suggest, and in the other of which the quinine shall be stopped after the first few days, more of the latter will die, and those of them who recover will have a longer run of fever and a more tardy convalescence. As already stated, many minor points in treatment, conducing to the welfare and comfort of the pa- tient, will suggest them- selves to every intelligent man, and need not here be specified. No. 1.-J. Z , aged forty. 1 2 3 4 5 6 7 105 104 103 102 101 100 99 98 97 96 Fig. 1160.--Case of Fever Arrested by Fifteen-grain Doses of Quinine every Eight Hours the Second Day, and every Six Hours the Third Day. 12 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 No. 2.-S. II , aged nineteen. 105 104 103 102 101 100 99 98 97 96 Pulse A.M. p.M. Fig. 1161.-Case of Simple Remittent Fever, preceded by two Irregular Chills within the Previous Week. Patient pretty comfortable all the time, eating and sleeping fairly. Bowels constipated. No jaundice. No. 3.-W. P , aged twenty-five. 105 104 103 102 101 100 99 98 97 90 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Pulse A.M. P.M. Fig 1102 Grave Remittent Fever. Onset sudden. Chill. Jaundice. Vomiting early. By the tenth day great prostration, subsultus, delirium, coma vigil, tongue dry, and brown sordes. Bowels constipated until on the fifteenth day several loose stools. Checked on sixteenth with opium. No. 4.-J. F , aged fifty. 105 104 103 102 101 100 09 98 97 90 A.M. P.M. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Pulse Fig. 1163.-Grave Remittent. Not seen till the fourth day. Great restlessness and vigilance from the beginning. Pulse weak. Breath absolutely fetid. All nervous symptoms grave from the outset, as starting, cries, delirium, picking at bedclothes. Bowels not loose. Profuse sweats. (No post-mortem examination allowed.) No. 5.-H. R. G , aged thirty. 105 | 104 103 102 101 100 99 98 97 96 A.M. P.M. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Pulse Fig. 1164.-Simple Remittent. Not seen till the sixth day. Jaundice. Vomiting. Constipation. Bilious stools followed Seidlitz powders. This man weighed about two hundred pounds and lost forty. The temperature charts introduced in this place are not of much value, standing alone as they must here, except 81 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon my assurance that they are fair samples of their several types. The brief notes appended to each are per- haps sufficiently explanatory. Nos. 1, 2, 5, and 6 were treated on the plan which I advocate. In No. 3 this was good deal of confusion prevailed for another ten years between typhoid and typhus fevers, the one being more common in France, the other in England, the symptoms being by no means very dissimilar in exceptional cases, or at least sufficiently alike to throw doubt upon the re- cently promulgated pathology. This doubt it was the privilege of American pupils of Louis to be instrumental in dispelling. James Jackson, Jr., of Boston, published in 1830, 1833, 1834, personal observations confirming the occurrence of intestinal lesions as the result of typhoid fever. Gerhard, of Philadelphia, in 1835, reported cases of typhus fever occurring during an epidemic at the Philadelphia Almshouse, which marked out plainly the characteristics of that dis- ease ; and in 1837, in association with Pennock, Gerhard established clearly the fact that typhoid and typhus were distinct diseases. This was fur- ther brought out the following year (1838) in Paris, and in 1840 in this country, by Geo. C. Shat- tuck, of Boston, as the result of observations in the London Fever Hospital, at the request of and follow- ing the teaching of Louis. Stille, of Philadelphia, who had previously been under Gerhard at the Philadelphia Hospital during the typhus epidemic, and who was in Paris at the same time with Shattuck, was also instru- mental in establishing before the Society Medicale d'Ob- servation the anatomical and clinical distinctions between the two diseases. As a result of these and subsequent studies and reports, the non-identity of typhoid and typhus fever was early recognized and accepted in the United States-earlier and more generally than in England. Dr. A. P. Stewart, of Glasgow, who, after studying fevers in the Fever Hos- pital of that place, resorted to Paris for the same pur- pose, accurately described the chief features of these two diseases before one of the Paris medical societies, in 1840, and was the first of his countrymen who did so. It was not, however, until ten years later (1849-1851) that a gen- eral recognition of the duality of the two diseases, of their specific characteristics, was enforced in Great Brit- ain by the authority of Sir William Jenner. Since that time typhoid fever has been everywhere accepted as a distinct morbid entity, and all difference of opinion as to its special characteristics may be said to have disappeared. Etiology.-No sooner were the problems of the semei- ology and pathology settled, and the conclusions gener- ally accepted, than the equally important question of the etiology of typhoid fever took their place, and a discus- sion arose which is by no means closed to-day. The medical world is still divided into two parties : (a) those who hold that typhoid fever is not only a distinct disease, but a specific disease having a specific poison, which is only produced by itself, and only reproduces itself ; (b) those who though acknowledging its distinct symptomatology and pathology, still hold that it at times arises autochtho- nously or spontaneously ; that mere filth, or according to some who embrace this view, even depressing emotions which derange the digestion, may give rise to these spe- cial results. These two theories were propounded and ably sup- ported by Drs. Budd and Murchison, respectively, and since the year 1850 are largely identified with their names. Advocates of each way of interpreting the facts already recorded, and those newly observed are still found, but the weight of authority to-day is decidedly on the side of the specific nature of the poison, and against the proba- bility of the disease ever having a spontaneous origin. Observations are constantly adduced, it is true, which cannot be satisfactorily explained in this way, but they are fewer than formerly, and each year, with increasing knowledge, will undoubtedly become fewer still. The argument from analogy with other infectious dis- eases whose specific character has been already demon- strated, or shown to be highly probable, has a force which it did not possess when Murchison wrote his classi- cal treatise on continued fevers. The Etiology is generally considered under Predispos- ing and Exciting Causes. No. 6.-Edith R , aged fifteen. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 105 104 103 102 101 100 99 98 97 96 A.M. P.M. Pulse Fig. 1165.-Grave Remittent. Sudden onset, severe chill, great prostration. Bow- els loose on fourth to sixth days. Subsultus. Faint on sitting up. Chill again on night of 11th, and morning of 12th, accompanied with vomiting. Tongue dry and brown, sordes. not adhered to after the first week. In No. 4 quinine was not persistently used. Carbolic acid, the sulphides, and some other "false gods" were introduced. Probably, how'ever, the patient would have died anyhow. Edward W. Schauffler. FEVERS, CONTINUED : TYPHOID FEVER, (Ayos, Smoke; secondarily, Stupor.) Synonyms.-English, Enteric Fever; German, Abdomi- naltyphus ; French, Dothienenterie, or Dothienentherite, or Fievre Typhoide ; Italian, Tifo Enterico ; Spanish, Fiebre Continua, Tifo. History.-There can be no doubt that this disease has prevailed extensively from very remote periods, but its authentic history, like that of so many other infectious diseases, is of quite recent date. Indeed, for this there are especially good reasons in regard to typhoid fever, for the intestinal lesions are the essential and distinguish- ing characteristics of the disease, and these would only be described carefully after frequent autopsies. Ingeni- ous attempts have been made to associate passages in the works of Hippocrates with this disease, but such have hardly carried conviction to others than their originators. Typhoid fever, as we know it, is not distinctly recogniz- able in any of these descriptions, and it is not until the seventeenth century that the clinical conditions ending in death, and followed by autopsies revealing intestinal le- sions, are to be found in medical literature. Spigelius, Lancisi, Baglivi in Italy; Friedrich Hoffmann in Germany; Willis, Sydenham, and Huxham in England, all described cases of typhoid fever with such exactness, as to leave no doubt of the identity of the disease. Mor- gagni in France, in the eighteenth century, gave a par- ticularly clear delineation of the course of the disease, and of the intestinal lesions. It still remained, however, for the nineteenth century to define its distinguishing characteristics, and to differentiate typhoid fever from all other diseases. The Germans are disposed to attribute priority of rec- ognition and determination of the distinctions between typhoid and typhus fevers to Hildenbrand, of Vienna, who published a treatise on Contagious Typhus in 1811 (translated into English by Dr. S. D. Gross in 1829). It is true that he distinguished between " contagious typhus" and what he calls "originary typhus," but his ideas about his " originary " typhus were extremely misty, and I think the impartial reader of his treatise will find much difficulty in identifying it with typhoid, although the " contagious " disease answers fairly well to typhus fever. Bretonneau, Petit and Serres, Louis and Chomel in France, during the first thirty years of this century, did more, by their careful observations at the bedside and their patient labors in the autopsy-room, to elucidate the symptoms and course of the disease, to connect these with the pathological lesions, and to place the whole in the clear light by which we regard this very im- portant disease to-day, than any or all of their predeces- sors. Even after the publication of their observations a 82 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. Predisposing Causes.-Age . This is the most impor- tant of the predisposing causes. It is essentially a dis- ease of youth, the great majority of cases occurring be- tween fifteen and thirty years of age, and this holds true in general of all countries. Statistics on this and other points are generally made up from hospital patients, but would probably not vary much as to age if applied to those treated at home. Murchison deals with the largest figures, extending over a period of twenty-three years at the London Fever Hospital. He states that persons un- der thirty years of age are more than four times as liable to typhoid fever as persons over thirty. Of 5,911 cases admitted to the London Fever Hospital, between the years 1848-70 (twenty-three years), 56.70 per cent., more than one-half, were between fifteen and thirty years of age; 28.58 per cent., more than one-fourth, were under fifteen ; 13.30 per cent, were over thirty ; while only 1 in 71 cases exceeded fifty. The contrast between typhoid and typhus fevers in this respect is shown by the same tables, only 24.87 of the typhoid cases being over twenty- five years of age during a period of years when 50.66 per cent, of the typhus cases were over that age. For five years preceding 1870, in Berlin, Zuelzer reports the following table of cases of typhoid among every 10,000 inhabitants of all classes : A statement of the deaths from typhoid occurring in Basle during fifty years gives the following for the dif- ferent months ; January, 192 ; February, 143 ; March, 137; April, 121 ; May, 160; June, 169 ; July, 186; August, 202 ; September, 237 ; October, 237 ; November, 236; December, 193. Murchison's 5,988 cases at the London Fever Hospital, during twenty-three years, were distributed through the different months as follows : January, 433; February, 306; March, 318 ; April, 209 ; May, 232 ; June, 335 ; July, 434; August, 721 ; September, 803 ; October, 839; November, 819; December, 539-27.7 per cent, of the entire number were admitted in the two months of Octo- ber and November, and only 7.3 per cent, in the two months of April and May. Of 621 cases treated at the Pennsylvania Hospital dur- ing ten years, 89 were admitted during spring, 259 during summer, 182 during autumn, and 91 during winter. So marked is the prevalence of typhoid in the months of September, October, and November, that it is often spoken of popularly as " fall " or "autumnal" fever. Owing to exceptional causes, epidemics may occur at other seasons of the year. In the older cities the disease has a ten- dency to become endemic, and to last through the winter months. Moisture and temperature, level of ground-water: These do not seem to have any constant relation to the prevalence of typhoid. It is found to be active during and after both cold and hot seasons, dry and damp weather, although it is said that a warm, dry summer fa- vors abundant typhoid in the autumn. Murchison re- gards warmth, with moisture and but little rain, as the most favorable combination of circumstances. Von Pet- tenkofer and Buhl succeeded in establishing a relation between low ground-water and increasing typhoid for Munich, but this does not hold good for other places and other countries. Such a connection is far from being in- variable for every year and for all places. Wet seasons, as well as dry, are followed by, and coincide with, abun- dant typhoid. In Berlin it has been shown that the in- habitants most exposed to the influences of the ground- air are not those most affected by the disease. Individual idiosyncrasy plays a part as a predisposing cause in this as in other infectious disorders. Some per- sons and some families seem proof against the poison, even in an active form, while others contract the disease upon slight provocation. An inherited predisposition has sometimes been suspected as reappearing through several generations. Notwithstanding the immunity usu- ally conferred by one attack, some persons have been known to pass through several distinct attacks at differ- ent periods. Phthisis, pregnancy, and lactation are sup- posed to confer a certain immunity. The robust are quite as likely to be attacked as the fee- ble, and in the opinion of some are even more prone. Intemperance, fatigue, and mental emotions, can only be admitted as predisposing causes very indirectly. Exciting Causes.-As far-back as our knowledge of the disease goes typhoid fevei' presents the same picture. As we see it to-day it breeds true. Typhoid fever produces typhoid fever. It is a specific disease ; both analogy and observation afford rational ground for the belief that it has its specific poison. This has not yet been satisfac- torily eliminated, notwithstanding many attempts and un- tenable discoveries. It probably will be. The latest and most serious attempts to associate certain microbes with the disease are those of Klebs and Eberth. These are both bacilli. That of Klebs is a long, thread-like, rod- shaped organism, without divisions and without branches. Eberth's bacillus is ashort, thick rod with slightly round- ed extremities, several being at times joined together. This bacillus has certain distinguishing characteristics in its appearance, its response to staining, and its mode of culture ; it is found in the ulcers of the walls of the intes- tine, in the mesenteric glands, and forming plugs in the vessels of the spleen and liver, and occasionally in the lungs. These organisms have not been found in other affec- tions, even in such as are accompanied by severe intes- From 8 to 10 years of age... " 10 to 15 " " " .. .. 18 From 35 to 40 years of age... .. 13 .. 22 " 40 to 45 " ' i ii .. 16 " 15 to 20 " " " .. .. 32 " 45 to 50 " ii 41 .. 13 " 20 to 25 " " " .. 31 " 50 to 55 " U it .. 27 " 25 to 30 " " " .. .. 20 " 55 to 60 " it 4 1 .. 7 " 30 to 35 " " " .. .. 14 " 60 to 65 " .. 10 This table gives the usual ratio up to thirty years, but betrays some singular discrepancies in the later years. Liebermeister found that 77 per cent, of the typhoid pa- tients in the hospital at Basle, from 1865 to 1870-a period of five years-were between 15 to 30 years of age ; and Fiedler reported that in Dresden 81 per cent, of all the typhoid patients were between those ages. The average age of 291 cases occurring at the Massa- chusetts General Hospital was about twenty-two years. It should not be forgotten that typhoid fever does occa- sionally occur in the aged, and by no means infrequently in the very young. Undoubted cases in infants under a year old are on record. The symptoms often are so little marked in the very young, that the nature of the trouble is liable to be overlooked. Subsequent immunity to ex- posure, it is fair to suppose, is sometimes due to an early unrecognized attack. The susceptibility is greatest be- tween the ages of fifteen and twenty-five ; next between ten and fifteen ; and next between twenty-five and thirty. Sex: If guided by hospital statistics, one would con- clude that the disease is somewhat more common among men than among women. On the other hand, men are more likely to resort to hospital treatment, and the dif- ference may perhaps be explained in this way. As a fact, either sex is probably about equally liable. Of the ty- phoid cases admitted to the Middlesex Hospital, London, during a period of four years, 157 were males and 136 females ; of the former 8.2 per cent, died, and of the lat- ter 19.8 per cent. Upon these figures, apparently, the regis- trar of the hospital bases the statement that more males than females are attacked by typhoid fever, yet more females die; but the figures are too small, and the period of time too limited, to warrant such a conclusion. Locality : Typhoid fever is no respecter of locality. It prevails alike in cities, in towns, in villages, in hamlets, and in solitary houses ; among the poor and the well-to- do ; on high and low ground ; over a sandy or clayey soil. It is, perhaps, of all infectious diseases, the most con- stantly to be found, under the greatest variety of con- ditions. Season of the year : In all countries of the Northern Temperate Zone the last six months of the year, from July to December, are those in which typhoid fever is most prevalent, and in the Southern Temperate Zone the corresponding months, from February to July, are simi- larly prominent. September, October, and November are three months in which the largest number of cases occur, as shown by tables from various localities. 83 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tinal ulcerations ; they are found quite constantly in ty- phoid fever. Eberth himself found them in eighteen out of forty cases. Friedlander and Meyer report finding them in eighteen out of twenty-two cases ; Gaffky in twenty- six out of twenty-eight cases. Klebs acknowledges their presence, but considers them merely a stage of develop- ment of his own long bacillus. These forms could not be found in the water of a contaminated well, to which an epidemic was clearly traced. Inoculation upon animals has been attended with negative results. Whether the typhoid reported among domestic animals is the same dis- ease as typhoid in man, and whether they are suscepti- ble to the poison, is not definitely known. Up to this stage the bacillus typhosus possesses about the same credentials as the bacillus of cholera, with the dif- ference of being, perhaps, somewhat less well indorsed. Although it may seem strange that the specific organ- ism-if there be one-of so common and important a mal- ady as typhoid fever should not have been discovered before this, the peculiar complications of the problem must be borne in mind. A great variety-even greater than in health-of micro-organisms are undoubtedly present in the intestines and in their contents during the active period of the affection, which are products and not causes of the condition. In the meantime, as with cholera, we are justified in considering that this poison is contained in the alvine dis- charges, and is spread by them. It is not contagious in the sense of being propagated by personal contact, of be- ing ordinarily contained in an active form in the emana- tions from the lungs and skin. The poison, when dis- charged from the bowel, re-enters the system by the alimentary canal. There is no absolute proof that it may not be suspended in a heavily charged atmosphere in such a way as to be swallowed with the air, and occasional cases would seem to demand such an explana- tion. Ordinarily it is absorbed in liquids-water, milk, etc.-with food, from the fingers, etc. There is reason to think that the poison is not active when first discharged from the bowel, and that at least twenty-four hours are usually required to develop that activity ; at times it is probable that a less time is required. Moderate heat and moisture are the best elements for the development of the poison. There are sufficiently numerous trustworthy observations to show that neither the lapse of time (two or three years), extreme dilution, filtration through a hill-side, nor several degrees of frost, destroy the infectious capacity of the typhoid poison when once developed. Filth : Typhoid fever is a filth disease in the same sense that cholera is a filth disease ; in filth the seed finds a suit- able soil. It is, however, as impossible for us to-day to accept the pythogenic theory of Murchison as to accept the contagious theory of Budd. Filth alone does not pro- duce typhoid fever any more truly than it produces cholera. Such a position is not invalidated by our in- ability to account for the first appearance of typhoid, or to explain the source of the poison in some puzzling cases and mysterious epidemics. We are now allowed to state that small-pox begets small-pox, and is begotten only by small-pox, though we cannot explain the origin of the first case or trace every outbreak to its source. The same is true of scarlet fever. The minute and patient investigations of English health- officers within the past fifteen years, in following up and tracing back epidemics, have revealed frequent sources of propagation in infected milk and water-supplies, which had hitherto never been suspected, and in which pytho- genesis or spontaneous generation would otherwise have been resorted to as an explanation. These investigations are but a little further development of Dr. Austin Flint's observations on the epidemic at North Boston, recorded forty years ago. Credible observers on the Continent of Europe and in this country report cases and epidemics traceable unquestionably to the turning up of a manure- heap, or of soil, in which it was subsequently proved that typhoid dejections had years before been deposited, and in the same way to soiled bedding and clothing, packed away for a time and transported to a distance. It is recognized that a "septic," or "sewer," or "slow" fever, resembling typhoid in certain general symptoms, may be produced by decayed food, by emanations from, or solutions of, decomposing excreta, perhaps by disor- dered digestive processes. Vast quantities of filth are continually finding entrance to the human economy by the digestive tract, and by the respiratory organs, without producing typhoid fever at all, or until impregnated by the typhoid poison. The last ten or twelve years have disclosed the specific poisons of several other infectious diseases. Past prog- ress in making clear the previously inexplicable, the probability of further advances in these directions, our present knowledge, reason, analogy-all should dissuade us from resorting to the filth theory as a source for ty- phoid fever, or to so unphilosophical an hypothesis as a spontaneous generation or de novo origin, to explain what we cannot as yet occasionally make clear to our- selves in its transmission. One of the latest reported epidemics, that at Plymouth, Pa., offers so many instructive lessons, and was studied and reported on with so much care, that we make room for a brief summary of its salient features. Plymouth is a town in the Wyoming Valley of Penn- sylvania, of 8,000 inhabitants, situated on the left bank of the Susquehanna River, two and a half miles below the city of Wilkesbarre with a population of about 30,000. A portion of the sewage of Wilkesbarre, and of Kingston, a small town opposite it, enters the river above Plymouth. The hygienic and sanitary surroundings of Plymouth are, and have been for years, most miserable ; its inhabitants are for the most part coal-miners. During nine months in the year it is supplied abundantly with pure water from a stream which dashes rapidly down the sides of the mountains, and is dammed by solid masonry at four different elevations. The water is distributed through the town by the Plymouth Water Company, through their pipes and hydrants, which ramify everywhere ex- cept upon a suburb called Welsh Hill, whose constant supply the year round is from the Susquehanna River or from wells. During periods of drought, the water com- pany resorts to the Susquehanna River water. From March 20th to March 26th, water was pumped from the river into the company's mains, the three lower reservoirs of the mountain stream being nearly empty at this time. During this period the river was lower than for years be- fore, its surface was frozen tight, and its water was un- usually befouled by the sewage of Wilkesbarre. On March 25th a thaw began, followed by slight rains ; on the 26th the superintendent of the water company, finding the two upper reservoirs of the mountain stream full, caused the water of the third reservoir to be let down directly to the lowest reservoir, and on the even- ing of this day pumping from the Susquehanna River ceased, and the town was again entirely supplied from the mountain stream. Suddenly, about April 10th, an epidemic of genuine typhoid fever, as shown not only by the clinical condition and history of the patients, but by a number of autopsies, broke out in Plymouth, and spread with great rapidity, about fifty cases occurring daily, until five or six hun- dred were prostrated; and in all there were some twelve hundred cases, with one hundred and thirty deaths out of a population of 8,000. There was no unusual prevalence of typhoid fever in Plymouth or in the towns around it-including Wilkes- barre-previous to the appearance of this epidemic ; there was none in the neighboring towns during or subsequent to the epidemic. In the first two or three weeks of the epidemic those who exclusively used well-water, and those who exclusively used river-water, escaped the in- fection. Of children living in houses supplied with well- water, only those who attended the public schools, and drank the hydrant-water of the Plymouth Water Com- pany, took the disease, while those kept at home did not suffer. It was also noted that those who habitually used beverages other than water were safe from the at- tacks. On Welsh Hill, a suburb containing a population of 84 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. four to five hundred persons, using exclusively either well-water or Susquehanna water pumped from a point in the river a quarter of a mile nearer the sewers of Wilkesbarre than that supplied to the town of Plymouth itself, there were but nine cases of typhoid. Five of these used water, while at work or at school, from the pipes of the Plymouth Water Company in other parts of the town ; two of the cases using well-water exclusively were among the latest affected, and were reasonably sup- posed to have contracted the disease from their neighbors. In the village of Broadway, another suburb of Ply- mouth, containing two hundred inhabitants, there are only two wells, of which the water is considered by the inhabitants to be so unwholesome that it is rarely used for drinking or culinary purposes. The chief water-sup- ply there is that of the Susquehanna River, also taken from a point considerably nearer the sewers of Wilkes- barre than the pumping station of the Water Company of Plymouth. In this village not a single case of fever ap- peared. In an adjoining village, called Ridge Row, of one hun- dred inhabitants, the people are supplied with the same kind of water as are those of Broadway. The one or two cases of fever in this village were with people who had frequented the town of Plymouth and there drank water from the hydrants. Not a single case existed among those who had exclusively used the Susquehanna water. These facts being established, it was impossible to sus- pect the river or Susquehanna water, or the wells, and Drs. Shakspeare and French decided that they had noth- ing whatever to do with the origin and spread of this epi- demic. The circumstances of the case were such that the food-supply, including milk, etc., could not possibly have caused so general a development. The hypothesis remained that the mountain-water-their usual supply- conveyed to the homes of the people the sole cause of the disease. This supposition being followed up, was soon converted into positive proof. It was found that in a dwelling on the sloping bank of the mountain stream, a little distance above the third reservoir, and within seventy feet of the bed of the brook, there was a case of typhoid fever running its course through January, February, and March; that during most of this period the ground was frozen and covered with snow; that during the illness of this patient the evacuations passed in the night were habitually carried out and thrown upon the snow toward the stream, no at- tempt at disinfection having been made ; that about March 25th a thaw began, followed by slight rains; that on the 26th the water of the third reservoir, as before said, was let down directly to the lowest reservoir, and on the evening of this day pumping from the Sus- quehanna River ceased, and the town was again entirely supplied from the mountain stream; that thus nearly three months' accumulation of infectious typhoid-fever de- jecta was suddenly washed with the melting snow into the brook, and rapidly reached the lower reservoir, and was thence distributed through the pipes and hydrants of the Plymouth Water Company ; that fifteen days after this date (April 10th) the epidemic began; that no other source of unusual pollution of the mountain-water could be elucidated. It has since been shown, by Dr. Benjamin Lee, that this case had its origin in Philadelphia, and that an effi- cient health board might have saved the town of Plymouth a very large sum of money. The lessons, both negative and positive, of this epi- demic, thus reported, are so plain that he who runs may read them. It shows how easy it is, without care or knowledge, to attribute results to wrong causes ; that sewage-defiled water alone does not produce typhoid fever, though pure mountain-water containing typhoid de- jecta does ; that refrigeration does not destroy the activ- ity of the typhoid poison ; it emphasizes the vital impor- tance of disinfection of the dejecta, and of protecting the water-supplies of towns and cities against a fecal con- tamination which, often comparatively innocuous, may at any time become deadly. A report of the English Local Government Board, on an epidemic of typhoid fever in 1879, at the towns of Caterham and Redhill, illustrates forcibly the propaga tion of this disease by the contamination of a pure water- supply by a small amount of specific poison. Of 558 houses in Caterham, 419 were supplied with water from the Caterham Waterworks Company. Of the 47 persons attacked during the fortnight from January 19th to February 2d, 45 resided in houses where this water was in use, the other two used the water away from their own homes. At the same time an epidemic broke out at Redhill, eight miles from Caterham, but having the same water-supply, and it was shown that 91 of the 96 people attacked used this water of the Caterham Company. On the other hand, Reigate, a town adjoining Redhill and similarly situated, but not connected with the Cater- ham Waterworks Company, had no typhoid. Moreover, neither at the Caterham Lunatic Asylum, with two thousand inmates, nor at the barracks, with live hundred soldiers, was there any typhoid ; but bbth of these insti- tutions were supplied from their own wells, and the in- mates of houses drawing their water-supplies from wells escaped through the first weeks of the epidemic. There were in all 352 cases, with 21 deaths. An investigation by the health officers showed that the use of the water from the Caterham Waterworks Com- pany was the only factor common to all the earlier cases, scattered over a wide extent of country. Careful inquiry at length elicited that a workman, engaged with others upon alterations in the source of supply of the Water- works Company, began to ail January 5th ; that from this date until January 20th, when he gave up work, he had had copious diarrhoea ; that some of his evacuations escaped into the water. Subsequent examination of this man showed that he had been suffering from a mild typhoid fever. The first cases of typhoid in Caterham and Redhill appeared January 19th, just two weeks after the contamination of the water-supply by the discharges of the sick workman. Ex uno disce omnes. The limits of this article will not permit the introduction of further evidence of this char- acter, of which there is a vast amount. The histories of these two epidemics, however, suffice to illustrate the points I have wished to emphasize. Malaria : There is a general impression, particularly in the South and West, that typhoid fever and malaria are antagonistic. This impression is supported in a certain measure by observations, but the truth seems to be that, with the settlement and cultivation of new countries, the conditions favoring malaria are removed, and those fa- voring typhoid fever replace them. The use of the dis- tinct term typho-malarial to designate a separate disease, is unnecessary and undesirable. The "Rocky Moun- tain Fever," so called by practitioners on the slope of that great mountain chain, exhibits frequent divergences from the true clinical features of typhoid fever, and may show a continued remittent type, but the pathology observed in not a few of these cases links them to typhoid fever. Those who have seen many cases of typhoid are pre- pared for wide clinical variations. Course of the Disease.-Incubation.-The period of incubation, as with other infectious diseases, is a variable one, and probably depends upon the susceptibility of the individual, as shown in idiosyncrasy or constitutional condition, more than on the concentration and activity of the poison. From hospital patients it is difficult to draw any conclusions of value, either as to the period of incu- bation or duration of the disease. But cases have been recorded in which there is little room for error, as to the time of invasion, and from which maximum, minimum, and average periods may be fixed in a general way. Cases of less than a week's incubation are open to suspi- cion, and those reported instances in which immediate illness has followed the sudden opening of drains, etc., are probably, in their inception at least, due to septic or miasmatic poisoning. On the other hand, the instances of very long incubations, over four weeks, are but little better authenticated. The number of cases with a period of incubation not included between ten days and three weeks is probably small. 85 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. During this period the patient is able, as a rule, to pur- sue his ordinary occupations, though generally with less vigor, and there is apt to be diminished appetite. Period of Invasion.-This stage begins with the first feelings of malaise, which are often accompanied by a chill or chills. There is headache, dulness, and listless- ness, general soreness and chilliness, sometimes epistaxis, often diarrhoea, sometimes moderate abdominal tympa- nites, with tenderness and gurgling in the right iliac fossa, and the tongue presents a thin, whitish coat, not extend- ing to the tip and edges, which may be rather red. All or only some of these symptoms may be present, but are hardly pathognomonic, as many of them may be present in the early stage of other febrile affections. In the tem- perature, however, we find an important aid to diagnosis. If, in addition to the above systemic symptoms, the temperature rises steadily from day to day, and from morning to evening, and reaches 103° or 104° by the fourth day, there»will be little reason to hesitate as to the diagnosis. By this time the fecal discharges will begin to exhibit the characteristic light yellow color and pea- upon pressure-present themselves upon the abdomen and back; scattered sibilant rales are heard over the chest; the splenic area is enlarged ; the urine is dimin- ished in quantity, high colored, slightly albuminous; a mild form of delirium or of coma-vigil is developed. With these conditions the end of the second week will be reached. Third Week.-At this stage the remissions in tempera- ture from evening to morning will begin to be somewhat more marked, and the morning temperatures a little lower from day to day ; the pulse and respirations, however, keep up their former frequency and may be even more rapid ; the pulse is softer and weaker, and is apt to ex- hibit a slight dicrotism, due to the diminished tension of the arterial walls ; the tongue is dry, brown down the centre and red at the tip and edges ; the teeth are covered with sordes. The frequency of the alvine discharges presently begins to diminish, and the consistency to im- prove. The patient, however, exhibits the exhausting effect of the disease more than in the previous week ; he lies generally upon his back, and presents a dull, stupid Fig. 11G6.-Temperature in a Typical Mild Case of Typhoid Fever from First Day of Attack. (After Wunderlich.) soup consistency. By the end of the first week the tem- perature will have reached the maximum point which it is likely to hold during the disease, and the stage of inva- sion may be considered as at an end. Second Week.-From the end of the first week the tem- perature pursues a pretty steady course from the highest point, rising from morning to evening, and falling from evening to morning from 1° to 2|° F., the chart devel- oping the characteristic zigzag appearance; the counte- nance becomes more dull; the eyes more suffused ; the face more flushed ; the tongue more coated ; the intesti- nal discharges thinner and more frequent ; the abdominal tenderness and tympanites more marked ; the skin drier, congested, and showing evidence of paresis of the vaso- motor nerves in the ready production of Trousseau's taches cerebrates ; both skin and breath exhale a peculiar odor ; the pulse increases in frequency-rising, perhaps, from between eighty and one hundred to between one hundred and one hundred and twenty-and is more in proportion to the temperature ; the characteristic rose spots-small pink papules the size of a pin's head, slightly elevated above the surface and disappearing appearance, from which he can usually be easily roused ; muscular tremor is shown upon attempts to move ; speech and the protrusion of the tongue are attended with slow- ness and hesitation ; a smart tap upon one of the large muscles is followed by a swelling due to the contraction of the degenerated muscular fibres ; the heart-sounds are feeble ; the emaciation is pronounced ; the rose spots be- gin to disappear. This brings the disease to the end of the third week. Fourth Week.-About the end of the third week, or within a few days thereafter, the temperature will touch normal in the morning, although there will be a differ- ence of from 2° to 4° F. between the morning and even- ing temperatures ; the pulse and respirations will dimin- ish in frequency, the former falling from between one hundred and twenty and one hundred to between one hundred and eighty, at the same time improving in char- acter ; the sibilant rales in the lungs and the signs of hy- postatic congestion-if such have existed-will gradually disappear ; the tongue will begin to clear and to become moist at the tip and edges ; the dejections, from having been five or six in the twenty-four hours, and perhaps at 86 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. times passed in bed involuntarily, will not occur oftener than once or twice in that time, or even in forty-eight hours ; they will also begin to be more formed. The signs of nervous exhaustion are less striking, and the patient begins to enjoy hours of quiet, natural sleep. By the end of the fourth week further progress is made in this direction ; the temperature varies but little from normal either morning or evening; the pulse finds the level of health; the tongue is clean and moist, and the patient may be fairly pronounced a convalescent. Such is the course of a typical case of typhoid fever of average severity ending in recovery ; but individual cases vary from this in an infinite number of ways. In fact, there is no disease presenting a more diversified picture clinically. Any of the above symptoms may be exagger- ated or absent altogether. The patient may not take to his bed at all, as in the so-called ambulatory typhoid ; the period of convalescence may supervene rapidly upon a febrile course of not more than ten days or two weeks; and, on the other hand, instead of terminating in three weeks the pyrexia may continue for five or six weeks, or even much longer, and that without any genuine relapse. Some authorities (Cayley) explain these variations in dura- tion by the statement that we have in typhoid two forms of fever to deal with-a primary, due to the infection of the system by the typhoid poison, and a secondary, caused by the gangrene and ulceration of the intestine, and con- sequent septicaemia. Delirium, again, instead of being of a mild, stupid type, may be very active and acute, the pa- tient requiring watching to prevent his getting out of bed or jumping from a window. Anatomical Lesions, Morbid Anatomy, Pathology. -For a description of the various pathological lesions, and they are numerous-such as parenchymatous degener- ation, cloudy swelling of the vital organs, fatty degener- ation of the substance of the heart, hypostatic congestion of the lungs, ulcerations of the larynx and oesophagus, en- largement of the spleen, thrombosis, abscesses, diphtheri- tic affections, etc.-common to typhoid fever and other wasting febrile diseases, the larger treatises should be con- sulted. The changes in the intestinal glands, and especially in the solitary and agminated glands (Peyer's patches) of the ileum, constitute the characteristic lesions of typhoid fever; these are invariably present, and in the later stages are peculiar to this disease ; they are generally most pro- nounced in the neighborhood of the ileo-csecal valve, the patches being most numerous in this part of the ileum. The process may extend to the solitary glands in the large intestine. The individual glands forming a Peyer's patch number from one to four hundred, and give the mucous membrane in health an unequal and roughened appear- ance. The patches are elliptical, situated on the free borders of the intestine opposite the insertion of the mes- entery, their long diameter being parallel with the longi- tudinal axis of the intestine. They number from thirty upward, are confined to the small intestine, and, as before said, are most numerous and least scattered in its lower third. These glandular lesions are usually described as pass- ing through four stages : 1, The stage of swelling and hyperplasia of the intestinal and mesenteric glands ; 2, necrosis and sloughing ; 3, ulcerations ; 4, healing. In general terms, it may be said that during the first week the glands become gradually enlarged and the mucous membrane undergoes the usual changes of catarrhal in- flammation ; during the second week necrosis of the super- ficies of the glands sets in ; during the third week there is sloughing of the necrosed glandular tissue, forming ulcers which from the end of the third week begin to clean, and then pass on to the stage of healing. At what- ever period of the disease a patient dies, some of the intes- tinal glands will be found in the first stage, and at most autopsies some will be found in the first three stages. The process less often passes on to the second and third stages in the solitary glands. The primary change consists in an increase in the vascularity of the glands, and in a general proliferation of their lymphatic elements. Many of these elements in- crease considerably in size, forming multinucleated cells. Tig. 1167.-Temperature in a somewhat more Severe Case of the Dis- ease, with Relapse. (From the author's own experience.) 87 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seen in swollen patches. Generally the slough, in sepa- rating, exposes the submucosa and muscular coat, par- ticularly the latter, which forms the floor of a large ma- jority of typhoid ulcers. It is unusual for an entire patch to slough out, and the perfectly ovoid ulcer oppo- site the mesenteric attachment is rare. More commonly the sloughing commences in different portions of a patch, and small irregular losses of substance result, which may gradually extend and thus form one large ulcer. A large patch may present three or four ulcers divided by septa of mucous membrane. Very often the terminal six or eight inches of the ileum is one large ulcer, with islets of mucosa left here and there. Those originating from the patches naturally affect an oval form, with the long di- ameter in the direction of the gut, and those originating in the solitary glands affect a spherical form. " In rare cases the ulceration may extend slightly beyond the con- fines of the glands. The sloughing or disintegration of the new tissue being completed, there is no induration or thickening of the base or edges of the ulcer. The base of a typhoid ulcer is smooth and clean, and is usually formed of the submucous or muscular coat of the intes- tine-occasionally of the peritoneum alone. The edges are thin and undermined, and consist of a well-defined fringe of congested mucous membrane, as may be seen by floating the gut in water. Healing, or cicatrization, is the fourth stage. The ma- Both Peyer's patches and the solitary glands become en- larged and prominently raised above the surface of the intestine ; the latter varying in size from that of a pin's head to a large pea. They present a grayish-white ap- pearance, and a soft consistence. The hyperplasia ex- tends to the adenoid reticulation of the patches, and to the contiguous mucosa. The swollen condition of the lower part of the ileum is largely due to the great in- crease, intertubular and submucous, of the lymph ele- ments. The affected patches can be seen from the peritoneal surface, and the parts in which they occur can be felt to be thicker and firmer than those contiguous, owing to heteroplasia of the neighboring tissues. These changes are accompanied, and even preceded, by an acute ca- tarrhal process. The solitary follicles are not invariably affected, but in rare cases they have been known to be alone involved. This hyperplasia of the lymph elements of the intestinal glands is not peculiar to typhoid fever, and the severity of the attack is not always in direct ratio to the degree of the hyperplasia. Death may occur at this stage from the intensity of the fever, or the depres- sing action of the poison upon the nervous system. The swollen follicles may undergo resolution, and this is probably what takes place in the so-called "abortive typhoid the individual follicles of the gland may rupt- ure, discharging their contents externally and giving the Fig. 1168.-Portion of Ileum from a Case of Typhoid Fever Fatal on the Seventeenth Day, showing the partially Detached Sloughs. The mor- bid process has advanced farther in the agminated than in the solitary glands. The mesenteric glands are much enlarged. (After Murchi- son.) patches a peculiar reticulated appearance ; or the process, in most cases, passes on to the second stage, of Necrosis and Sloughing.-The hyperplasia of the lymph- cells having reached a certain degree, resolution is im- peded, the vessels become choked, an anaemic necrosis is induced, a slough forms, which must be separated and thrown off. This process may be superficial, affecting only the mucous tissue or even only a part of this ; or it may be, and usually is, deeper, extending to and involv- ing the submucosa (Fig. 1168). It is always more intense toward the ileo-csecal valve. The solitary glands may be capped with small sloughs. They have a yellowish brown color from the bile pigments. The depth to which the necrosis extends depends on the intensity of the lymphoid infiltration ; it may be deep in the muscular coat, and even reach the serosa, when perforation be- comes imminent. The retrograde process advances more rapidly in the follicles than in the interfollicular tissue, pigment is deposited in the depressions thus formed, and the shaven-beard appearance is produced-which, how- ever, cannot be regarded as characteristic of typhoid fever alone. Ulceration.-The separation of the sloughs is gradually effected from the edges inward, and entails among other dangers that of opening blood-vessels and perforation of the coats of the bowel. The size of the ulcer is directly proportionate to the depth and extent of the necrosis. The entire thickness of the mucosa may not be affected, and small, shallow losses of substance may frequently be Fig. 1169.-An Irregular. Round Ulcer, after Sloughing of an Infiltrated Peyer's Patch. A portion of the brown slough is still adherent. The necrosis has extended to the peritoneum, which is perforated. The owning is still partly closed by the adherent slough. (Taken from a man, nineteen years old, who died on the twentieth day of the disease.) (After Zuelzer.) jority of deaths occur before this stage is reached. The process begins with the development of thin granulation tissue, which covers the base of the ulcer and gives it a soft, shining appearance. The undermined edges ap- proximate to, and unite with, the floor of the ulcer, and from its margin new epithelial covering is gradually formed. The gland structure is not regenerated. The site of a healed ulcer is slightly depressed, is less vascular than the surrounding mucous membrane, and is pigmented. In some cases, especially of relapse, the floor of the ulcer becomes the seat of a secondary ulceration ; or occasionally an ulcer heals in one part and extends in another; and again, there may be ulcers healing in one part of the intes- tine, with fresh ulcers and patches in a state of hyper- plasia elsewhere. The secondary ulceration is said to be more apt to cause profuse haemorrhage and perforation than the pri- mary sloughing of the glands. The tuberculous ulcer of the intestine presents a strong contrast to the typhoid ulcer, and it is as necessary to distinguish the two as to distinguish between the clinical symptoms of acute tuberculosis and typhoid fever; at the same time it is easier to do so. The edges and base 88 Reference Handbook of THE Medical Sciences. PLATE XI Fig.l. l.G. u.c. C. V.I.C. A. C. P. G.' 1.0. l.G. p.p.' P. C. F.U.- A.G. p.c. l.G. Fig. 2. LESIONS OF TYPHOID FEVER. (AFTER CRUVEILHIER.) H. HKNCKE, KITH. N Y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. of the tuberculous ulcer are thickened and indurated, and the nodules of new-growth, tending to become case- ous, are seen scattered in its floor. It rarely, if ever, heals. The thickening of the tissues at its base makes per- foration a very exceptional occurrence. Some contrac- tion of the gut is attendant upon the extension of the ul- ceration. The Mesenteric Glands.-The changes in these glands are probably secondary to those in the intestinal. They likewise are the seat of an acute hyperplasia, which usu- ally undergoes a gradual process of resolution. Soften- ing and suppuration may exceptionally occur, or, the cap- sule of the gland being destroyed, the softened matters may escape into the peritoneal cavity, causing peritonitis. Treatment.-Treatment properly includes the whole management of the patient. In those not uncommon cases where the evening temperature does not rise above 102° F., nor the pulse advance beyond 110, and there are no complications, the actual "treatment" may not go beyond rest in bed and a liquid diet. A patient being fairly suspected of typhoid fever should be ordered to bed. The physician should imme- diately inform himself, when practicable, of the condition of the house-drainage and water-supply. The origin of the disease should, if possible, be discovered and cor- rected. The ventilation and regulation of the tempera- ture of the sick-room should be secured. Carpets, cur- tains, window-hangings, and unnecessary furniture, it is well to remove. The bed is best in the middle of the room, certainly not in the corner ; a second bed or mov- able couch is very desirable. The mattress should be neither very soft nor very hard-hair is the best ma- terial, and upon it a rubber cloth should be placed. The bed covering should be light; fever patients are apt to be too warmly and weightily covered. The patient's pulse and temperature should be taken at least twice a day, say between six and eight a.m., and between six and eight p.m., and recorded on a chart; if they can be taken oftener, so much the more accurate picture is given of the course of the disease. The temperature in the axilla is sufficiently accurate for practical purposes in this dis- ease, if proper precautions-such as wiping out the axilla and keeping the arm close to the side-are observed. During the first week of typhoid fever many patients undoubtedly get out of bed to evacuate the bowels, and it is very seldom that any ill result can be traced to this; it is, however, safer, and in the end more convenient, to in- sist upon the use of the bed-pan from the first, although to some its use is very uncomfortable, and regard should be had to the form most convenient to the individual. The dejecta should be persistently and unfailingly disinfected ; too much stress cannot be laid upon this point. They should be passed into a disinfectant solution, another portion of which should be added after their passage. This will be referred to again under the head of Disinfectants. Soiled bedding, clothing, linen, etc., should be placed in a disinfecting solution before being taken from the sick-room, and when taken thence placed, as soon as pos- sible, in boiling water. It is desirable, even when there is no hyperpyrexia, that the patient be sponged morning and evening. Water at any desired temperature, with or without the addi- tion of vinegar, alcohol, bay-rum, toilette-vinegar, etc., may be used. When the fever is pronounced, the water should be cool, about 75° F., and the sponging repeated more frequently. The process is best carried out by placing an old blanket under the patient and going over different portions of the body successively. Diet.-These details attended to, the regulation of the diet is of prime moment. The general principles to fol- low are that it be easy of administration ; that it be suit- able in amount; given at proper intervals ; easily digest- ed ; unirritating in its passage through the alimentary canal. Good pure milk may be made to meet these re- quirements better than anything else. The individual as well as the disease is to be considered ; but, in general, from two to four ounces of milk every two to four hours, or two to four pints in the twenty-four hours, will be in- dicated during the first three weeks. If too much is given at a time, hard curds are formed in the enfeebled stomach ; if too much is given in the twenty -four hours, large and distending masses of pultaceous feces are formed in the bowel, unless diarrhoea prevents this. The inclination of the patient may often be consulted with advantage ; but a certain minimum amount of nourish- ment is to be insisted on through the early weeks. When milk in small quantities disagrees, lime-water, aerated wa- ters, or boiling may be resorted to. A few patients can- not, or will not, take milk in any form. And even for those who can, for whom it is the staple, a variety is needed. Broths of beef, of veal, of chicken, or of mut- ton, given twice a day, in addition to milk, four to six ounces each time, or oftener and in somewhat smaller quantities without milk, are useful, and often agreeable. Barley or rice may be boiled in the water, which should be well strained. An egg, if really fresh, may be drop- ped in and stirred up ; gelatin may be added. ' Beef-teas, if not increasing the activity of the bowels, may be added with advantage ; the stimulation thus provided is very useful, and nourishment may be secured in other ways. For increasing the digestibility and nutritious ness of milk, broths, beef-teas, etc., the peptonizing process may be resorted to. Chocolate boiled in milk or water, if finely ground and not highly flavored, and cacao deprived of fat and treated in the same way will sometimes prove useful and acceptable adjuvants to other diet. The Germans give fruit-soups, made by boiling fresh or dried fruits in water, flavoring with sugar, lemon-peel, etc., and strain- ing ; these are refreshing, but have little nourishment. Wine-whey made with sherry or Madeira, milk-punch made with brandy or rum, eggnog, Borde iux if really good, may be given in addition to the above articles if required. A few of the forms of nourishment most suit- ed to the early weeks of typhoid fever have been sug- gested, the practical experience of each practitioner will doubtless suggest others. A state of solution, requiring only absorption and not digestion, would be the ideal one for the administration of nourishment in febrile dyspepsia. Pavy and Hoppe- Seyler have shown, however, that the stomachs of ani- mals in a pyretic state may be made to yield a digestive fluid. H. v. Hoesslin has instituted a course of experi- ments to test how far various foods are really utilized in typhoid fever, and received into the nutrient currents, which show that in a number of not very ill patients cer- tain foods of acknowledged digestibility-e.g., egg and milk, milk, meat-juice, wheaten gruel, yolks of eggs, etc. -were very fairly utilized, and that, in particular, the greatest part of the albuminates was absorbed. Diet in Convalescence.-When the temperature falls to normal, and convalescence begins, the vexed question of increasing the diet arises. Patients do, unknown to their doctors, eat solid food all through an attack of typhoid fever with impunity. Still more often, and this' some- times with the doctor's consent, they begin to eat freely with the return of appetite and the fall of evening tem- perature to the normal, and this without evil conse- quences. I think, however, that the old rule-if one must have a rule-to wait a week after the evening tem- perature remains at normal before increasing the diet, either in amount or consistency, otherwise than very gradually and tentatively, is a good one, and that he who follows it in his practice will, in the long run, have fewer relapses and shorter and better recoveries. Eggs-raw, soft-boiled, or dropped-oyster-soup with a finely crumbed cracker, porridges of various consistencies, meat-juice, scraped beef, soft dipped toast, etc., may gradually be added while the digestive and absorptive organs are re- covering their normal activity and chemistry. Care should be taken well on into convalescence that the food, of whatever description, be taken in moderate but fre- quent portions. Drinks.-A fever patient should have a liberal supply of pure cold water. He is not likely to take more than he requires. All the conditions present indicate its necessity. Pieces of cracked ice, kept in a flannel crater over the top of a bowl, and covered with flannel, at the bedside, will be very grateful to the dry mouth if given occasionally. 89 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The unmedicinal sparkling waters, as Apollinaris, Ross- bach, siphon soda, etc., are at times refreshing. Some practitioners rely a good deal upon the administration of some one of the mineral acids-dilute hydrochloric, sul- phuric, or phosphoric. Water acidulated with one of these in the proportion of a drachm to the pint makes an acceptable drink. It is important to keep the mouth as clean and moist as possible, for which purpose the alka- line waters, glycerine and water, or the same with a little borax added, may be employed. Bowels.-It is not often that interference with the bow- els is required. If the diarrhoea is exaggerated, the stools being both copious and frequent-more than four or five in the twenty-four hours-after the diet has been regu- lated, it may be thought best to give a suppository of a grain of opium, a rectal injection of laudanum in starch or water, or even to give a small dose of morphia, of par- egoric, or of elixir of bismuth by the mouth. On the other hand, constipation may be present in such degree as to increase the dulness and pain in the head, At such times a rectal enema, or even some castor-oil or a Rochelle powder, will do great service. But, as said, if the diet is properly regulated one need seldom interfere with the bowels. Some practitioners, especially among the Ger- mans (Wunderlich, Liebermeister, Friedreich), favor the early administration of calomel-before the ninth day- in doses of eight grains, three or four times daily, for one or two days. They maintain that the subsequent diarrhoea is thereby diminished, the course of the disease is ren- dered lighter, and not rarely aborted, and the mortality- rate diminished. Calomel is given to remove the poison from the bowel, as well as to antagonize it. Iodine and carbolic acid are given as antiseptics to destroy it in the bowel, and counteract its effects in the intestinal glands. Iodine is recommended in the form of one part iodine and two parts iodide of potassium to ten parts water, of which three or four drops in a wineglass of water, fre- quently repeated and continued for some time. Carbolic acid is given in combination with iodine or in enema. Bartholow and J. C. Wilson, of Philadelphia, suggest from one to three drops of a mixture composed of two parts tincture of iodine and one part liquid carbolic acid, to be given in a wineglass of ice-water after food every two or three hours. I confess to no especial enthusiasm for any of these forms of interference. The early use of calomel, which sometimes is undoubtedly attended with apparently favorable results, is a revival of an earlier practice. When tympanites is troublesome, turpentine'stupes or ten drops of the oil in emulsion every two or three hours internally, a simple enema, or the introduction of the long rectal tube are all, at times, useful. Haemorrhage from the bowel is generally announced by a sudden fall in temperature, without other assignable cause. If not profuse and not repeated, haemorrhage may require no other treatment than perfect quietude, and perhaps enough opium to dull the bowels. Stimulants should be avoided immediately after haemorrhage. If fur- ther treatment is required, the conventional agents are the vegetable or mineral astringents internally; the applica- tion of cold-in the form of ice-bags-externally. I have very little confidence in either of these, and the latter may exert a depressing action on the general system. A subcutaneous injection of several grains of ergotin-three to five grains-offers more rational hopes of positive re- sults. Perforation, which according to Murchison occurs in about 11.50 per cent, of the fatal cases, is generally an- nounced by pain and collapse, and, except in those rare instances where two portions of bowel are glued together and the perforation takes place between them, opium in large and early doses offers the only hope, though a slen- der one, for a favorable result. A localized peritonitis may occur without perforation, in which case great care should be taken to keep the bowels quiet. Pyrexia and Hyperpyrexia.-In the treatment of any febrile disease, and especially of typhoid, it is not to be forgotten that a continuous high temperature is more ex- hausting than an intermittent or remittent temperature which reaches a higher maximum. Moreover, in esti mating the bearing of any temperature the frequency and character of the pulse should be carefully considered. An evening temperature of 102° F., or even of 103° F., with a morning remission, may be regarded as the normal result of the typhoid process. An evening temperature rising above 103° F., especially if the morning remission be slight, suggests the propriety of interference. The various modes of controlling temperature may be classed under the two heads of (1) the external application of cold, and (2) the internal exhibition of antipyretics. 1. Cold may be applied externally by means of sponge baths, the wet pack, sprinkling the exposed surface of the body, putting the patient in the cold bath. Sponge Baths with water at a temperature of 75° F. are grateful, refreshing, tranquillizing, keep up the action of the skin, can be given without fatigue to the patient, and, if frequently repeated, will exert a certain positive effect upon the temperature and nervous system. They are not, however, efficient in controlling a marked hy- perpyrexia. The wet pack, or sprinkling the body, cov- ered only with a sheet, has a more pronounced action. The cold bath is still more effective. Cold Baths.-In regard to cold baths, it may be said, in general, that mild cases do not require them, and in advanced cases-after the second week-they are less safe. Great care must be exercised in giving them to young children and old persons. The patient should al- ways be carefully watched, and the administration of some form of stimulant, either during or after the bath, is often indicated. The bath should be rolled to the bed- side, and at least two attendants are required, that as lit- tle fatigue as possible may ensue to the patient when being lifted in and out. The bath may be given as a cold bath, at a fixed temperature of from 65° to 70° at the outset, or as a graduated bath, the water being gradu- ally cooled from 85° to 65°. The graduated bath con- sumes more time, and for many patients is quite as much of a shock as the cold bath. With either method the pulse must be carefully watched. In the cold bath, ten or fifteen minutes will generally suffice to produce shivering, when the patient should be removed. It is to be borne in mind that the temperature almost always con- tinues to fall considerably after removal from the bath When the temperature returns to the initial point the bath is to be renewed. In this way five or six baths may be required in a single day. It is claimed by the advocates of this treatment that it should be commenced early in the disease, and steadfastly persevered in to se- cure its full advantages. It is generally acknowledged to increase the tendency to relapse, and not a few authori- ties accuse it of increasing the tendency to intestinal haemorrhage. It certainly involves some disturbance to the patient, and an increase of labor on the part of at- tendants. Dr. Brand, of Stettin, formulates his method thus : Baths of 64° to 68° F., of fifteen minutes' duration, must be administered from the fifth day of the fever, and be repeated day and night, every three hours, as long as the temperature of the rectum exceeds 102° F. ; he also affirms that every case of typhoid fever treated thus, regularly from the beginning, will be free from compli- cations and will get well. Since the introduction of the systematic use of cold baths (cold water had often been used in earlier times) in 1861, the typhoid-fever death-rate in the German hos- pitals and Prussian army has shown, according to most of the available statistics, a very marked decrease. At the Charite Hospital in Berlin, the death-rate fell from eighteen to thirteen per cent.; at the Bethanien Hospital the reduc- tion was about the same. In the Prussian army the death- rate was reduced from fifteen to 9.7 per cent. Ziemssen, in the Munich Hospital, with 2,223 patients under treatment, during a series of years, secured a mortality-rate of only 9.2 per cent. At the Hospital of Basle the rate was re- duced from 27.3 to 8.8 per cent. Dr. Brand himself ad- duces statistics of over 8,000 consecutive cases, with a rate of 7.4 per cent, of deaths. In his private practice he, at the same time, claimed to have treated 211 succes- sive cases'without a death. After making all allowances 90 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. for the fallacies of statistics, it is hardly to be wondered at that, with such results, the treatment of typhoid fever by cold baths has been received with enthusiasm, and very generally practised in Germany. Out of Germany this treatment has been less eagerly adopted, except at Lyons, in France, where it was intro- duced and warmly advocated by Dr. Glenard, who had an opportunity to investigate Dr. Brand's method during captivity in Prussia in 1870-71. The systematic use of cold baths has not made headway in Paris, nor yet in the great fever hospitals of London. Considerable difference of opinion exists outside of Ger- many as to the desirability of such routine treatment. In the United States the treatment has not been exten- sively practised, and does not seem likely to be generally adopted either in hospital or in private practice. Al- though the cold bath may always be held in reserve as a valuable auxiliary, I believe it will eventually be demon- strated that as routine treatment equally good results may be reached by other methods less disturbing to the patient, and less laborious for the attendant. 2. The Internal Exhibition of Antipyretics.-It has been the custom for a good many years past to attack ele- vated temperatures by the internal exhibition of various remedies, among the most used of which may be men- tioned quinine, salicylic acid, salicylate of soda, digitalis, alcohol, and more recently the synthetical compounds of German chemical laboratories, viz., kairin, antipyrin, thallin, etc. Of these alcohol, digitalis, quinine, and anti- pyrin alone demand consideration. Alcohol: The administration of alcohol is to be gov- erned by the pulse rather than by the temperature ; but although its stimulant and sustaining properties are most marked, it may still be conveniently spoken of with anti- pyretics. The alcoholic treatment of fevers was intro- duced more than forty years ago by Dr. Todd, since when it has at times been used in an excessive and in- discriminate way, from which there has been a proper reaction, and the present tendency is to regulate the use while avoiding the abuse of alcohol in typhoid and other fevers. Sir William Jenner gives in a few words good guidance on this point. When in doubt as to the wisdom of giving alcohol, do not give it, and when there is a question of a larger or smaller dose, prescribe, as a rule, the smaller. If given, it should be for the purpose of attaining a certain definite object and for the relief of cer- tain symptoms. Its effects should be carefully watched, and the desired results obtained with the smallest possible dose. Its administration, except as a gentle stimulant in the form of wine, of wine-whey, or of milk-punch, is rarely indicated before the end of the second week. In the presence of unusual tremor, suggesting deep sloughs of the intestine, of active delirium, or in almost any case with a rising pulse of one hundred and twenty, alcohol should be given, and the dose regulated according to the effects, as shown by pulse, tongue, and countenance. From four to twelve ounces of brandy in divided doses will usually be sufficient in the twenty-four hours, but in advanced cases manifesting much exhaustion, sixteen and even twenty ounces may be required, and will sometimes turn the scale between death and life. The addition of five grains of carbonate of ammonia, every two or three hours, or of a drachm of aromatic spirits of ammonia, is useful and will limit the amount of alcohol required. Digitalis: Digitalis was recommended by Murchison in typhoid to control the febrile movement. It is supposed to equalize the circulation by its action on the peripheral terminations of the vaso motor nerves, to which the arte- ries of the mesenteric system respond more than the super- ficial vessels ; at the same time the primary effect upon the heart is to slow and steady its action by stimulating the vagus. Too small a dose will not produce the first effect; too large a one will accelerate and then paralyze the weakened heart, and a fall in temperature will follow, as it would the exhibition of any depressing poison. Those who have confidence in their discrimination as to the proper dose in the individual case, who are sure that the antipyretic is less dangerous than the fever, will use digitalis in typhoid ; I have seldom had occasion to do so. Quinine : Many practitioners are in the habit of giving from six to eight grains of quinine during the twenty- four hours as a tonic and stimulant to the heart's action ; but to get the antipyretic action, much larger amounts in concentrated doses must usually be given. If given in the evening, the fall of temperature coinciding with the usual morning remission will be greater ; if given in the morning, the evening maximum will be modified. Less than fifteen grains given in a single dose, or within the space of an hour, will usually prove disappointing in lowering appreciably a high temperature; more than thirty grains so given is liable to cause cerebral and gastric disturbances, although some authorities recom- mend from forty to fifty grains-a dose which I consider decidedly injudicious. When quinine is effective, the temperature begins to fall in a few hours, reaches its low- est point in six to ten hours, and remains below the pre- vious maximum for twenty-four hours or longer. In some cases quinine is not well borne, and in not a few it produces an inappreciable antipyretic effect or none at all. Antipyrin: My own experience and that of my col- leagues at the Boston City Hospital (where antipyrin has been in use since June, 1884), as well as the recorded ex- perience of others in Germany and this country, lead me to believe that antipyrin, or possibly some other still better synthetical laboratory compound yet to be discov- ered, is likely to take the place of quinine as an antipy- retic, and in a large measure of cold baths also. With antipyrin, supplemented by cold sponging or the wet pack if need be, I think the temperature in nearly all uncom- plicated cases of typhoid fever can be kept within the line of safety. From their observations upon the quinolin-hydrogen compound in quinine, certain German chemists were led to the formation synthetically of various antipyretic com- pounds having quinolin-hydrogen as a base. The first of these affording promise of successfid clinical application was from the laboratory of Drs. Fischer and Koenig, of Munich, and was called kairin ; the second, antipyrin, was obtained by Professor Knorr, of Erlangen. Other compounds-kairolin, thallin, etc.-have been tested clin- ically, but up to the present writing antipyrin is the most promising. This artificial alkaloid is obtained by reac- tion of diacetic ether on aniline, or by oxidation of quin- olin or chinolin. It comes in the form of a white crys- talline powder, having a slightly bitter taste, and faint aromatic odor ; very soluble in both alcohol and water, and generally well tolerated by the stomach. It may be given in water, in wine, or in aromatics. Filehne, who made the first therapeutical studies with antipyrin, as he had previously with kairin, suggested its administration in three successive hourly doses of two grammes (thirty grains) each. Given according to this formula, the fall in temperature should begin to declare itself about an hour after the first dose, reach- ing its maximum in from three to five hours after the exhibition of the full dose of six grammes; and should last, on an average, about eight hours, though sometimes it will last at least twice as long. A fall in temperature of from three to five degrees is thus very easily and pretty uniformly secured. The change in the pulse is by no means always proportioned to that in the temperature. These doses sometimes occasion profuse sweating, some- times slight nausea, less often a chill. The antipyretic effect can generally be reached by smaller doses. A single dose of thirty grains (two grammes) may be given, followed by two of fifteen grains each ; single doses of fifteen grains each, repeated if necessary, will sometimes suffice. Individuals develop idiosyncrasies toward antipyrin as they do toward other drugs, but I think experience justi- fies one in regarding antipyrin as a rapid, efficient, and reasonably safe antipyretic without antiperiodic proper- ties ; whose administration in proper doses is, as a rule, unattended by serious discomforts or drawbacks. By re- ducing a high temperature it frequently substitutes calm for excitement and sleep for restlessness, but has no other specific effect ip modifying the course of typhoid fever. 91 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. I have not given it as a rule, however, unless the evening temperature (axilla) reached 104° F. Liebermeister expresses himself as likely to prefer qui- nine as an antipyretic, if he were forced to choose between that and cold baths ; with the alternative as between an- tipyrin and cold baths, one might go further and willingly renounce the cold bath. Strumpell, of Leipsic, on the other hand, is of opinion that, if reduced to the alternative of relying exclusively upon baths or exclusively upon in- ternal antipyretic medicines, one should not hesitate in preferring the former. The latter, he thinks, are only indicated when with prolonged high temperature either the cold baths are contra-indicated for certain reasons, or when the hyperpyrexia continues notwithstanding the use of cold baths. Both agents will be found at times of unquestionable service, and each will sometimes be found a desirable supplement to or substitute for the other. Recrudescence and Relapse.-These are both com- mon phases of typhoid fever, and it is not always easy to classify each return of pyrexia under the one or the other term. In general, a sudden temporary elevation of tem- perature would be called a recrudescence, and a more gradual and prolonged elevation a relapse. A typical simple relapse, as exhibited on a chart, shows a rising tem- perature following some days of normal temperature after the primary attack has run its course. According to Ir- vine, "the temperature begins to rise, and continues to rise, with little intermission, until it reaches its height on the fifth day of relapse ; from the fifth day to the eighth or ninth day it is steady, but shows a slight inclination downward ; on the eighth or ninth day it falls suddenly several degrees, possibly to subnormal levels ; from such levels it ascends even to former heights, but this rise in simple cases is, so to speak, ephemeral. Fever persists to the fifteenth day, when in the simple cases a rapid, though intermittent, fall continues to the twenty-first day of the disease, at which time convalescence commences, and goes on with remarkable rapidity in many cases." This is a very idealized picture, even of the simple re- lapse. Relapse indulges in quite as many freaks as the primary typhoid may indulge in. To appreciate this, it is only necessary to remember that the same case may ex- perience several (two, three, or even four) relapses. The relapse may be engrafted immediately upon the primary attack ; it may complicate or be complicated by recrudes- cence ; one relapse may be intercurrent with another, etc. Relapse is generally accompanied by a return of the char- acteristic symptoms, such as diarrhoea, rose-spots, en- largement of the spleen • and it is liable to any of the complications attendant upon primary typhoid. But the duration is generally shorter, and, notwithstanding the debilitated state of the patient, a fatal termination is less common than in primary typhoid. Recrudescence is generally due to some indiscretion ; true relapse is probably the result of a secondary auto- infection with the typhoid poison, and will be frequently observed where there has been no imprudence whatever either of diet or otherwise. On the other hand, instances of various indiscretions unattended by any evil conse- quences, and of an early return to solid food against or- ders without paying the threatened penalty, are almost equally common. Complications.-Although, for the sake of brevity, I have avoided describing the various pathological changes and clinical complications, other than those connected with the bowels and especially characteristic of the dis- ease, which are incident to typhoid fever, a few of these are encountered in so large a number of cases that they merit separate mention. Epistaxis.-Nose-bleed, in the period of invasion, is so common an occurrence as to be considered almost a diag- nostic detail. At this period it is usually slight, requires no treatment, and is even a source of relief to the head- ache and dulness. Later in the disease nose-bleed is less usual, but is apt to be more profuse, and may necessitate plugging of the posterior nares. Exceptionally life may be endangered, and an enfeebled patient may not rally from a severe epistaxis in the later stages. Bronchitis occurs undoubtedly more often in cases where early and suitable care has not been given to the patient, but is quite common in other cases as well. It is often due to weakness and the dryness of the buccal and pharyngeal mucous membranes, and to the consequent inability to raise and expel the bronchial secretions. The rales may be so loud as to be audible at a distance from the chest. Bronchitis is sometimes associated with a lob- ular pneumonia, and in the later stages with hypostatic congestion of the lungs. All these conditions disappear with the pyrexia, and their best treatment is that directed to supporting the strength of the patient and controlling the fever. A genuine croupous pneumonia sometimes complicates the disease ; and, when appearing early, may be regarded as a direct manifestation of the typhoid poison, to which the term typhoid-pneumonia is applied. Thrombosis.-Venous thrombosis, as would be expected from the weakness of the heart, is frequent both as a com- plication and as a sequel. It occurs generally in cases which have run a prolonged and exhausting course. The femoral veins and their branches are those most often affected, and of these the left more frequently than the right. An elevation of temperature, a hardness of the vein, and swelling of the leg announce and accompany the condition. Complete rest, elevation of the leg, flan- nel bandaging, and, later, possibly some small blisters, are indicated as treatment. Either as a complication or a sequel, thrombosis is sometimes painful and tedious, but fortunately only in exceptional instances does it give rise to embolism of the pulmonary artery and death. Disinfection and Disinfectants.-The following are, in brief, the recommendations of the Committee of the American Public Health Association on Disinfection and Disinfectants, as given in their report, for the disin- fection of human excreta and of clothing, but it should be borne in mind that the experiments upon which they are based may require revision : Disinfection of Excreta.-Chloride of lime, or bleach- ing-powder, is, perhaps, entitled to the first place for disinfecting excreta, on account of the rapidity of its action. As a standard solution (No. 1), it is recom- mended to dissolve chloride of lime of the best quality in soft water, in the proportion of four ounces to the gallon. Of this solution, use one pint for the disinfection of each discharge. Mix well, and leave in the vessel for at least ten minutes before throwing into the privy-vault or water- closet. The same directions apply for the disinfection of vomited matters. Infected sputum should be discharged directly into a cup half full of the solution. For a standard solution (No. 2), dissolve corrosive sublimate and permanganate of potash in soft water, in the proportion of two drachms of each salt to the gallon. This is to be used for the same purposes and in the same way as Standard Solution No. 1. It is equally effec- tive, but it is necessary to leave it for a longer time in contact with the material to be disinfected-at least an hour. The only advantage which this solution has over the chloride of lime solution consists in the fact that it is odor- less, while the odor of chlorine in the sick-room is con- sidered by some persons objectionable. The cost is about the same-about two cents a gallon. It must be remem- bered that this solution is highly poisonous. It is proper, also, to call attention to the fact that it will injure lead pipes if passed through them in considerable quantities. For another standard solution (No. 3), add to one part of Labarraque's Solution (liquor sodae chlorinatae) five parts of soft water. This solution is more expensive than the solution of chloride of lime, costing eight to nine cents a gallon, and has no special advantages for the pur- poses mentioned. It may, however, be used in the same manner as recommended for Standard Solution No. 1. Disinfection of the Person.-The surface of the body of a sick person, or of his attendants, when soiled with in- fectious discharges, should be at once cleansed with a suitable disinfecting agent. For this purpose Standard Solution No. 3 may be used. Disinfection of Clothing.- Boiling for half an hour 92 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. will destroy the vitality of all known disease-germs, and there is no better way of disinfecting clothing or bedding which can be washed than to put it through the ordinary operations of the laundry. No delay should oc- cur, however, between the time of removing soiled cloth- ing from the person or bed of the sick and its immersion in boiling water or in one of the following solutions; and no article should be permitted to leave the infected room until so treated. Standard Solution No. 4: Dissolve corrosive subli- mate in water (it is soluble in cold water in the propor- tion of one part to sixteen, a solubility greatly facilitated by heat) in the proportion of four ounces to the gallon, and add one drachm of permanganate of potash to each gallon if desirable to give color to the solution. One fluid ounce of this standard solution to the gallon of water will make a suitable solution for the disinfection of clothing. The articles to be disinfected must be thoroughly soaked with the disinfecting solution, and left in it for at least two hours, after which they may be wrung out and sent to the wash. Before using this solution for disinfecting clothing, decolorize it by adding a little Labarraque's So- lution or a little chloride of lime. Solutions of corrosive sublimate should not be placed in metal receptacles, for the salt is decomposed and the mercury precipitated by contact with copper, lead, or tin. A wooden tub or earthen crock is a suitable receptacle for such solutions. Clothing may also be disinfected by immersion for two hours in a solution made by diluting Standard Solution No. 1 with nine parts of water-one gallon in ten. This solution is preferable for general use, especially during the prevalence of epidemics, on account of the possibility of accidents from the poisonous nature of Standard Solution No. 4. When diluted as directed, this solution may, how- ever, be used without danger from poisoning through the medium of clothing immersed in it, or by absorption through the hands in washing. A poisonous dose could scarcely be swallowed by mistake, owing to the metallic taste of the solution and the considerable quantity which would be required to produce a fatal effect-at least half a pint. Clothing and bedding which cannot be washed may be disinfected by exposure to dry heat in a properly con- structed disinfecting chamber for three or four hours. A temperature of 230° F. should be maintained, and the clothing freely opened and exposed. Convalescence.-Convalescence from typhoid fever is always slow, and may be very prolonged. It is always a matter of weeks, and may be a matter of many months. During this period a general supervision of the patient is desirable-care as to food, clothing, exercise, occupation, rest. A better summing up of the disease-process in its rela- tion to the process of convalescence cannot be given than in the closing words of Hoffmann's volume on the patho- logical-anatomical changes in the organs in typhoid fe- ver : The poisonous materials are, as a rule, taken into the body with the food, and carried into the blood from the lower portion of the ileum, as the place where the food tarries the longest, and where particularly favorable con- ditions for absorption are found. With this absorption, tissue-changes take place in these parts which cause the onset of a severe febrile movement, and this in turn en- tails a parenchymatous degeneration of the various organs. Under an extreme development of these phenomena, at- tended by a number of unfavorable complications, the patient succumbs. But in most cases the fever declines with the return of the intestine toward health. Nutrition regulates itself, and the degenerated organs are gradually renovated. When one therefore reflects how in all parts of the body large portions of important organs are destroyed during the typhoid process, one easily understands why typhoid patients in general experience such pronounced weakness for such a long time, and why typhoid fever is followed by a so much longer convalescence than so many other less generally destructive diseases. The restoration of such a large portion of the most important portions of the system as are destroyed during the disease taxes to the utmost the ability of those which are left, and is ren- dered laborious precisely by the fact that the very deliv- ery of new material for rebuilding is greatly impeded by the destruction of large areas of the lymph-glands in the intestine. Reflecting on these points, instead of being surprised at the slowness of convalescence, one is led to wonder at the recreative force which, undaunted by such impedi- ments, builds up afresh in a comparatively short period a large part of the whole body ; and, at the same time, one understands why it is that the convalescent, after passing safely through an attack of typhoid fever, feels rejuve- nated and as if he were born anew. Untersuchungen uber die Pathologisch-Anatomischen Veriinderungen der Organe beim Abdominaltyphus, Dr. Carl Ernst Emil Hoffmann. Leipzig, 1869. Real Encyclopedic der Gesammten Heilkunde, Professor Albert Eulen- burg, Artikel, Abdominaltyphus. W. Zuelzer, Zweite Autlage. Wien und Leipzig, 1885. Lehrbuch der Speciellen Pathologic und Therapie der inneren Krank- heiten, Dr. Adolf Strumpell. Icr Band. Leipzig, 1885. Archiv f. Experiment. Pathologic, vol. xiii. Virchow's Archiv, vol. Ixxxi. ; ibid., vol. Ixxxiii. Von Ziemssen's Handbook of General Therapeutics, vol. i. New York, 1885. A System of Practical Medicine, William Pepper, M.D., vol. i., art. Ty- phoid Fever, James H. Hutchinson. M.D. Philadelphia. 1885. Practical Medicine, Alfred L. Loomis, M.D. New York, 1884. Practice of Medicine. Austin Flint, M.D. Philadelphia, 1881. Notes on the Morbid Anatomy of Typhoid Fever, Wm. Osler, M.D., Third Pathological Report Montreal General Hospital. 1885. N. Y. Med. Journ., June 13,1885. Benjamin Lee, M.D., Am. Public Health Assoc.. 1885. Report to Mayor of Philadelphia, May 12, 1885, M. S. French, M.D., E. O. Shakspeare, M.D. Proceedings Philadelphia Co. Med. Soc., May 13, 1885. Proceedings State Med. Soc. Penn., May 28, 1885. A Treatise on the Continued Fevers of Great Britain, Charles Murchi- son, M.D. 2d edition. London, 1873. Introduction to Pathology and Morbid Anatomy, T. Henry Green, M.D. London, 1876. Relapse of Typhoid Fever, J. Pearson Irvine, M.D. London. 1880. Croonian Lectures on Some Points in the Pathology and Treatment of Typhoid Fever, Wm. Cayley, M.D. London, 1880. Principles and Practice of Medicine, Charles Hilton Fagge, M.D. Phila- delphia, 1886. George B. Shattuck. Bibliography. Explanation of Plate XI. Fig. 1.-Typhoid Fever; Death from Pleuro-Pneumonia, after Thirty- seven Days of Convalescence. VIC, ileo-ctecal valve, the seat of numer- ous and extensive ulcerations in process of cicatrization ; C, colon, with ulcer showing muscular fibres on its floor, likewise cicatrizing; UC, ul- cers cicatrized; PG, Peyer's patch honeycombed. Fig. 2.-Typhoid Fever; Death on the Twenty-first Day. GL, hyper- trophied lymphatic glands; GLO, hypertrophied lymphatic gland opened; C, caecum ; VIC, ileo-ceecal valve ; PC, Peyer's patches beginning to cic- atrize. Comparatively recent formations: PP, PG, Peyer's patches, with partial sloughs ; FU, ulcerated follicles ; IG, subperitoneal injection. FEVERS,CONTINUED: TYPHO-MALARIAL FEVER. This term, which was suggested by Woodward in 1862, and has since been widely adopted, cannot be justified upon scientific grounds ; for, as conceded by Woodward himself,1 'and generally admitted by recent authorities, " it does not designate a distinct type of disease, but is simply a term which is conveniently applied to the com- pound forms of fever which result from the combined in- fluence of the causes of malarious fevers and of typhoid fever." If we accept this definition of the term upon the au- thority of its author, we will be obliged to admit that typho-malarial fever is simply a clinical variety of typhoid fever in which the symptoms are more or less modified by the fact that the patient has also been subjected to the influence of the malarial poison, and the propriety of making a separate heading for such cases in our nosolog- ical tables may be questioned. If, in accordance with this definition, the sole difference between typhoid fever and typho-malarial fever consists in the presence or absence of a malarial complication, it would be reasonable to expect that the mortality from the complicated cases-typho-malarial-would at least equal that from the uncomplicated cases. But if we refer to the statistical tables published in the first medical volume of " The Medical and Surgical History of the War of the Re- 93 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bellion," we shall find that this is not true of the cases in- cluded under this heading by the medical officers of our armies during the war. On the contrary, the mortality from typho-malarial fever is very much less than from ty- phoidfever. This is shown by the following table, taken from the writer's recent work (1884) on " Malaria and Malarial Diseases," p. 83 • attack, and that in infants the pyrexia of enteric fever commonly presents this character in so marked a manner as to have led to the designation " infantile remittent." There is reason to believe that the non-recognition of this fact leads to frequent mistakes in diagnosis, and that many cases of simple enteric fever, and especially the mild cases, are improperly classified under the head- ings "malarial," "typho-malarial," and "remittent fever." This results largely from the fact that the diag- nosis has been made at an early period in the progress of the disease, before the distinctive characters of typhoid fever have been developed, and at a time when the py- rexia is, as stated, very often remittent in its character. In speaking of mild cases of enteric fever, Dr. Geo. B. Wood, in his "Practice of Medicine" (ninth edition), says : " In some instances the disease presents no other symptoms than those of moderate fever, with the char- acteristic phenomena of a slight diarrhoea or tendency to- ward it, some meteorism of the abdomen, and perhaps a few rose-colored spots. The tongue remains soft, moist, and whitish throughout; there is no vomiting, no con- siderable nervous disorder, no great prostration ; in fine, none of these peculiar symptoms commonly denomi- nated typhous. The disease runs its course in two or three weeks, sometimes even in less time, and then sub- sides spontaneously, leaving no unpleasant effects. Such cases are often mistaken for miasmatic remittent, es- pecially as they not infrequently have a daily remission, and exacerbation of the febrile symptoms." Since the introduction of the term "typho-malarial fever," such cases are very commonly classed under this heading, and it is certainly a decided gain to have them rescued from the group of malarial fevers to which they were formerly so often relegated, under the convenient heading "remittent fever," a term which in this country, in Europe, and especially in India, has been made to serve as a catch-all for a variety of febrile complaints differ- ing widely in their etiology and having nothing in com- mon except a more or less remittent character of the py- retic movement. The supposition that a large share, at least, of the cases which appear in our statistical tables under the heading "typho-malarial fever" are identical as regards etiology with the cases included under the heading "typhoid fe- ver" is supported by a consideration of the data con- tained in the first medical volume of " The Medical and Surgical History of the War of the Rebellion." This is shown by the following table, and remarks taken from the writer's work on "Malaria and Malarial Diseases," heretofore referred to (p. 21): " The figures in the tables from which our general sum- Annual Rate per 100 of Sickness and Mortality from Continued and Malarial Fevers in the Armies of the United States dur- ing the War of the Rebellion.* Ratio of cases to mean strength. Ratio of deaths to mean strength. Ratio of deaths to cases. White. Colored. White. Colored. White. Colored. Typhoid 2.62 2.14 1.05 1.19 39 89 53.24 Typho-malarial. 2.43 3.94 0.19 1.01 7.08 17.28 Remittent 11.62 16.05 0.16 0.52 1.39 3.27 Intermittent .... 36.54 62.77 0.04 0.06 0.18 0.10 Congestive inter- mittent 0.53 1.32 0.14 0.36 26.23 31.30 We find by referring to the third column in this table that the percentage of mortality in the cases designated simply "typhoid " was, in the case of the white troops, more than five times as great, and in the case of the col- ored troops more than three times as great, as in the class of cases designated " typho-malarial." It will scarcely be maintained that a complication can exercise a favor- able influence upon the severity and fatality of a specific disease. We are, therefore, obliged to suppose either that this malarial complication only manifests itself in the milder forms of typhoid ; or that a large share of the cases diagnosed "typho-malarial" are simply uncompli- cated typhoid of a mild form ; or that under this heading a large number of cases are included which are not ty- phoid at all, but belong to a distinct species of fever of a much milder type. In the latter case, it is evident that it will be necessary for those who maintain the existence of a distinct form of continued fever to define its characters, and to give it a specific name, inasmuch as typho-malarial fever is now generally recognized as being simply a clin- ical variety of typhoid. There can be no doubt that a large proportion of the cases which in our army statistical tables appear un- der the heading "typho-malarial fever" are, in truth, mild cases of typhoid. And it may be that under the influence of a malarial complication the pyrexia in such cases has a more decidedly remittent character than in similar cases without complication. But it must be remembered that uncomplicated typhoid often pre- sents a decidedly remittent character at the outset of the White Troops in Field, Garrison, and Hospital-General Summary. 1 3 □ 1 S' Q 3' 3 ? s 0 5 T> 3 7 3 -3 d I 5 p 5* r 3 ) 3 3' 3 s 2 288,919 112,876 39.07 21,965 7.60 11,769 4.06 Number of cases. Ratio per cent, of cases to mean strength. 1862. 059,955 23,346 3.53 282,675 42.83 991*88 Number of cases. s 4.87 Ratio per cent, of cases to mean strength. o CT 10,116 11,729 361,968 Number of cases. 1-1 co 1.73 53.58 6KI Ratio per cent, of cases to mean strength. £ £ CT 1 9,739 13,149 320.559 Number of cases. i g 1.50 ' 2.03 49.64 Ratio per cent, of cases to mean strength. mary has been made relate to the fiscal year, which in- cludes the period from June 30th of one year to July 1st of the following year; the data, therefore, under the heading 1862, for example, relate to the last six months of 1861 and the first six months of 1862. The change in nomenclature, made in accordance with the recommenda- tion of a board of medical officers, of which Dr. Wood- ward was a member, took effect soon after the commence- ment of the fiscal year 1863, and it is quite apparent from an inspection of the table that the class of fevers pre- viously known as ' common continued fevers ' subse- quently fell into the group denominated typho-malarial. "The broad fact which our table shows, is that the relative proportion of cases of typhoid fever diminished, and the relative number of cases of malarial fever in- creased, as the war progressed. Thus, upon comparing the first two years with the last two years, we find that the sum of the annual ratios is as follows • Typhoid fe- ver, first two years, 12.47 ; last two years, 2.99 ; malarial fevers, first two years, 81.90 ; last two years, 103.22. This 94 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. affords us a criterion for determining whether the group of fevers called, prior to 1863, ' common continued fever,' and subsequently ' typho-malarial fever,' is more nearly allied, etiologically, with true typhoid or with the mala- rial fevers. Taking, as above, the sum of the ratios for the first and last two years of the war, we obtain the fol- lowing ; Typho-malarial fever, first two years, 7.59; last two years, 3.76. Evidently the causes which produced this group of fevers diminished as the war progressed, as did those which produced the fevers recognized as ty- phoid, while the relative proportion of cases of malarial fevers increased. " The etiological deduction is apparent, and the reasons for this increase of one class of fevers and decrease of another are not difficult of comprehension. In the first place, our armies moved southward as the war progressed, and came more within the influence of the malarial poi- son. And, perhaps, this general movement southward, in which, however, the Army of the Potomac did not to any considerable extent participate, carried our troops, to some extent, outside of the endemic prevalence of en- teric fevers. This, however, is open to question. In the second place, it is a generally recognized fact that expos- ure to malaria, and attacks of malarial fevers, not only do not confer immunity, but predispose to further attacks. The increased number of cases of malarial fevers is, therefore, accounted for. " On the other hand, attacks, however mild, of the specific fevers, protect those attacked, to a greater or less extent, from future attacks. That this immunity applies to typhoid, as well as to yellow fever and the eruptive fevers, there can be no doubt. . . . " The history of armies in all parts of the world shows that new levies are especially subject to typhoid fever, and to the mild continued fever so often called by some other name, while seasoned troops are, to a great extent, exempt from it" (op. cit., p. 22). In further support of the view that the etiological con- ditions, which produce the cases denominated typho-ma- larial, correspond with those which produce typical cases of enteric fever, we may call attention to the fact that the so-called typho-malarial fever frequently occurs in localities where intermittents and remittents are unknown; that it may prevail during the winter months, and in cities which are far removed from malarial influences ; that its prevalence is often traced to insanitary conditions of the same nature as those which are concerned-as pre- disposing causes, at least-in the production of epidemics of typhoid ; and, finally, to the fact that in fatal cases, which have been diagnosed as typho-malarial at the out- set of the attack, the lesions of enteric fever are com- monly found at the autopsy. If, as some claim, there is a form of continued fever widely prevalent in the United States, which, although influenced by the same predisposing causes, is specifically distinct from true enteric fever, and also from the ma- larial fevers, properly so-called, then we must protest against the use of the name typho-malarial fever as ap- plied to such cases, inasmuch as, in accordance with the definition given by the originator of the name, this term is generally understood to designate a clinical variety of typhoid fever. George AL Sternberg. contagious fever, occurring at times of famine and over crowding, are presented in the medical literature of the early centuries of our era, but, according to the historical sketch in Murchison's Treatise, no precise description of a typhus epidemic is recorded until we come to the writ- ings of two Italian physicians of the sixteenth century. In our own country, in the States along the Atlantic sea- board, typhus has frequently been epidemic. In the medical literature of the early decades of this century, many references, under the names " spotted " fever, and typhus fever, are made to epidemics prevalent not only in the larger but also in the smaller towns. There exists, however, no certain record of earlier date than that of Gerhard,1 who, in some published observations on the epidemic of typhus which visited Philadelphia ill 1836, showed clearly the non-identity of typhus and typhoid fever. To him belongs the credit of being the first, in this country, at any rate, to establish this distinction. Although typhus is a disease of temperate climates, its existence in tropical countries has been claimed. Its chief habitat has been England and Ireland. Causes.-That sex plays no part in the etiology of ty- phus is shown by the statistics of different hospitals. Murchison publishes a table, showing the sex of typhus patients admitted into the London Fever Hospital during a period of twenty-three years. Out of a total of 18,268 cases, there were 9,322 females, and 8,946 males. Among the cases admitted into Riverside Hospital, New York, during the epidemic of 1881 and 1882, out of a total of 735, the males numbered 626, and the females 109. Dif- ferences may be accounted for by accidental circumstan- ces, or by the excess of one sex over the other in the pop- ulation. Thus, in the New York epidemic, the1 very large majority of the patients were men who were admitted from cheap lodging-houses. Children are not so prone to the disease as adults, but age, as a factor in the causa- tion, seems to be largely accidental also. The number of children under five years of age, on the records of typhus epidemic, is in marked contrast, it is true, to the number of children of the same age on the records of an epidemic of any of the other exanthemata. But the main factors in the propagation of typhus, namely, poverty and over- crowding, with deficient ventilation, may suffice to ac- count for the preponderance either of age or of sex. The following table shows the age and sex of the ty- phus cases admitted into Riverside Hospital, during 1881-82. The admissions and deaths, and the ratio of deaths to admissions, are also shown. Table I. Age. Admitted. Died. Ratio of deaths to admissions in percent- ages. No. Per cent. Male. Fe- male. No. Per cent. Male. Fe- male. 5 and under 4 0.54 2 2 5 to 10. 25 3.40 20 5 10 to 20. 75 11.20 62 13 7 3.95 6 1 9.83 20 to 30. 205 27.89 174 31 30 16.95 25 5 14.63 30 to 40. 215 29.26 178 37 54 30.51 44 10 25.12 40 to 50. 120 16.33 106 14 33 18.64 28 5 27.50 50 to 60. 62 8.44 57 5 35 19.77 32 3 5&45 60 to 70. 25 3.40 24 1 15 8.48 14 1 60.00 70 to 80. 4 0.54 3 1 3 1.70 3 75.00 Totals.. 735 160.00 626 109 177 100.00 152 25 24.08 1 Transactions of the International Medical Congress held in Phila- delphia in 1876, article Typho-Malarial Fever. FEVERS, CONTINUED: TYPHUS FEVER. Typhus fever, a contagious and epidemic disease, the outgrowth of overcrowding, famine, and filthy living, has been de- scribed under various names, chosen with reference to certain symptoms, its contagious or epidemic character, the eruption, or the localities in which it has commonly prevailed. Thus, it has been called pestilential fever, pu- trid fever, spotted fever, typhus exanthematica, adynam- ic fever, camp-fever, jail-fever, ship-fever, and hospital- fever. Its present common appellation, from rvipos, stupor, (literally, smoke, mist), was given more than a century ago by Sauvages. Its classification, as a disease distinct from typhoid fever, dates back, however, scarcely half a century. Numerous vague descriptions of epidemics of Thus, more than one-half the patients were between 20 and 40. Out of a total of 735 cases, only 4 were of five years and under, a percentage of 0.54. Murchison's table gives a percentage of 1.29 for these years. During a period in which 2,014 cases of small-pox were treated at Riverside Hospital, 456 were of five years and under, a percentage of 22.64. Typhus is generally considered to be a disease of cold weather. So long as the necessary conditions of desti- tution and overcrowding exist, the weather in itself has little influence in the causation, as may be shown by a 95 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. comparison of statistics. The Glasgow epidemic of 1847 reached its height in midsummer (Murchison). Physician of Riverside Hospital, escaped the contagion during an active service covering the greater part of two years, but subsequently fell a victim to the disease. The typhus-poison is probably contained in the cutane- ous and pulmonary exhalations. It may be transmitted through the air, or conveyed by fomites, so that actual contact with the sick is not necessary for the transmission of the poison to the healthy. The pungent, sickening odor given off by the breath and skin of a typhus patient is one of the marked features of the disease, and some ob- servers are of the belief that those in whom this odor is strongest are most apt to communicate the poison to oth- ers. It is not probable that the poison can be transmitted beyond a very limited distance in the open air. A patient in an airy room is not likely to infect others, unless they come in very close contact with him. Nor is there any likelihood of the disease being carried through the air from an infected house to other houses in the neighbor- hood. Clothing may become so thoroughly saturated with the poison as to be a source of contagion. At River- side Hospital a laundress contracted the disease appar- ently through such means. Murchison relates some in teresting observations bearing on this point. No instance is known where an attending physician has carried the disease in his clothing from the bedside of a patient. The period of incubation of typhus is about twelve days. Occasionally it greatly exceeds this, and it may extend to two or three weeks. On the other hand, nu- merous instances are recorded in which, probably on ac- count of the great concentration of the poison, the effects were produced almost immediately. The most infec- tious period of the fever would seem to be that during which the odor given off from the breath and skin is strongest, that is to say, after the first week. Percy, at the Glasgow Royal Infirmary, reached the conclusion, " from numerous observations and experiments," that the disease was not contagious before the ninth day. The common opinion is that during the first week and during convalescence there is little danger. It is doubtful whether the dead body can communicate the disease. Experiments have failed to produce the disease in the lower animals. The most plausible arguments in support of the theory of the spontaneous development of typhus are derived from the study of cases arising in isolated localities, or in institutions at times when no epidemic is prevailing. Martin 5 gives a brief account of an outbreak of typhus in a family of seven, all of whom slept in one bed of straw. The baby, and the child above it in age, were the only ones to escape. Typhus had not appeared in the dis- trict for more than twelve months, and no communication with other cases could be traced. In another instance, where the isolation was seemingly also complete, four very dirty children sick with measles, and all in one bed, were tended by their mother, ■who took her rest in the same bed. Ten days after the appearance of the measles the mother was seized with typhus. In all such instances, however, there is the possibility of the presence of the specific germ as the cause. The reports furnished the Surgeon-General's Office show a total of 2,501 cases of typhus, with 850 deaths, among the troops in the Union armies from May, 1861, to June 30, 1866.6 But the medical officers of the Northern and Southern armies assert that typhus did not prevail to any such extent, and that the cases thus reported were mostly cases of typhoid, relapsing, and malarial fevers. Woodward1 admits that he has read " descriptions of several small groups of cases, occurring at various points throughout the army, in which he is satisfied that the di- agnosis was correct." In an official report8 to the Surgeon-General of the Confederate army, Surgeon Joseph Jones remarks "No case of true typhus fever came under my observation dur- ing the war in any army, in any field hospital, general hospital, or military prison." He sought for the fever among the sick and wounded in the Confederate armies and in the prisons, and he interrogated numerous medical officers. He is of the opinion that nearly all, if not all, typhus cases upon the Confederate sick reports were Table II. Showing the Typhus Admissions a?id Deaths at Riverside Hospital for each month of 1881, and the Ratio of Deaths to Admissions. Admissions. Deaths. Ratio of deaths to admissions, in percentages. J anuary .. .. February .. .; March . ... .. 49 2 4.08 April. ... . 170 44 25.88 Mav 110 28 25.45 June 86 13 15.11 J uly 55 26 47.27 August 15 8 53.33 September 1 October 21* 1 4.76 November December 506 123 24.31 * Twenty children and one adult. Intemperance is an active agent in the causation. Craigie and Davidson2 have shown that more than one- half of the whole number of typhus patients at the Edin- burgh and Glasgow infirmaries had been intemperate. Tin>re is no protecting idiosyncrasy, neither does one attack assure absolute immunity from a second. One in- stance, in which the disease occurred twice in the same individual, and within the same year, came under my observation. The most powerful of all predisposing causes are those attendant upon poverty. This was well exemplified in the recent New York epidemic. A majority of the cases were admitted into the hospital from overcrowded and illy ventilated lodging-houses, the haunts of the most destitute class in our population. To one of these houses the source of the contagion in a large proportion of the cases, admitted in 1881, was traceable. The building it- self had originally been a church ; by utilizing the pews for sleeping-bunks, and by constructing a triple tier of bunks above them, the church had been converted into a lodging-house. This resort and others, where the disease was prevalent, were not closed immediately by the health authorities. It was deemed wisest to make some attempt looking to an improvement in the sanitary condition of such places, meanwhile keeping them and their frequent- ers under watchful supervision day and night. By the adoption of such a plan, it was thought that the cases, as they were developed, might be more readily discovered, and a scattering of the disease be thus prevented. The results apparently justified the measures taken. Evidence as to the contagiousness of typhus is seen in the rapid succession of cases in a family, or house, or neighborhood ; in hospitals, among the physicians, nurses, and others in attendance upon typhus cases ; and in the importation of the disease into previously healthful local- ities. The outbreak in New York in 1881 ran a rapid course, and was confined almost wholly to a particular class of the people. The outbreak in the Camden County, New Jersey, Almshouse, in 1881, was traceable to an in- mate who, shortly before his admission, had frequented cheap lodging-houses in Philadelphia. The almshouse was crowded and the disease spread rapidly.3 Of 22 members of the house staff of Bellevue Hospital, during the prevalence of typhus in New York in the years of the civil war, 15 contracted the fever.4 Of 14 who were em- ployed as nurses, orderlies, and helpers among the typhus patients at Riverside Hospital in 1881, 12 contracted the disease. Nurses almost invariably are taken ill soon after assuming their duties in typhus wards. Physicians may escape for a time, owing, perhaps, to their less intimate re- lations with the sick. Dr. A. R. Mott, Jr., late Resident 96 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. cases of typhoid fever. Dr. Jones pertinently adds,' that the experience at Andersonville prison most strongly sustains the view that a specific poison is necessary to the generation of typhus, since all of the conditions deemed necessary by those who favor the theory of a spontane- ous development were apparently there present. Although the immediate cause of typhus is not known, it certainly is more in accord with recent knowledge concerning the etiology of other infectious diseases to as- sume the existence of a specific germ, a contagium vivum. Klebs, in an address10 delivered before the Section of Pathology at the International Medical Congress, in 1881, announced the discovery of a bacillus in the blood of typhus fever patients. I have not been able to find any published record of his investigations. More re- cently, the micro-organism occurring in typhus has been studied by Fred. W. Mott and J. Blore,11 who pre- sented the result of their work in a paper before the In- ternational Medical Congress, in 1883. They " examined the blood of twelve cases during the pyrexial stage, and in all moving organisms, like minute screws, have been seen. Occasionally their form may be made out; and we consider them to be dumb-bell micrococci undergoing division. Often single cocci could be seen, and these were found to measure about a half-millimetre. In one case there were large numbers in the blood after the fever had subsided ; but, as a rule, they disappeared on convalescence. We have examined the blood of other fever patients, and not found them. Another fact noted about the blood was a great increase of the white cor- puscles." No artificial cultivations and no inoculations have been made. The pathogenic nature of this micro- organism, therefore, is yet to be determined. Clinical History.-The following is but a brief and general clinical description. The symptoms more in de- tail will be considered subsequently. The onset of typhus is apt to be abrupt. The patient complains of chills, or chilly sensations, lassitude, head- ache, pain in the back and limbs, and vertigo, rarely of nosebleed ; loss of appetite, and, in some cases, of nau- sea and vomiting, and constipation. There is a stagger- ing gait ; the patient feels and looks as if his knees would give way under him ; the hands shake, and the tongue trembles when protruded. The prostration at the be- ginning may be so overpowering as to compel him to take to bed. He is restless, and what sleep he obtains is disturbed by dreams or mild delirium. The face is flushed, the conjunctivae injected, and the pupils often dilated. The temperature rises rapidly to 104° or 105°, and continues with slight morning and evening variations. The pulse is accelerated, full and soft. These are the phenomena observed during the first two or three days of the attack. On the fourth or fifth day, a usually bright maculated eruption appears, which is not infrequently preceded by an erythema. With the advance of the dis- ease the eruption becomes more abundant and dark, and at the end of a week true petechiae may be seen. With this commonly more prominent eruption is mingled another, a subcuticular mottling, the two eruptions together giv- ing rise to the names, mulberry rash, and measly rash, of typhus. The headache passes away as the more promi- nent nervous symptoms of the second week are devel- oped. The delirium then becomes muttering and inco- herent, or active, or even violent; or the mental state may be one of profound stupor ; or coma-vigil may be the striking symptom. The prostration increases. Mus- cular twitching, subsultus, carphologia, and other symp- toms of the typhoid state are present. The expression is dull, heavy, and apathetic ; the face dusky, the eyes more deeply injected, and the pupils perhaps contracted or ir- regular. Deafness is common during the second week. Sordes collect upon the teeth and lips ; the tongue is dry, brown, and tremulous. Diarrhoea, or incontinence both of faeces and urine, may supervene. Retention, and more rarely suppression, of urine are symptoms at this stage. The urine is not uncommonly albuminous. The respirations are quickened, the high temperature contin- ues, and the pulse is increased in frequency, irregular, or intermittent, reaching often 135. From this condi- tion the patient may not rally, but pass into profound coma and die. On the other hand, what is called the crisis of the fever may be reached about the fourteenth day, bringing with it a sudden and marvellous improve- ment in all of the symptoms. The return to health is rapid. A relapse is extremely rare. Countenance and Skin.-The typhus physiognomy may almost be said to be pathognomonic. Unless active delir- ium be present, the expression is commonly one of per sistent apathy. The half-closed eyelids and lips, the injected eyes, the sordid teeth and mouth, the dry, brown tongue, and the dull-red, dingy, or livid face are all com- mon features of the second week. The intensity of color in the face is in some degree a measure of the severity of the case. The color is not circumscribed, though it may be brightest on the cheeks. Occasionally a diffuse, simple erythema, or rash, faint or bright, or a rash limited to small areas, may precede the typhus eruption and persist for a day or two. It may also continue for a time after the appearance of the typhus spots. It is the result of an active hyperaemia of the cu- taneous capillaries; later in the disease a passive congesr tion of these capillaries produces the dusky appearance of dependent parts. The typhus spots do not all appear at once, neither do they come in successive crops as do the papules of typhoid fever. Several days may elapse, however, before the eruption is complete. In the early stages it may tempo- rarily disappear from a part. The spots vary greatly in size, some being mere pin-points, and others three or four lines in diameter. They are at first, in many instances, distinctly papular, and disappear on pressure. Their color is pinkish, or reddish, but, as the disease advances, they become .darker, owing to the escape of blood-pigment from the capillaries. With the deepening of color their papular character is lost, and the eruption then becomes macular. The usual typhus macules are not sharply out- lined ; their color shades off into that of the surrounding skin. Unless the eruption be reddish-brown, or petechial, nothing of it will be found after death. It may never reach the dark, or petechial, stage, and again it may be intensely haemorrhagic from the beginning. No order is observed in the appearance of the eruption on the differ- ent parts of the body. Any part may be the seat of its first appearance, or it may appear in various parts simul- taneously. Some observers claim that the face and neck seldom present the eruption, but this is contrary to my experience. The quantity varies greatly. In a very small number of cases no eruption at all can be found ; in others there is only the mottling, or a few faint macules. At the London Fever Hospital the eruption was said to be absent in about seven per cent, of the cases, but Murchison con- siders this an overestimate. The persistence of the erup- tion depends upon its character ; when faint, it disappears before the cessation of the fever; when petechial, it lasts into convalescence. The mottling often vanishes after a few days. The quantity of the eruption and the depth of color are, as a rule, proportionate to the severity of the case. Purpuric spots, taches bleuatres, and sudamina are sometimes present. Until the approach of convales- cence the skin is generally dry ; but the opposite condition frequently exists, especially in certain severe cases, where the skin is cold and the sweating often profuse. Desqua- mation has been known to occur. Loss of the hair very seldom follows an attack. The peculiar, aminoniacal odor, associated with the disease, has already been mentioned. Temperature.-The rapid rise of the temperature of the body during the first days of the fever, and its mainte- nance at a high point for a week or more, are features peculiar to typhus. The maximum is usually between 104° and 105", and is often attained before the fourth day, but it may not be reached before the middle of the second week. Exceptionally, even in severe cases, the rise is not above 103°. The evening temperature is highest, differ- ing but a degree or so from that of the morning. A re- mission is usual about the eighth or tenth day, succeeding which there is a gradual decline till the fourteenth or fif- teenth day, when a sudden fall of several degrees takes place. This is the typical curve, and the one presented 97 Fever. Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the majority of uncomplicated cases. Great variations are met with. Even in fatal cases the temperature may have a low range throughout; on the other hand, it may rise above 105°, and the patient recover. Complications are a cause of irregularity. Just before death the tempera- ture may reach as high a point as the ordinary clinical thermometer registers. During convalescence a subnor- mal temperature is not uncommon. At Riverside Hos- pital a temperature of 96° was not infrequently recorded ; I have a record showing a temperature of 95° on the eighteenth day. Pulse.-As Stokes has shown, the cardiac impulse and the first sound, except in mild cases, are weakened. In very severe cases, for a varying period preceding the ter- mination, they may be quite imperceptible. Although a feeble pulse is indicative of a weakened cardiac impulse, exceptions to the rule are met with. Murchison quotes a case narrated by Stokes, in which, for ten days prior to death, an imperceptible radial pulse was associated with a strong cardiac impulse and distinct sounds. The ra- pidity of the pulse increases with the rise in the tempera- of grave import-are met with. In certain severe forms the number of respirations may fall below the normal. Digestive System.-Loss of appetite persists until conva- lescence. Nausea and vomiting I have observed not in- frequently among the early symptoms. They are some- times troublesome symptoms in the later stages. Great thirst is common. The tongue at first is lightly furred and moist, but during the second week it generally be- comes dry and brown, or coated -with sordes, and in some instances fissured. Tympanites and abdominal tender- ness are occasional symptoms. The early constipation is often relieved by laxatives, taken before the patient's ad- mission into a hospital, and a diarrhoea may thus be in- duced. But aside from those cases in which the diar- rhoea follows the use of laxatives, given either before or after admission, there is a small percentage in which the diarrhoea is spontaneous. The stools have no peculiar character. In the worse, forms they are thin or watery, and of a light-yellowish or greenish color. Urine.-The quantity of urine passed during the first week is often greatly diminished; later it is usually in- Fig. 1170.-Chart Showing Temperature in a Severe Case of Typhus, from First Day of Attack.* ture, but they bear no definite relation to each other. The pulse will often continue to be rapid after the tem- perature has fallen. In the majority of cases the pulse reaches 120, and very frequently exceeds this. A tem- perature of 104°, with a pulse of 120 for several days, does not have so grave an import as in typhoid fever. A subnormal pulse-rate occurring during the course of the fever, and especially in convalescence, is not uncommon. In one young man I observed a pulse ranging between 44 and 50 for two or three days prior to convalescence. Ex- ceptionally the rate does not exceed 100, even in fatal cases. The character of the pulse at the outset is full and compressible ; gradually it becomes smaller and fee- bler, and, in very bad cases, thready, tremulous, dicrotic, irregular, or intermittent. Respiratory System.-Cough is apt to occur early, ow- ing to the frequency of bronchitis as a complication. It is quite usual for patients to refer all of their early symp- toms to a supposed " cold." The respirations are at first only slightly increased, but as the fever approaches its height, and especially when hypostatic congestion ex- ists, they generally exceed thirty per minute. Irregular, sighing, Cheyne-Stokes, and spasmodic respirations-all creased. The bladder calls for particular attention, aa retention is not uncommon in severe cases. Suppression seldom occurs. The color of the urine is normal or pale yellow, rarely reddish or dark brown. The reaction, late in the disease, I have found to be faintly acid, seldom al- kaline. From an early high specific gravity there is a fall in the later stages to 1012 or 1008. In six cases in which the quantity of urea contained in the urine during and after the second week was determined I found that the amount was diminished, and that occasionally the daily quantity was far below the average. In the flocculent pre- cipitate, often noticed, were triple phosphates, amorphous phosphates, urates of ammonia, and bladder epithelium, seldom casts of any sort. Albumen is frequently present, but not often in any considerable amount. * Patient twenty-five years of age. October 14th, date of beginning of illness; chilly feeling all day, weak, no appetite, nausea ; next two days vomiting ; October 17th, at night, delirium for first time ; October 18th (fifth day), eruption on hands, arms, and body : disappeared for a time from hands and arms. Intense headache and cramps in limbs, great prostration. During second week, quiet delirium, subsultus, car- phologia, vomiting. Brandy, whisky, and wines used. Eruption pro- fuse and petechial. Urine highly albuminous. Baths and sponge-baths. No quinine. Convalescence good. 98 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fever. Nervous System.-Headache is an almost invariable and often a most distressing symptom of typhus. It may be the first indication to the patient of the impending trouble. It continues with little abatement well into the second week, only to disappear when other nervous manifesta- tions become prominent. Occasionally it will cease after a few days ; on the other hand, it may not prior to con- valescence. With the pain in the head come the dull aches in the back and the severer, cramp-like pains in the muscles of the extremities. Dizziness is also one of the first and most constant symptoms. This and the early loss of muscular strength cause the staggering gait, which is sometimes the occasion of a threatened arrest for drunk- enness. Indeed, typhus patients of the tramp class are not infrequently arrested in the streets, and sent into station-houses and into the cells of public hospitals. In the majority of cases the muscular weakness is of gradual development; the patient complains at first of a tired feel- ing simply, and is disinclined to make any exertion. Delirium is, as a rule, present in all cases, except those of the mildest type. Occasionally the cerebral symptoms indicate nothing more than slight mental confusion. Whatever the degree of mental disturbance, it is apt to be most marked at night, and to become more pronounced as the disease progresses. It is not uncommon to find an early active delirium, though in the majority of cases this does not supervene before the second week. It is likely to appear earlier and to be a more persistent symp- tom among the more intelligent. Every variety of delir- ium is to be met with, the form seeming to depend upon the peculiarities of the individual, his previous health, occupation, etc. The usual form noted in the New York epidemic of 1881-82 was the low, muttering delir- ium. Deep somnolence, or coma-vigil, subsultus, car- phologia, relaxation of the sphincters, muscular rigidity, and uraemic convulsions are among the grave symptoms of the second week. Oscillations of the eyeballs are occa- sionally noticed. The pupils at first are often dilated, but during the second week in many severe cases they are contracted, or irregular, and insensitive to light. Ringing in the ears and deafness are common. Cutaneous anaes- thesia, but much more frequently cutaneous hyperaesthe- sia, is met with. Some patients present the latter symp- tom in a marked degree. Stages and Durations.-The course of the disease has been somewhat arbitrarily divided into stages, some writers making three, others five, six, or eight. One of the most characteristic features of typhus is the improve- ment marking the stage of defervescence. The symptoms of the " typhoid state" vanish often as if by magic, in the course of a few hours, and in their place come the quiet sleep of approaching convalescence, a lower temperature, a firmer pulse, and the countenance of returning intelli- gence. After the improvement has once begun, it goes on rapidly. Within a month the patient is usually re- stored to full strength of body and mind. The average duration of the disease up to convalescence is about four- teen days. The mean duration- of 500 uncomplicated, recovered cases, analyzed by Murchison, was 13.43 days. In none of the cases was convalescence delayed beyond the nine- teenth day ; in 69 it commenced before the twelfth day. In 100 fatal cases, not all of them uncomplicated, the mean duration was 14.6 days. In 4 the fatal result oc- curred on the eighth day, and in 5 on the nineteenth day. Complications and Sequelae.-Meningitis is rarely met with in typhus. It was present in 3 of 128 fatal cases at the Riverside Hospital. In a few cases a certain degree of mental imbecility is observed to persist some time after convalescence is reached. Acute mania has been noted as a sequel. Paralyses of individual muscles and of groups of muscles are occasionally seen. The muscu- lar pain may continue after the fever has subsided. Deafness often continues for a time after the other symp- toms have abated. Otorrhoea was not infrequently a complication among the cases at the hospital. (Edema glottidis seldom occurs. Bronchitis has already been men- tioned. Hypostatic congestion of the lungs is common, but true pneumonia is rare. I have seen one case com- plicated with pleurisy and pneumonia. Gangrene of the lung is among the rarer accompaniments of typhus. I have seen it but once. Besides epistaxis, haemorrhages occur in various situations-beneath serous and mucous membranes, from the gums, uterus, and urinary tract and into the muscles. Arterial and venous thrombosis, and embolism, are now and then met with. Granular degen- eration of the heart-muscle may be a source of great dan- ger, even during convalescence. In one of my cases, death was the immediate result of the patient's suddenly assuming the sitting posture. Dysentery as a complica- tion has been of quite common occurrence in some epi- demics. Diarrhoea has already been referred to. A few cases complicated with haemorrhage from the bowels have been reported. I have noted jaundice only in one instance. Inflammation of the tongue, or more frequently of the salivary glands, especially of the parotid, occurs in a small proportion of cases. The glandular swelling is sometimes extensive and painful, and interferes with mastication. Parotid swelling may result in very destructive suppura- tion. The occasional diffuse, brawny swelling of the neck, indicating a low grade of inflammation, is more to be feared than the parotid enlargements. Cancrum oris is rare. Corneal ulceration, bed-sores, gangrene of the extremities, and gangrene occurring in parts free from pressure, as the tip of the nose and the ears, are among the less frequent complications and sequelae. Gangrene from whatever cause is usually not extensive ; it caused the loss of both feet, however, in one of the fatal cases at Riverside Hospital. Erysipelas and necrosis are un- usual in typhus. Other infectious diseases may coexist. I have seen herpes in only one instance. Diagnosis.-In the absence of the eruption a positive diagnosis is impossible. In those cases in which the erup- tion is quite indistinct, or in which an eruption of a doubt- ful character is present, the physiognomy, nervous symp- toms, temperature, and splenic enlargement may suffice for a probable diagnosis. Out of a total of 735 cases at Riverside Hospital, there were but 6 in which the erup- tion was absent. Besides these rare cases, which in other respects present the common features, certain apparently abortive attacks are met with, characterized simply by a few days of fever with headache, lassitude, and loss of appetite. Such attacks have been observed among those in attendance upon hospital cases. That other diseases are frequently mistaken for typhus is shown by the fact that 108 patients, or about an eighth of the entire number sent as typhus to Riverside Hospital, during the three years following the outbreak of 1881, were wrongly diag- nosed.12 Among the number were 8 of small-pox, 1 of measles, 12 of typhoid fever, 13 of malarial fever, 3 of meningitis, 3 of cerebro-spinal meningitis, 6 of acute alco- holism, 8 of pneumonia, and 10 of various skin eruptions, including 1 of syphilis. The opposite error of mistaking typhus for other diseases was not so frequently made. Thirteen cases of typhus, however, were sent as small- pox. Small-pox was epidemic in New York during this period (over two thousand cases were admitted into the hospital). The mistakes, in the twenty-one instances in which these diseases were confounded, arose chiefly from the presence, in the small-pox cases, of an early, intense haemorrhagic eruption, and from the presence of papules in the typhus cases. In these malignant small-pox cases the patient may die before the vesicular stage of the erup- tion is reached ; in one instance the proper diagnosis was not made until after death. Typhus was twice mistaken for measles, making only three instances of error as re- gards this disease. The patients were adults. During a part of the period when typhus and small-pox were both epidemic, cases of measles were refused admission into the hospital ; this, and the fact that the typhus epidemic was confined almost wholly to adults, partially explains the infrequency of error. A haemorrhagic form of mea- sles, and a deep mottling in typhus, are liable to mislead. In addition to the twelve cases of typhoid fever mentioned above, there were two of typhus, which were at first di- agnosed as typhoid. Delay is often necessary before a differential diagnosis of these two diseases can be made. Dr. Mott cites two instances. A case which very well 99 Fever. Fibroma, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. illustrates the difficulty, I here present. The patient had been sent to the hospital as a case of typhus. He had an abundant, bright papular eruption, low muttering deliri- um, and diarrhoea. I thought it best to isolate him. Two days after his admission, the papules quickly gave place to a profuse petechial eruption. Autopsy showed no ulcera- tion of Peyer's patches. In this connection it is of inter- est to note, that the first cases of typhus to attract atten- tion in New York, after an interval of several years of immunity from the disease, were supposed to be cases of typhoid. The patients, four adults, all members of one tenement-house family, were received at Riverside Hos- pital in September, 1880. Isolation of the cases was ad- vised by Dr. E. G. Janeway, who was asked to see the cases after their admission. One of the four, aged fifty- five, died. The autopsy was negative as regards typhoid fever. Twenty days from the date of the admission of these cases, one of the hospital nurses was taken ill with well-marked typhus. One case of scarlet fever, showing punctate haemorrhages, was received with the diagnosis of typhus. On the other hand, 10 of typhus were received as cases of scarlet fever, from an institution in which the latter disease had recently existed. The patients were children. The eruption in each instance was scant, and it had been preceded, and was accompanied, by an ery- thema, not general, but in patches, especially bright on the forearms. Cerebro-spinal meningitis was the first di- agnosis in a case of typhus in a young girl. The cerebral symptoms of acute alcoholism are sufficiently like those of the earlier stages of typhus to account for the mistakes in the six instances recorded. The facies of pneumonia and of typhus often bear a close resemblance. I have known acute ulcerative endocarditis to be twice mistaken for typhus. One of the cases is narrated in Dr. Mott's paper ; the other occurred recently in the service of Dr. Priest. In each there was slight delirium and a rise of a few degrees in the temperature. In the latter case there were scattered cutaneous haemorrhages, dark in color, corresponding in size with typhus macules, and many of them exhibiting a minute yellowish centre. The autopsy revealed advanced acute ulcerative endocarditis, splenic infarctions, and numerous subperitoneal haemorrhages, similar in size with those in the skin. A dirty, unhealthy, and pediculous condition of the skin was a factor which contributed largely to the diag- nostic errors. Prognosis.-Table I. shows that the rate of mortality among 735 cases, complicated and uncomplicated, was 24.08 per cent., which is a rate higher than usual. Mur- chison gives the rate, at the London Fever Hospital, as 18.92 per cent, for a total of 18,268 cases. At various other hospitals and infirmaries, throughout Great Britain, the mortality was 15.26 per cent, for a total of 41,403 cases. Age has a decided influence upon the mortality. In early childhood typhus is a comparatively trivial affec- tion. Not one of those under ten years of age at River- side Hospital died. Murchison's statistics would indicate that the disease is more fatal under ten than between ten and twenty. After adult life is reached the mortality progressively increases. The high death-rate at River- side Hospital is partially explained by the relatively large percentage of patients above the age of forty. The fatality is greater among males than among females. At the Lon- don Fever Hospital the mortality was about the same for each of the first seven months of the year, and was higher by three or four per cent, than for the last five. It is usual for the rate to diminish with the subsidence of an epidemic, but the opposite was true of the New York epi- demic. No new cases were received at the hospital after August (Table II.), excepting twenty children and one adult in October, yet the mortality for July was 47.27, and for August 53.33 per cent. In the New York epi- demic the combined effects of intemperance and destitu- tion were also largely operative in determining the high rate of mortality. The gravity of particular symptoms has been referred to in the clinical description. Morbid Anatomy.-The graver pathological appear- ances found in typhus are not in any sense distinctive. They are common to many infectious diseases. The re- suits of sixty-three autopsies made at Riverside Hospital in 1881 are here summarized. Rigor mortis was seldom marked or of long persistence. Emaciation in uncompli- cated cases was usually very slight. The face often, and the under surface of the body almost always, showed the common post-mortem livid discoloration. In those cases, in which the eruption had been abundant and petechial in life, traces of a fading eruption were discernible. Changes in the color of the voluntary muscles were not noticed. Murchison speaks of them as being " often of a dirty grayish-red hue," and showing under the microscope granular and waxy changes. Haemorrhage into the sub- stance of the rectus abdominalis was found twice ; of the internal oblique, once ; of the psoas magnus, once ; and once into the abdominal subcutaneous adipose tissue. The heart-fibre was often pale and soft ; granular and fatty changes were shown by the microscope. The blood was generally dark and fluid. Bronchitis, oedema, and hypostatic congestion of the lungs were very common. Pneumonia, as a complication, was met with three times; pleurisy four times. The pericardium often contained a bloody serum, and the amount of serous fluid was fre- quently increased. The same may be said of other serous cavities. If any lesion may be called characteristic of typhus it is the enlargement of the spleen. When death occurred within two weeks from the time of onset the spleen almost invariably was found increased in size. Its usual weight was eight or ten ounces, in one instance it was seventeen ounces, and in another twenty and one- half ounces. As a rule, there was a greatly diminished consistence of the organ, and sometimes the spleen pulp was reduced to a chocolate-colored diffluent mass, and all appearances of a trabecular framework lost. It not infrequently happened that the spleen was ruptured dur- ing its removal. The autopsies were in many cases made so soon after death as to preclude the possibility of post- mortem changes being the cause of the abnormal consist- ence. Numerous small haemorrhages and ecchymoses in the spleen-substance and on its surface were observed in some of the specimens. The dark color, which a fresh section presents, quickly changes to a bright red on ex- posure to the air. The kidneys in many instances were congested, and the cortex showed cloudy swelling. Oc- casionally the surface and the substance of the organ exhibited punctate haemorrhages. Congestion and fatty degeneration were occasionally noted in the liver. The lesions of typhoid fever were excluded in every instance. Occasionally Peyer's patches showed the shaven-beard appearance. In other respects, aside from a quite com- mon congestion, the intestinal tract was healthy. The mesenteric glands were normal. Now and then ecchy- moses were present on various parts of the peritoneum. In those cases in which the cranium and spinal canal were opened, an increase in the amount of serum, which at times was blood-stained, and an increased vascularity of the membranes and of the nervous tissue, were the only changes noticed. By some observers the cervical sympa- thetic glands have been found enlarged. The presence of micro-organisms in the blood has been spoken of under another section. The article there quoted also gives the results of the microscopical examination of the muscular substance of the heart. In the connective tissue, between the muscular fibres, there was a great increase of leuco- cytes ; " among the leucocytes in all six cases were plugs of micrococci, generally pretty uniform in size." They were individually somewhat larger than those of erysipe- las and diphtheria. The authors add that the micrococci were possibly ' ' merely the factors of incipient decom- position." Treatment. - The conditions, which are so well known to favor the propagation of typhus, naturally sug- gest the means to be employed for its prevention; and these are, chiefly, cleanliness and a plentiful supply of fresh air and good food, in addition to the speedy isola- tion of cases. The room which has been inhabited by a typhus patient, its belongings, and the clothing of the pa- tient, should be thoroughly aired and disinfected. Fresh air, in liberal amount, is also demanded, not only for the welfare of those in attendance upon the sick, but for the 100 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fever. Fibroma. sick themselves. Nothing -will contribute more to the pa- tient's comfort, and tend more to lessen the risk to others, than care in this regard. The question of ventilation in the treatment of typhus becomes, therefore, one of the greatest importance. During 1881-82 the cases at River- side Hospital were, with few exceptions, treated in tents, which are to be commended for their cleanliness and the ease with which they may be ventilated. The latter qualification does not obtain, however, unless certain precautions are observed in their construction. A hos- pital-tent should have high walls, and preferably should be of large dimensions ; one covering an area fifty by twenty-five feet is of convenient size. The walls should be so contrived that they may readily be rolled up, and the tent-ends that they may be thrown wide open. The fly should have its own ridge-pole, that a good air-space may exist between the two canvases. Holes may be made in the roof of the tent for additional ventilation. The medical treatment of typhus is essentially that of any other continued fever. It is not necessary to re- peat here what is given elsewhere. As yet no remedies have succeeded in shortening the duration of the disease. If it be proved that the disease is due to a micro-organ- ism, the discovery of a specific remedy may follow. Much, however, can be done to relieve symptoms and to sustain life till the dangerous period is passed. Of the various remedies which have been proposed for the pur- pose of neutralizing the typhus-poison, the dilute sul- phuric and hydrochloric acids have been most extensively employed. Murchison states that he has seen "marked improvement follow the commencement of the acid treat- ment at whatever stage of the disease it was tried." Flint found the mortality, among seventy cases treated without acids at Bellevue Hospital, to be twenty per cent.; the mortality among seventy-eight treated with di- lute sulphuric acid was 10.25 per cent. Acids were freely given in a series of cases at Riverside Hospital, but with- out any striking result. The reduction of the tempera- ture is most readily and agreeably affected by the system- atic use Qf cold water. The bath, sponging, the cold affusion, the rubber coil, and the wet pack, are the meth- ods in use. Any one of these, fully carried out, is effec- tive, though I believe the bath to be preferable. A seri- ous objection, but not an insurmountable one, is the inconvenience attending its use. The objections urged on account of the fatigue and excitement, alleged to be in- duced in the patient, do not hold good. The patient comes out of a bath with a clearer mind, a brighter and more intelligent expression, a better pidse, and a grateful sense of renewed strength. These effects are of incalcu- lable good. The temperature is but temporarily reduced, to be sure, but the bath may be given as frequently as need be. Unless the temperature rise above 103°, inter- ference is hardly necessary. The water in which the pa- tient is immersed may at first be tepid, and afterward cooled to any required degree. The susceptibilities of the patient must be the guide both as to the method and as to the degree of cold. When from any cause it is ad- visable not to make use of the bath, or the affusion, or the pack, frequent sponging may be substituted. The action of the water may be aided by quinine, but large and re- peated doses are necessary. Its effects are likewise tran- sient. I have never seen any great benefit come from its use. Murchison is of the opinion that, given at the stage of crisis, when the temperature is rising instead of fall- ing, it may save life. Other drugs used for the purpose of reducing temperature, have been found to have little efficacy. Alcohol must be the main reliance in those ex- treme cases characterized by great enfeeblement of the heart and the nervous phenomena of the typhoid state. It was required in unusually large amount among such cases at Riverside Hospital, owing partly, no doubt, to the previous intemperate habits of the patients. Twenty- four ounces, or more, of whiskey a day were not infre- quently given. Ordinarily a third, or a half, of this quantity would suffice. The quantity may be rapidly di- minished after the break in the temperature occurs. Fre- quently, when one form of alcohol is not tolerated, an- other may be. Occasionally recourse must be had to the lighter wines. To aid the action of alcohol, digitalis may be given with advantage. In addition to its tonic effect upon the heart, it is valuable as a diuretic. Diuresis is to be further promoted by the free drinking of water. Nourishment should be given regularly and generously. It may consist of such articles as milk, eggs, beef-tea, chicken-broth, and the like. Milk was the article of diet upon which my chief reliance was placed. One to two quarts a day were given. If it should be vomited, the addition of lime-water, or the use of peptonized milk, may meet the difficulty. In the less severe forms of the disease a more varied diet may be prescribed. There need be no fear that harm will be done by over-feeding during convalescence. Headache may be relieved by the use of the ice-cap, or the rubber coil. I have had better success, however, with drachm or two-drachm doses of the fluid extract of guarana. The result was almost al- ways very gratifying. In twenty minutes or half an hour after the administration of a single dose, a severe head- ache would entirely disappear. A good preparation of coffee might act as well. Morphine or chloral may be used to overcome the restlessness and sleeplessness. Bev- eridge 13 strongly objects to the use of the former drug, but, in the many cases in which I have used it, I have never known it to do harm. Occasionally, camphor may act admirably by allaying nervous excitement and pro- moting sleep. For the relief of diarrhoea the ordinary remedies suffice. Bismuth was most commonly used at Riverside Hospital. It was rarely necessary to resort to opium. The glandular swellings may often be success- fully treated in their earlier stages by the application of iodine. For cancrum oris I should strongly recommend the method of treatment originated by Dr. C. J. Mac- Guire,14 which consists in the cleansing of the parts with any disinfectant solution, and the thorough application of bismuth. My experience with this method is limited to two or three cases, occurring in scarlet fever and small- pox. In these it was successful. Dr. MacGuire had a series of twenty-four cases ; the first four were treated in the ordinary way and resulted fatally ; bismuth was used in the succeeding twenty, and all recovered. Frank IK. Chapin. 1 American Jour, of the Med. Sciences, February, 1837. 2 Quoted by Murchison. 3 Dr. Braum: Transactions of the Medical Society of New Jersey for 1881. 4 Austin Flint. 5 Dublin Jour. Med. Sci., vol. Ivi., 1873, and vol. Ixvii., 1879. 6 Med. and Surg. Hist, of the War of the Rebellion, Med. Vol., p. 637. 7 Outlines of the Chief Camp Diseases of the TJ. S. Armies, p. 153. 8 Printed in the U. S. Sanitary Commission's Memoirs, Med. Vol., p. 600. » Idem, p. 643. 10 The Relations of Minute Organisms to Certain Specific Diseases. Brit. Med. Jour., vol. ii., for 1881, pp. 279-281. 11 Brit. Med. Jour., 1883, vol. ii., pp. 1058-1060. 12 Vide The Diagnosis of Typhus Fever, by the late Dr. A. R. Mott, Jr., American Journal of the Medical Sciences, April, 1884. 13 Quain's Dictionary of Medicine. 14 Medical Record, New York, February 3, 1883. FIBROMA. The fibroma is a tumor whose chief mass is composed of connective tissue. Since a new formation of connective tissue is one of the most frequent patholog- ical processes which takes place in the body, it is often difficult to draw the line between mere hyperplasias of such tissue and true fibromas. Virchow has placed one of these diffuse hyperplasias of connective tissue, the ele- phantiasis Arabum, with the fibromas. This is a disease most often found in tropical countries, and is generally due to some obstruction of the lymphatics. It shows itself in an increase of all the connective tissue of a part, as a leg, penis, scrotum, etc., which often reaches enor- mous size. One might, however, equally well speak of an advanced interstitial nephritis as fibroma of the kidney. Surgeons have been long since agreed to separate all such processes from the true neoplasms which appeal- as more or less circumscribed growths. It is perhaps more difficult to differentiate the connec- tive-tissue hyperplasias in certain organs, due to chronic inflammation or syphilis, from true fibromas. In the testicle, for instance, we can have such a process advanc- ing until in places nothing of the original glandular tissue of the organ remains. Macroscopically, and even micro- 101 Fibroma. Fibroma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. scopically, such a testicle could scarcely be distinguished from a fibroma and it is possible that some of the few cases reported of fibroma of the testicle were really such hyperplasias. In the mamma we can have the whole breast changed into a firm, solid mass in consequence of this diffuse hyperplasia of the stroma. In most cases, however, we can distinguish such conditions from the true fibromas, as the latter are more or less circumscribed and separated from the glandular tissue. At times the microscopic diagnosis may be more difficult than the macroscopic. We may have any of the physiological types of con- nective tissue represented in the fibroma. They may very properly be divided into two chief divisions-the hard and soft fibromas. The soft correspond to the type of areolar tissue. They are generally round, aud may be divided into several lobes. On section a variable amount of clear, watery fluid escapes from the cut surface. This fluid, on examination, will be found to contain but few cellular elements, and is altogether different from the opaque, milky fluid, filled with cells, which can be ex- pressed from the malignant tumors. Sometimes the con- nective tissue takes the form of broad bands, which trav- erse the tumor in every direction ; in other cases no dis- tinct arrangement of the fibres can be made out. The cells seen between the soft and hard fibroma, aud frequently both sorts of tissue are found in the same tumor (Fig. 1171). Some of the fibromas are much richer iu cells than others. In the same tumor places may be found which are made up exclusively of spindle-cells, and gradations from such tissue to that of the ordinary tendon. Such tumors represent the transition steps between the fibroma and sarcoma, and are known as fibro-sarcomas. Both the Fig. 1172.-Fibro-Sarcoma of the Upper Jaw. The connective tissue contains more cells than does that represented in Fig. 1171; in some places it has an embryonic character. X 75. fibroma and sarcoma are connective-tissue tumors, and only differ in the types of the connective tissue which they respectively represent; the sarcomas being formed of such connective tissue as is found in the embryo. In the soft fibromas elastic fibres are frequently found, in some cases being so abundant as to form almost the chief mass of the tumor. A special name has been proposed for such growths, but little would be gained by its adop- tion. In all sorts of fibromas, but especially in the soft, we often find places where the tissue is infiltrated with small, round, granulation-cells, this being most probably due to inflammatory processes which have taken place in the tumor. Much confusion has been caused by grouping under the fibromas tumors composed of other sorts of tissue. Fig. 1171.-Section of a Fibroma of the Ovary. The tumor is dense and compact; the cells are few in number; in several places on the section bands are seen in which the cells are more abundant. X 75. generally conform to the type of fully-formed connective- tissue corpuscles. They are small, spindle-shaped, and contain a long rod-shaped nucleus. Mixed with these will be found others which are larger, rounder, and pro- vided with several processes. The large granular plasma- cells, described by Ehrlich, are seldom missed. These cells have the peculiarity that their granular contents stain more deeply, with certain of the analine staining re- agents, than does the nucleus. These soft fibromas are much more common than the hard, and it may be said, in general, that they compose the majority of the fibromas seated in the subcutaneous or submucous tissue. The hard fibromas are most often found in internal parts, as along the course of the nerves, and on the periosteum. They are composed of tissue which has its physiological type in the connective tissue of the tendon. They are hard, firm, and elastic to the touch, and they often cut with a creaking sound similar to cartilage. Their cut surface is smooth and glistening. Little or no fluid es- capes on section, and on scraping them with a knife, noth- ing but a few fibres come away. The connective tissue is arranged in the form of firm bands, and these some- times form concentric nodules. The cells are spindle- shaped, small, aud few in number. Every gradation is Fig. 1173.-Fibroma Molluscum. (Virchow.) The ordinary myoma of the uterus was formerly consid- ered a fibroma, and, indeed, was taken as the type of the hard variety. Even now gynaecologists are accustomed to speak of such growths as fibromas, although they are entirely composed of the smooth muscular fibres of the uterus. In the same way, the tumors composed of con- nective tissue which develop along the course of the nerves were generally spoken of as neuromas. The 102 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fibroma, Fibroma. true fibroma of the uterus is fully as rare a tumor as the neuroma. When the fibromas are seated beneath the skin and submucous tissue, they always follow the line of least re- sistance in their growth, and push before them the tissue which covers them. Often they become distinctly poly- poid. This is best seen in the fibromas of the skin, the fibroma molluscum of Virchow. These tumors develop in the loose subcutaneous areolar tissue, most frequently about the face and back. They are so soft that they may give the feeling of fluctuation. Generally they are round, dependent, and attached to the skin by a thin peduncle. Sometimes they are broad, and when they become de- pendent, from their weight, they arc attached by a broad fold of tlie skin. Such tumors have been designated un- der the name of cutis pendula. These fibromas of the skin are frequently multiple-the whole body may, indeed, be covered with them-and they often attain enormous dimensions. Virchow mentions one that weighed thirty- two and a half pounds, and Dardel has seen one of sixteen pounds. In the mucous membranes, tumors analogous to these may be found, especially in the nasal cavities. These have not a tendency to multiple appearance. The pure fibromas have generally but few blood-ves- sels, and but little*blood escapes from them on section. In some localities, especially the so-called fibrous polypi of the nose, they have a very abundant supply of both arteries and veins, and their extirpation may give rise to considerable haemorrhage. We find, also, in some cases, large sinuses filled with venous blood, which communi- cate freely with each other. Such tumors are known as angio-fibromas, and represent the intermediate grade lead- ing to the true cavernous tumor. Nothing is known as to the presence of lymphatic vessels in fibromas. It is most probable that they are present, especially in the soft varieties. When the connective tissue in the lymph-an- giomas is abundantly developed, we would be justified in calling such a tumor a lymph-angio-fibroma. Nerves are only found in fibromas when the tumor develops in the sheath of the nerves, which then become enclosed in the tumor. Often the fibroma is surrounded by a capsule, formed of a tissue thicker and denser than the tissue of the tumor, which separates it sharply from the surrounding tissues. Others are not so well differentiated, and bands of tissue pass from the tumor into the surrounding tissues. The total extirpation of such a tumor is difficult, and at times almost impossible. Even in those which appear as polypi, bands of fibres from the peduncle may penetrate deeply into the tissues. The most frequent seat of fibromas is the subcutaneous and submucous cellular tissue. As has been said, these are most often of the soft variety, and generally take the polypoid form. Their next most frequent place of ap- pearance is along the course of the nerves, developing from their sheaths. They form hard, spindle-shaped masses, and by the pressure which they exert may give rise to the most intense pain. They are frequently found multiple along a single nerve ; or the nerves of an ex- tremity, or even of the whole body, may be invaded by them. In one case I saw more than twenty such tumors, in size varying from a small pea up to that of a walnut, along the nerves of the forearm. They are frequently found as small, firm masses in the nerves which compose the cauda equina. In the periosteum they are also frequent, and here, as might be supposed, they are always associated with a new formation of bone. This osseous formation may assume greater proportions than the formation of fibrous tissue. A new formation of bone may take place in fibromas developing in other places than on the peri- osteum, but such an occurrence is rare. These periosteal fibromas form hard, firm masses, which may be mistaken both for enchondroma and osteoma. In the mamma the fibroma appears both as a firm, circumscribed tumor, with a well-marked capsule, and as a more diffuse growth. The latter form, as said, can hardly be differentiated from the fibrous induration due to chronic inflammation. In the larynx the fibroma is the most common tumor met with, next to the papilloma. They appear under the form of polypi, and are most frequently seated on the vocal chords or in the fossa of Morgagni. A curious form of fibroma is met with in the kidney. It appears as a pearly white, firm nodule, rarely larger than a small pea, and generally seated near the base of the pyramid. On section it appears more like a circumscribed interstitial nephritis than like a true tumor. The more or less al- tered urinary tubules traverse a mass of dense, firm con- nective tissue. Irritation is very often assigned as the causative mo- ment in the production of fibromas. As alleged instances of this are the fibromas of the lobe of the ear, due to the wearing of ear-rings, and their development in the prae- patellar bursa in persons whose occupation causes them frequently to kneel. They are, however, met with in both these places in persons in whom such a cause does not exist. Age seems to have no great influence on their production. They may be met with in any age, but it can be given as a general rule that old age does not favor their formation. They may appear at a very early age, or even be congenital. In the mamma they are most often found at the time of life when myomas of the ute- rus are most frequent-that is, between thirty and forty years ; they are as common in the mammae of virgins as in those of married women-a fact that does not speak much in favor of an origin dependent on irritation. In many cases, as in the fibroma molluscum of the skin and the multiple fibromas on nerve-sheaths, we must suppose that the tumor-formation depends on a special disposition of a particular tissue. Fibromas are frequently combined with other tumors which originate in the connective tissues. The most com- Fig. 1174.-Cross-Section of a Cysto-Fibroma of the Mamma. mon mixed form is with the sarcoma. Another combina- tion frequently met with is the myxo-fibroma. Here the cells have not the typical spindle-shape, but are more or less branched, and lie in a soft mucous-like matrix. We find, indeed, the myxoma much more often in combina- tion with fibroma than pure. Degenerations of all kinds are common. The most fre- quent form is the mucous degeneration, which leads to the formation of large cysts filled with a thick, viscid fluid. This process commences with an increase in the number of cells and a mucous degeneration of the intercellular substance, which becomes softened and fluid. The cells which lie in the part affected are destroyed. This form of degeneration can be confounded with an oedematous infiltration of the tumor which depends upon circulatory disturbances within the tumor, and can give to it the same gelatinous appearance seen in oedematous infiltra- tion of the skin. Both fatty degeneration and calcifica- tion are seen. The former leads to a softening of the whole tumor ; the latter appears first in small circum- scribed areas of the tumor, and can involve a large part of its mass. The capsule of the tumor may be in great part calcified. Ossification is very common in the fibro- mas which develop from the periosteum, and is sometimes met with in those which develop in other parts. Cysts are also found in these tumors which arise from causes other than degenerative processes. In fibromas of secreting glands, particularly in the mamma, portions of the milk-ducts may be cut off by the tumor, and in this way cysts are formed. The tumor then grows into the cyst in the form of polypus-like masses, pushing the se- creting epithelium before it. There is nearly always some new formation of epithelium due to the irritation, and in this way the most complicated histological appear- 103 Fibroma. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ances are produced. On section such a tumor usually shows certain clefts or irregular fissures, with here and there a small cyst. The whole tumor may, indeed, grow into such a cyst, and when this is opened appear as a large irregular polypus. In most cases these cysts are small, and their contents often become calcified. The growth of the pure fibroma is slow and constant. There seems to be no limit to the size which they may attain ; they produce the larg- est tumors known, and it is not uncommon to meet ■with them weighing fifteen to twen- ty-five pounds. One that I have lately seen, seated on the anterior abdominal walls of an o 1 d negress, where it had been growing steadily for thelast twenty years, would probably weigh thirty pounds if re- moved. They are not generally infectious to the surrounding tis- sues, and do not exert any other influence on them than that pro- duced by pressure. Such pressure can lead to very serious consequences when important parts are concerned. Thus, the fibrous polypi of the nasal cavities may press the bones of the face apart, leading to the characteristic frog-face. When they are seated on the nerve-sheaths, their pressure can cause in- tense suffering. The skin covering them may become thin, and, being more subjected to traumatic influences on account of its elevation above other parts, ulceration may result. The fibromas are dense tumors ; they are poor in cells, and their cells are intimately connected with their formed the other tissues. Luecke gives it as a general rule that when the operation is a complete one there will be no re- turn. It is probable that in some of the cases in which a return after operation was observed the tumor was not a simple fibroma, but a combination with sarcoma. Some few cases have been reported where a metastasis in internal organs took place. Virchow mentions a case in which secondary tumors were found in the mesentery and omentum, the primary tumor being an immense fi- broma of the uterus. Other cases of metastasis in the lungs are reported. There seems to be no tumor which may not under circumstances become malignant. One form of fibroma differs so much from the others as almost to deserve a special place. This is the keloid. So many different things have been understood under this name, that Billroth has proposed to give it up alto- gether. Luecke defines the keloid as a fibroma of the skin which appears under the form of a growing cicatrix. But, besides this, some forms of hypertrophic true cica- trices, which differ from ordinary cicatrices by their tendency to return after extirpation, have been classed with the keloids, and are known as cicatricial keloids. The others are known as spontaneous keloids. Often wounds, instead of cicatrizing in the ordinary manner, form an elevated band-like cicatrix which may be due to irritation of the wound or to various other causes. In most cases these hypertrophic cicatrices disappear spon- taneously in the course of time. In other cases a simple extirpation of the cicatrix suffices. But there are some cases in which a firm, dense tumor develops in the cica- trix. This tumor may remain as a flattened band, or from its weight may become dependent and polypoid. In such cases the skin over the tumor is white, smooth, and de- pressed in places. Histologically, such tumors are very rich in cells when they are young and growing rapidly. Later they are composed of dense tendinous connective tissue. When extirpated they have a tendency to return in the same place. Their place of development is not in the subcutaneous tissues, but in the fibrous tissue of the true skin, and they send in deep prolongations into the tissue beneath. They are thus rendered fixed and rigid, unlike the fibroma molluscum, which develops in the sub- cutaneous cellular tissue, and their complete extirpation is very difficult. They are more apt to form in the cica- trices which result from burns than in those which de- velop from other wounds. It has been remarked that they are more common in individuals who are the sub- jects of a special diathesis, as the scrofulous or syphilitic. The spontaneous or true keloid develops without a trauma. It appears most often in tropical climates, and gives rise to severe itching in stormy weather. It con- sists of dense connective tissue. Like the cicatricial ke- loid, it has the most pronounced tendency to return after removal, which is also due to the difficulty of complete extirpation. We know nothing about its etiology. It differs from all other fibromas in the similarity of its structure to that of a hypertrophic cicatrix. In the case Of the cicatricial keloid it is possible that the disposition to tumor-formation exists in the skin. This may be mani- fested in a weakening of the physiological resistance of the tissues toward the growing cicatrix, or in a disposition of the connective tissue to take on this special sort of growth. In some cases the diagnosis of a fibroma is very easily made. In the hard, firm circumscribed fibromas of the bone, the periosteum and the fascia, we find as diagnostic signs the firmness, the homogeneous consistence, and the non-implication of the skin. The slowness of growth will serve to distinguish the fibroma from the fibro-sarcoma and the sarcomas in general. Freedom from pain, except where they are so situated as to cause this from pressure, will distinguish them from scirrhous carcinoma. The soft or the softened fibromas can easily be confounded with fatty tumors or cysts. It is in differentiating a fibroma from fibroid induration of glands that a mistake in diag- nosis can most easily be made. In this case the most im- portant aid in a differential diagnosis is to be found in the previous history, which would in the fibroid induration show the previous existence of inflammatory processes. Microscopically, in such cases a mistake could arise more Fig. 1175.-Some of the Papillary Growths which Projected into One of the Cysts of a Cysto-Fibroma. (Cornil and Ran- vier.) Highly magnified. Fig. 1176.-Section of a Spontaneous Keloid from the Ear of a Young Negro. X 75. tissue. From this we should not expect them to produce metastases, and indeed fibromas have in general been con- sidered the most benign tumors. Cases, however, have been frequently known where they have returned after extirpation. This seems mostly to be due to the incom- pleteness of the operation, which is often rendered diffi- cult by the fibrous bands of the tumor reaching out into 104 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fibroma. Field Surgeon*. easily, if anything, than it should macroscopically. A mistake in the microscopic diagnosis could also be made in scirrhous carcinoma, where the epithelial growth was a very limited one. IF. T. Councilman. keepers who have the rank of captain. One hundred and fifty hospital stewards are also enlisted for duty. The medical staff then consists of 192 commissioned offi- cers (excluding storekeepers, who are temporary officers). Proportion The strength of the United States army, by of surgeons the last register, is 28,436, being 40 regiments to army. and one battalion. This gives a medical offi- cer to 148 men, or about 4| to a regiment. Of the 192 medical officers, at last advices, 23 were as- signed to executive or administrative duties; 8 were on duty in cities ; 2 were on duty at the Military Academy, and 1 at the Military Prison, leaving 158 for duty with regiments. From these 158 were absent 10 sick and 4 on ordinary leave of absence, leaving 144 for duty with regi- ments, or about 3? per regiment. Although the medical corps of the United States army is proportionately large, it is not too large. In the first place, the army of the United States is greatly subdivided, serving at separate points in regimental fragments. In the second place, theoretically, the regular army of the United States is but the nucleus for the volunteers or militia forming the main protection of the country in war. So the regular medical officers in time of war would be available for, and assigned to, the higher administrative duties, the knowledge of which they have specially ac- quired. None of them belong to regiments, though all liable to regimental duty. Vacancies occurring in the grades below the surgeon- general are filled by promotion of the senior of the grade next below. The lowest grade, of assistant surgeon, is filled by competitive examination. The highest grade, of surgeon-general, by selection from the whole corps. During the Revolutionary War, the number of regi- mental medical officers varied at different epochs, from one surgeon and one mate to one surgeon and four mates. During the Mexican War, to each regiment of volun- teers raised in 1846 were allowed one surgeon and one assistant surgeon ; which number was increased by an ad- ditional assistant surgeon to the regiments raised in 1847. At the commencement of the great war between the North and the South, but one medical officer, an assist- ant surgeon, wras allowed to a regiment; at the end of three weeks one surgeon was added, and this number proving insufficient, Congress, in 1862, authorized to each regiment of volunteers one surgeon and two assistants. This number of medical officers is greater than is needed to give merely professional attendance to a regiment serving together. But in point of fact, regiments are liable to be divided ; companies or detachments requiring medical attendance are separated from the main body, while medical officers themselves are liable to sickness, are sometimes absent on leave, may be assigned to a dis- tant hospital, or sent away from the regiment on any duty requiring professional knowledge and skill. Considering, then, all the circumstances, including the experience of our own and foreign armies, we affirm that the proper number of medical officers to a regiment, as now organized, is one surgeon and two assistant surgeons. II. Duties of Regimental Medical Officers.-The regimental medical officers are supposed to have been with the regiment from its organization, to be from the same region of country as the troops composing the regiment, and, therefore, to be more or less familiar with the physique and morale of the individual soldiers. Physical Examination.-Soldiers on a campaign must possess bodily vigor. The first duty of the sur geon, therefore, in point of time, is to examine each recruit or soldier as to physical ability, and reject those unfit to bear arms on account of physical disability. Little argument seems needed to show the necessity of this physical examination, but the statement of a fact or two will illustrate such necessity. During the war between the United States and Mexi- co, the volunteer forces lost in battle and from wounds, in proportion to numbers, but one- sixth as many as the regular army. Exclusive of those losses, and discharges by expiration of term of service, the regular army FIELD SURGEONS, DUTIES OF, IN TIME OF WAR. yEsculapius, the god of the healing art, was the first mil- itary surgeon of whom I find record. He accompanied Jason and the Argonauts on the expedition to Colchis. He is said to have been of a " quick and lively genius." It is not necessary for every modern military surgeon to be of " quick and lively genius," but the successful discharge of his higher duties requires application, knowl- edge, and sound judgment. In the following account of the duties of the military surgeon in field or campaign, rhetorical flourish will be scarce, but dry, practical details will not be wanting. The general principles enunciated are of course com- mon to the armies of all nations ; but certain details (such as the list of supplies allowed, etc.) refer more particularly to the army of the United States, and are in accordance with the experience gained in their campaigns. It is believed that they may advantageously be applied in all armies. I. Organization of Army Medical Department.- To facilitate the discharge of his duties and increase his efficiency, the military surgeon receives military rank- in some armies relative rank only ; in others (of which that of the United States is one), positive rank. All military experience has proved this to be neces- sary in securing to the surgeon the obedience and respect of his inferiors, and in placing him on an equality with his brother officers. In different armies different rank is given to medical officers, from that of major-general down. In the army of the United States the medical offi- cer of highest rank is a brigadier-general; of lowest rank, a first lieutenant. The duties of the military surgeon vary according to his rank and position. Some medical officers are attached to regiments as permanent regimental officers, and others be- long to the general staff, with duties largely administrative. Occasionally regimental medical officers are assigned to staff duties, and staff medical officers are assigned to reg- iments. The regimental medical officers are surgeons and assistant surgeons. The staff medical officers serve in different armies under different names. In the United States army the ranking surgeon of a brigade is styled " brigade surgeon of a di- vision, the " chief medical officer ; " of an army corps, or army, or military department, the "medical director." Some are assigned to duty as "medical inspectors," and "medical purveyors," while some, both staff and regi- mental medical officers, are assigned to duty in hospitals, hospital surgeons. In the United States volunteers, one surgeon with the rank of major, and two assistant sur- geons with the rank of first lieutenant, are al- lowed to each regiment of ten companies. The first organization of troops in this country, in 1775, comprised regimental surgeons and surgeon's mates. To these were soon added (1) hospital surgeons and mates, and (2) post or garrison surgeons and mates. In the beginning of 1815 the hospital department of the army comprised a physician and surgeon- general, purveying officers, hospital and garrison surgeons and mates, and hospital stewards; while regimental or- ganizations included regimental surgeons and mates. After several reorganizations, in 1821 regimental sur- geons and mates disappeared from the regular army, whose medical department was organized substantially as at present. It now consists of a surgeon-general who has the rank of a brigadier-general, of an assistant sur- geon-general, a chief medical purveyor, and four sur- geons with the rank of colonel, eight surgeons and two assistant medical purveyors with the rank of lieutenant- colonel, fifty surgeons with the rank of major, one hun- dred and twenty-five assistant surgeons with the rank of first lieutenant during the first five years of service and the rank of captain thereafter, and three medical store- General principles common to all armies. Rank. Titles of staff sur- geons. Regimen- t a 1 s ur- geons and assistants. Regi- mental medical officers, duties of. In 1815. Physical exami na- tion of re- cruits. Facts and figures fr o m w a r with Mexi- co. 105 Field Surgeons. Field Surgeons, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lost proportionately but about two-thirds as many as the volunteers. These latter losses represent deaths by dis- ease and discharges for disability. The soldiers of the regular army had been examined and the physically un- sound eliminated ; the volunteers, not. In the war between the North and South, 1861-65, the regular army lost by violent death an annual ratio of 27 per 1,000 of strength ; by death from disease an annual ratio of 32 per 1,000. The white volunteer forces lost by violent death an annual ratio of 33 per 1,000 ; by death from dis- ease an annual ratio of 55 per 1,000; that is to say, the volunteer forces died from disease in a ratio almost twice as great as the regulars. During this same war the regulars lost an annual ratio of 68 per 1,000 by discharges on surgeon's certificate of disability ; the volunteers, in the same way, 91 per 1,000. The great disproportion in these ratios of regular and volunteer losses, respectively, was due to the same fact as before stated in reference to similar differences occurring during the Mexican war ; the regulars were examined and selected ; the volunteers, not. The first medical director of the army of the Poto- mac, in his report of the first battle of Bull Run, in 1861, says : " I found the army with which we were to meet the enemy composed of fhe best, and also of the worst, material I had ever met with. This force had been hastily collected ; many of the men had never been examined by medical officers, and were inferior to those in the reg- ular army, where the physical defects are more carefully regarded." The State, indeed, has recognized the importance of such examination, and in August, 1861, the War Depart- ment had issued orders that volunteers should be physi- cally examined by the medical officer before muster in. But it is equally true that the examinations made were in the majority of instances perfunctory in their nature. Officers desired their regiments filled, because they re- ceived no commissions, and consequent pay, until a certain number of soldiers were enrolled in their regiment ; and while patriotism incited many to conceal their infirmities, that they might not be prevented from serving their coun- try, many others did their best to deceive the surgeon and secure muster in, from selfish motives-more partic- ularly the hope of large bounties. Surgeon Tripier reported that in October, November, and December, 3,939 men were discharged for disability from the one army of the Potomac, and that in 2,881 of these cases the disability existed at the time of enlistment. "It seemed," says Surgeon Tripier, "as if the army called out to defend the life of the nation had been made use of as a grand eleemosynary institution for the recep- tion of the aged and infirm, the blind, the lame, and the deaf, where they might be housed, fed, paid, clothed, and pensioned, and their townships relieved of the burden of their support." Candidates for the service should be examined stripped. Different countries have prescribed differing extremes of age between which a soldier may chlist. In the army of the United States, at present, youths from sixteen to eighteen may be enlisted as musicians only ; but above eighteen and under thirty- five for all duty. Experience has demonstrated to the author that these limits should be changed. Youths under twenty should for not be enlisted, except when their physical de- velopment is above the average. A very large proportion of such youths succumb to the hardships of a campaign. On the other hand, men from thirty-five to forty-five arq well able to undergo physical fatigue and deprivation, particularly those men who have passed the required physical examination. Examining surgeons are required to see that the can- didate "has free use of all his limbs; that his chest is ample ; that his hearing, vision, and speech are perfect ; that he has no tumors, or ulcer- ated or extensively cicatrized legs ; no rupt- ure or chronic cutaneous affection; that he has not received any contusion or wound of the head that may impair Ins faculties; that he is not a drunkard ; is not subject to convulsions; and has no infectious disorder, nor any other that may unfit him for military service." Generally the surgeon should examine for, and reject on account of, all physical imperfections impairing bodily effi- ciency, and all diatheses or hereditary states implying a like- lihood of disease. Mental incapacity of course disqualifies. Medical officers, however, are seldom left entirely de- pendent on their own judgment (often untried) in this matter. In many armies competent authority has issued from time to time lists of disqualifying infirmities. Such list is an authoritative guide to the surgeon. A list of disqualifications for military service in the army of the United States will be found in a previous article in this work, under the heading of Examination of Recruits. In the opinion of the author of this paper that list is open to the criticism of somewhat erring on the side of over-refinement. This is an error on the right side, for the examining surgeon must always remember that the evils resulting from a large ratio of sick are not confined to the filling of the hospitals, whose number and size, in an army composed of ideally sound men, should be calculated mainly for the wounded. Not only is the army absolutely weakened, but it is weakened in such a way as to interfere with and prevent its process of repair. The places of those killed in battle or dead from diseases may be promptly filled with recruits ; but those absent in hospital with chronic disabilities fill with their names the muster-roll of their regiment, and their places in the ranks cannot be supplied so long as they remain sick and in the service. In view, then, of the great disadvantages entailed upon an army in campaign by the presence of the sick and dis- abled, the importance of a rigorous examination of all candidates before enlistment or muster in, and of their rejection if physically unsound, cannot be too greatly emphasized. Examination and Disposition of the Sick.-The next duty of the surgeon, in point of time, should be the pres- ervation of the health of the well. But, as in every gath- ering of men some are very speedily taken sick, and require professional care and atten- tion, the second duty here considered will be the best mode of caring for the sick and wounded of the command, and the mode of procuring supplies of all kinds needed for their proper care, not neglecting to indi- cate the supplies needed. Therapeutics are abstractly the same in military or civil life. The military surgeon cannot have at his disposal, in the field, the whole armamentarium of his profession ; but he has sufficient. The absolute control of his patients which he possesses is in his favor. The surgeon and his sick are put in communication by a mechanism simple but systematic. Each morning, soldiers in each company who affirm that they are sick are gathered to- gether at a fixed and convenient time and place, previously announced to all concerned, and thence are conducted to the surgeon ; those who during the intermediate time are taken sick, are at once taken to the surgeon. The surgeon examines them. Those whom he considers sufficiently well to perform duty he so marks, in the company book in which the names arc recorded. Those whom he considers fit for some duty, but unfit for other, he marks accordingly. Those whom he considers fit for no duty he so marks, and places their names on his sick report, to be admitted into hospital or treated in quarters, as he deems proper. On the march he excuses from marching those unable to do so, and per- mits them to ride. All belonging to the foregoing cate- gories the surgeon prescribes for, or not, as he judges best, and in regard to them all, the decision of the sur- geon habitually is final, as recorded by him in the com- pany sick-book. The sick admitted to hospital are en- tirely under the control of the surgeon, whose prescrip- tions are filled by the hospital steward. The final disposition of the sick is as follows : Firstly, they are cured and return to duty. The surgeon orders them back to their command so soon as he thinks them able to perform their duty. Figures and facts from war of 1861-65. Care of sick, p r o- curing supplies. Sick, mode of deci ding about. Mode of examina- tion Age enlistment. Disquali- fications for a soldier. Sick, their disposition. 106 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Secondly, they die. Should this occur, the surgeon at once reports the fact to the quartermaster, who furnishes a coffin and prepares a grave ; and to the military com- mander, who furnishes an escort and buries the corpse. Thirdly, they are transferred elsewhere. Certain cases, for climatic or other reasons, fail to respond to the sur- geon's efforts. They neither die nor recover, but bid fair to profit by change of air and scene. Such cases the surgeon reports to the medical director. Besides the hos- pitals with the army, other general hospitals are estab- lished at suitable places more or less distant. To these, the regimental and other hospitals with the army are intermediary and feeders. The trans- fer of the sick to these hospitals is a delicate problem. Many sick and wounded, who from nostalgia or climatic causes fail promptly to convalesce, should be sent to other localities nearer home. But there is a class not so meritorious-malingerers, whose home- sickness is not a disease but a pretence, feigned for the purpose of escaping the dangers and hardships of the service. The surgeon must not be cajoled by these. They seek to leave the army with the purpose of never returning. As chronic pretenders, or as hangers-on in some capacity in home hospitals, they hope to, and often succeed, in remaining absent from the front. Unless ul- timate harm to the invalid will result therefrom, com- manders of armies desire that their sick and wounded be cared for within the limits of their armies, because they are more subject to control of such commander ; further, the removal of the sick from the field of active operations will liberate a certain number of men from their care, as while the nurses and attendants of the base hospitals may be unconnected with the army, those of the hospitals with the operating army must, almost of necessity, be drawn from the fighters. The surgeon's duty in the premises is clear. He must remember that the mere concentration of large numbers of sick and wounded tends to generate pestilence ; and on this account, and because hospital accommodations are better and more abundant elsewhere, he must often send elsewhere for treatment cases that otherwise require no change. In all events, the sick and wounded whose re- covery will probably be greatly hastened by a change, and those whose lives will be jeopardized by a stay, must be selected by the surgeon and promptly transferred to the base hospitals. Fourthly, they are furloughed. A certain proportion of patients take advantage of their enforced abstinence from duty to visit their homes and families; and certain others, by the advice of the surgeon, and as a therapeu- tical measure, do the same. These patients receive from military authority permission to absent themselves, on the recommendation of their attending surgeon. Fifthly, they are discharged from the military service on account of disability. There is a class of patients who have recovered as far as they can recover, probably, and still are unfit for duty ; such are the maimed by loss of limb or sight. These, with such as bid fair to recover only at a period so remote that it will be more to the Gov- ernment's interest to lose than to keep them, should be discharged from the service. Generally men of these classes are entitled to a pension. Sixthly, they desert. Occasionally a soldier under treatment deserts. These men require from the surgeon no notice, save to duly report their case. Seventhly, they are discharged from the service for. other cause than disability. Rarely, a soldier's term of service expires while on sick report, or he is discharged because a minor or something else. These cases are kept under the care of the surgeon until they recover or die, or opportunity occurs for them to go elsewhere. Supplies for the Sick.-The surgeon, having found his Supplies patients, must provide for their wants; food, for the sick, shelter, and medical supplies are the principal articles which the surgeon must find for his patients. Food.-A few articles of special diet are supplied by the Medical Department, and will be enumerated in their list of supplies ; but the bulk of the food for the soldier is issued by the Subsistence Department on a requisition, which is merely a blank form, filled in with the date, the number for whom food is required, and the articles and amount of food desired. This is signed by the surgeon. The soldier's ration is fixed by law, and will be described further on. It is the same for sick and well. Manifestly, the rations of a well man must be too much for a sick man, and some of the articles of diet of a well man cannot be eaten by the invalid at all. These superfluous amounts and articles are sold by the surgeon, and the receipts therefrom, called the hospital fund, are disbursed for the benefit of the sick. These three sources -the hospital supplies, the soldier's ration, and the hospi- tal fund-furnish for the sick an abundant and varied nourishment. Shelter.-The shelter which the surgeon obtains for his patient is the hospital. A regimental hospital, in its sim- plest form, consists of one or more tents with the necessary furniture, the tools for housekeeping, and the personnel necessary for its internal administra- tion. The personnel comprises, besides the necessary medical officers, the hospital steward, the cooks, and the nurses. The authorized number of hospital stewards has been before stated. He is a sort of major-domo. He superintends the hospital administration, and dispenses medicines, and is of so much value, and of so high qualifications, that he deserves a better pay and position than he enjoys in any army. For cooks and nurses both civilians and soldiers have been tried. In the writer's opinion the soldier cook and nurse are the best. They can be better con- trolled. They are selected from the soldiers of the command by the senior medical officer. Two cooks and ten nurses are the number allowed to a regiment. The hospital tent is of strong canvas and covered by a fly, which is simply a separate roof of canvas also. Its dimensions are 14 x 15 feet, with a height of 11 feet along the ridge pole, and sloping down to 44 feet at the sides. It is intended for 8 or 10 pa- tients. It has an opening at each end, vertical, and a lapel on one end by means of which several tents may be joined, end to end, with a continuous roof. Three hos- pital tents for patients are the prescribed allowance for a regiment, with one Sibley and one wedge tent for other purposes connected with the hospital. Where a larger supply, is needed, more can be had. Tents are obtained from the Quartermaster Department on requisition ; from the same department and in the same way the surgeon must procure what is known as camp and gar- rison equipage, comprising a spade, an axe, a pickaxe, a hatchet, a camp-kettle, and a mess-pan, and from the same source are procured, when needed, stoves, and hay and straw for bedding. It seems hardly necessary to say that in contingencies easily to be recognized the surgeon will take advantage, for hospital purposes, of houses in the neighborhood seized as a military necessity. But it will seldom be found that any building thus seized can equal, for hos- pital purposes, the hospital tent. In the treatment of his sick in these hospitals the mili- tary surgeon must apply the great universal principles which he has learned in civil life. Further remarks on hospitals are here dispensed with, as the subject will be fully treated in another part of this work by another writer. Medicines and Hospital Stores.-Medical and hospital supplies are procured from the medical purveyor on requi- sition, and fora longer or shorter period, accord- ing to the means of transportation or other ex- igencies of the service. The Supply Table of the Medical Department, on the following pages, contains a list of such supplies, and the quantities which experience has taught to be ordinarily needed. It does not pretend to indicate all things desirable, or that may be needed, but when not an infallible guide it is a valuable hint. The Regular Supply enumerates the standard articles to be habitually kept on hand ; the Supplementary List so en- larges the Regular Supply as to permit an indulgence of in- dividual preferences. The military surgeon is not obliged to obtain all articles on the list, nor is he restricted thereto. Sending the sick away from the army. Shelter. Hospital steward. Cooks and nurses. Hospital tent. Camp equi- page. Hospital and medical supplies. Food, how procured. 107 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Standard Supply Table of the Medical Department of the United States Army, Medicines.-Regular Supply: to be drawn annually unless otherwise directed. Allowance for Twelve Months. Allowance for Three Months. - - - - - - Articles. of one pany. of two panics. of four panics. of -six panies. of one ment. ral hos- l of 250 lundred in the Post com Post com Post com Post com Post regi Gene pita beds Five! men field • .-~ - - - Acacia (Gum Arabic), in 8-oz. bottles " (powdered), in 1-lb. bottles. . .oz. 8 8 16 24 32 96 . .oz. 16 16 48 48 64 96 is Acid, acetic, in 1-lb. bottles . .oz. 16 16 16 32 32 32 " carbolic (crystallized, pure), in 1-lb. g. s. bottles . .oz. 16 16 32 32 48 96 16 " '• 95 per cent, (for disinfection), in 1-lb. bottles " citric, in 1-lb. bottles ..lb. . .oz. 6 16 9 16 18 16 24 32 30 32 75 96 i6 " hydrochloric, in 1-l.b. g. s. bottles " nitric, in 8-oz. g. s. bottles " sulphuric, in 8-oz. g. s. bottles j . .oz. . .oz. 16 8 16 8 16 8 32 16 32 16 32 16 . .oz. 8 8 8 16 16 16 " aromatic, in 1-lb. g. s. bottles . oz. 16 16 16 16 16 32 16 " tannic, in 1 oz. bottles . .oz. 1 2 4 6 8 12 1 " tartaric (powdered), in 1-lb. bottles . .oz. 16 16 32 32 64 64 Alcohol, in 32-oz. bottles bott. 32 32 • 48 72 72 96 2 Alum, in 1-lb. bottles . .oz. 16 32 32 32 48 48 Ammonia, aromatic spirit of, in 1-lb. bottles ..oz. 16 16 48 64 64 96 16 " stronger water of, in 1-lb. g. s. bottles . .oz. 64 64 128 128 192 192 32 Ammonium, carbonate of, in 1-lb. bottles . .oz. 32 32 64 64 64 64 16 " chloride of, in 1-lb. bottles . .oz. 16 16 16 48 48 64 Arsenite of potassium, solution of (Fowler's solution), in 8-oz. bottles.oz. S 8 8 16 16 16 8 Atropine, sulphate of, in >«-oz. g. s. bottles . .oz. % X 64 W Bismuth, subnitrate of, in 1-lb. bottles . .oz. 16 16 16 32 64 16 Camphor (refined), in 8-oz. bottles . .oz. 32 32 64 96 128 96 8 Chalk, prepared, in 1-lb. bottles ... . .oz. 16 16 48 96 96 96 Chloroform, purified, in 1-lb. g. s. bottles . .oz. 64 64 128 192 192 224 128 Copaiba, in 1-lb. bottles .. oz. 64 64 96 112 144 96 Ether, compound spirit of (Hoffman's anodyne), in 1-lb. bottles.. . .oz. 16 16 16 32 32 64 " spirit of nitrous (sweet spirit of nitre), in 1-lb. bottles . .oz. 48 64 128 128 192 96 16 " stronger, for anaesthesia, in 1-lb. tins .... . .oz. 64 96 128 11)2 256 256 64 Extract of belladonna, alcoholic, in 1-oz. w. m. bottles . .oz. 2 2 2 4 4 4 1 " of buchu, fluid, in 1-lb. bottles . .oz. 32 32 64 96 128 64 " of ergot, fluid, in 8-oz. bottles . .oz. 8 8 16 16 24 32 8 ' ' of ginger, fluid, in 1-lb. bottles . .oz. 16 32 32 48 64 48 16 of hyoscyamus, alcoholic, in 1-oz. w. m. bottles .. oz. 2 2 4 4 6 8 " of ipecac, fluid, in 8-oz. bottles " of nux vomica (alcoholic, powdered), in 2-oz. bottles... . .oz. 8 8 8 16 24 32 8 . .oz. 2 2 2 2 2 4 " of valerian, fluid, in 1-lb. bottles Flaxseed, in 8-lb. tins . .oz. ...lb. 16 8 16 8 32 16 48 16 64 32 32 16 " meal, in 8-lb. tins ..lb. 24 32 48 72 96 96 Glycerin, in 1 -lb. bottles . .oz. 96 96 144 192 288 192 16 Glycyrrhiza, compound powder of, in 8-oz. bottles Iodine, in 1-oz. g. s. bottles . .oz. . .oz. 16 2 16 4 16 6 32 6 32 8 32 8 16 1 Iodoform, in 2 oz. bottles . .oz. 2 2 2 4 4 12 o Ipecac (powdered), in 8-oz. bottles . .oz. 8 8 16 16 16 32 " and opium, powder of (Dover's powder), in 1-lb. bottles... . .oz. 16 16 32 48 64 64 16 Iron, subsulphate of, in 2-oz. bottles . .oz. 2 2 4 4 4 6 2 " sulphate of (commercial), in 25-lb. wooden boxes... ..lb. 50 75 150 200 250 125 " syrup of iodide of, in 1-lb. bottles . .oz. 16 16 32 48 64 32 " and potassium, tartrate of, in 8-oz. bottles... . .oz. 8 8 16 16 16 8 " solution of tersulphate of, in 1-lb. bottles *... ..lb. 2 2 2 2 2 2 Lead, acetate of, in 1-lb. bottles 16 16 16 32 32 32 16 Magnesium, carbonate of, in 2-oz. papers . .oz. 8 16 32 40 48 48 " sulphate of, in 8-lb. tins ...lb. 16 32 48 64 3 96 64 ' 8 Mercury, corrosive chloride of (corrosive sublimate), in 1-oz. bottles.oz. 1 1 2 4 4 1 mass of (blue pill), in 8-oz. covered jars . .OZ. 8 8 16 24 32 32 8 " mild chloride of (calomel), in 4-oz. bottles " with chalk, in 4-oz. bottles . oz. . .oz. 4 4 4 4 4 4 8 8 8 8 8 8 4 Morphine, acetate of, in %-oz. bottles . .oz. M X % X " sulphate of, in J^-oz. bottles Mustard, black (ground), in 1-lb. tins . .oz. 1 1 2 3 4 2 1Z ..lb. 6 6 12 18 24 24 72 Oil, castor, in 1 quart bottles bott. 8 12 16 24 32 16 o " cod-liver, in 1-pint bottles bott. 12 16 24 32 40 48 " olive, in 1-pint bottles bott. 12 16 24 32 40 24 3 Oil of peppermint, in 4-oz. bottles . .oz. 4 8 12 16 16 8 4 " of turpentine, in 1-quart bottles bott. 6 8 12 16 24 12 1 Pepsin (lactated), in 2-oz. bottles . .oz. 4 4 8 8 12 12 2 Petrolatum, 105° F., in 1-lb. tins .. lb. 4 4 8 12 16 32 2 " 120° F.. in 1-lb. tins ..lb. 4 4 8 12 16 32 2 Pills, compound cathartic, in bottles ..No. 200 400 600 800 1000 600 400 Pills of camphor (grain two) and opium (grain one), in bottles ... .No. 200 " of mercury (green iodide of), (V6 gr. each), in bott. of 100 each.No. 200 200 300 400 500 200 100 " of opium (one gr. each), in bottles Plaster, blistering, in 1-yd. tins yds. 2 2 3 3 4 4 1 " mustard, in 4-yd. tins • yds. 4 4 8 8 12 12 12 Potassa, solution of, in 1-lb, bottles . .oz. 16 16 16 16 16 16 Potassium, acetate of, in 1-lb. bottles . .oz. 16 16 16 16 16 32 " bicarbonate of, in 1-lb. bottles . .oz. 32 32 48 64 64 32 " bitartrate of (powdered), in 1-lb. bottles " bichromate of, in 1-lb. bottles . .oz. . .oz. 16 16 16 16 32 16 32 32 32 32 48 32 " bromide of, in 1-lb. bottles 16 16 32 64 64 64 16 " chlorate of (powdered), in 1-lb. bottles . .oz. 32 32 48 64 96 96 16 " iodide of, in 1-lb. bottles . .oz. 48 64 112 208 224 112 16 " and sodium, tartrate of (powdered), in 1-lb. bottles. . .oz. 96 96 192 192 208 96 32 Quinine, sulphate of, in 1-oz. bottles . .oz. 24 36 60 72 88 100 20 Silver, nitrate of (in crystals), in 2-oz. bottles .. . .oz. 2 2 2 4 4 4 2 * The ingredients for preparing hydrated oxide of iron as an antidote for arsenical poisoning should always be kept on hand in bottles holding re- spectively about ten (10) troy ounces or three hundred (300) grammes of solution of tersulphate of iron, and about eight (8) troy ounces or two hun- dred and forty (240) grammes of water of ammonia. 108 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Medicines-Continued. Articles. Allowance for Twelve Month*. Allowance for Three Months. Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Silver, nitrate of. moulded, in 1-oz. bottles oz. 1 1 2 2 2 4 1 Soap, castile lb. 8 12 16 24 32 24 8 Sodium, bicarbonate of, in 1-lb. bottles oz. 48 48 96 96 128 96 16 • " borate of (powdered), in 1-lb. bottles oz. 16 16 16 32 48 48 Squill, syrup of, in 1-lb. bottles lb. 8 12 24 24 32 20 4 Tincture of aconite (root), in 8-oz. bottles oz. 8 8 16 16 16 16 8 " of arnica flowers, in 1-lb. bottles oz. 16 16 32 32 32 32 16 " of chloride of iron, in 1-lb. g. s. bottles .. .. oz. 32 32 64 128 192 96 16 " of cinchona, compound, in 1-lb. bottles oz. 64 96 128 192 192 128 " of digitalis, in 4-oz. bottles oz. 4 4 8 12 12 24 " of gelsemium, in 4-oz. bottles ....oz. 4 4 4 4 4 4 " of gentian, compound, in 1-lb. bottles .... oz. 32 48 80 112 112 64 " of myrrh, in 1-lb. bottles oz. 16 16 32 32 32 32 " of opium (laudanum), in 1-lb. bottles ... .oz. 32 48 64 96 128 96 16 " " camphorated (paregoric), in 1-lb. bottles .... oz. 48 48 112 144 192 96 32 Vaccine virus, quantities as required * Zinc, oxide of, in 8-oz. bottles " sulphate of, in 8-oz. bottles 16 .... oz. 8 8 16 io 16 8 oz. 8 8 16 16 16 8 8 - * Vaccine virus is to be procured by special requisition upon the Surgeon-General direct. Supplementary List of Medicines. Allowance fob Twelve Months. Allowance fob Three Months. Articles. © c . O tA two ies. four ies. c . 0 ti Post of compan Post of compan Post of compan Post of compan Post of regime! General pital of beds. Five hun men in field. - - - - - - - Acid, arsenious, in 1-oz. bottles oz. 1 1 1 1 1 1 " benzoic, in 1-oz. bottles oz. 1 1 1 2 2 2 " gallic, in 1-oz. bottles oz. 1 1 1 1 1 1 " hydrobromic, diluted, in 4-oz. bottles oz. 4 4 4 8 8 16 " hydrocyanic, diluted, in 1-oz. g. s. bottles oz. 1 1 1 1 1 1 " phosphoric, diluted, in 8-oz. g. s. bottles oz. 8 8 8 8 8 8 " salicylic, in 8-oz. bottles oz. 8 8 8 16 16 16 Aloes (powdered), in 2-oz. bottles oz. 2 2 2 4 4 4 Ammonium, bromide of, in 1-lb. bottles oz. 16 16 32 64 64 64 i6 " valerianate of, in 2-oz. bottles oz. 2 2 2 4 4 4 Amyl, nitrite of (5-drop pearls), i i boxes.... doz 2 2 3 3 4 6 i Antimony and potassium, tartrate of (tartar emetic), in 1-oz. bott.. .oz. 1 1 1 1 1 1 Apomorphine, hydrochlorate of, in ^-oz. bottles oz. % % % % % Arsenic and mercury, solution of iodide of (Donovan's solution), in 1-oz. bottles oz. 1 1 1 1 1 1 Brayera (kooso-powdered), in 8-oz. bottles oz. 8 8 16 16 24 24 Bromine, in 1-oz. g. s. bottles Capsules, gelatin, in boxes of 100 each oz. 1 1 1 1 1 1 ... .boxes. 6 8 12 16 20 20 2 Cerate, resin, in 1-lb. tins lb. 1 1 1 1 1 4 1 Chloral, in 1-oz. g. s. bottles : oz. 8 12 16 24 32 64 8 Chrysarobin, in 1-oz. bottles oz. 1 1 1 1 1 1 Cinchona (powdered), in 1-lb. bottles ......oz. 16 16 16 32 32 64 Codeine, in %-oz. bottles oz. % % % % >8 % Collodion, in 2-oz. bottles oz- 2 4 8 8 8 8 2 Copper, sulphate of, in 4-oz. bottles oz. 4 4 4 4 4 4 4 Creasote, in 1-oz. g. s. bottles oz. 1 1 1 1 1 1 Digitalis (leaves), in 1-oz. packages oz. 4 4 4 8 8 8 Ergotin, in 1-oz. bottles oz. 1 1 1 1 1 1 Extract of cascara sagrada, fluid, in 4-oz. bottles oz. 4 4 4 8 8 8 of castanea, fluid, in 1-lb. bottles oz. 16 16 16 32 32 32 " of colchicum seed, fluid, in 4-oz. bottles oz. 4 4 8 8 12 16 4 of colocynth, compound (powdered), in 8-oz. bottles oz. 8 8 16 24 32 32 u of eucalyptus, fluid, in 1-lb. bottles oz. 16 16 16 32 32 32 " of glycyrrhiza, in paper oz. 24 32 64 96 96 96 " of hamamelis, fluid, in 1-lb. bottles " of Indian cannabis, fluid, in 8-oz. bottles " of pilocarpus (jaborandi), fluid, in 4-oz. bottles oz. 32 32 32 64 64 64 oz. 8 8 8 16 16 8 oz. 4 4 4 8 8 8 " of physostigma (calabar bean), in J,-oz. bottles oz. % % X % % % " of rhubarb, fluid, in 8-oz. bottles oz. 8 8 8 16 16 16 " of sarsaparilla, fluid, in 1-lb. bottles oz. 16 32 64 64 64 64 " of taraxacum, fluid, in 1-lb. bottles " of wild cherry (bark), fluid, in 1-lb. bottles oz. 16 16 16 16 16 16 oz. 16 16 32 48 64 64 Insect powder, as required Iron and ammonium, citrate of, in 8-oz. bottles " " quinine, citrate of, in 1-oz. bottles Iron, reduced (by hydrogen), in 1-oz. bottles oz. 8 8 8 16 16 16 oz. 2 4 6 8 12 12 oz. 1 1 1 2 2 3 " dried sulphate of, in 4-oz. bottles oz. 4 4 4 8 8 16 " pyrophosphate of, in 4-oz. bottles oz. 4 4 8 12 16 24 Lithium, carbonate of, in 1-oz. bottles oz. 1 1 1 2 2 2 Lycopodium, in 2-oz. bottles OZ. 2 2 2 4 4 4 2 Mercurial ointment, in 1-lb. jars lb. 1 1 2 3 4 6 1 Mercury (metallic), in bottles oz. 4 4 4 4 4 4 " ointment of nitrate of (citrine ointment), m 4-oz. covered jars.oz. 4 4 8 12 16 16 " oleate of (10 per cent.), in 1-lb. bottles 16 16 16 32 32 32 109 Field Surgeons. Field Surgeons, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Supplementary List of Medicines- Continued. Articles. Allowance for Twelve Months. Allowance for Three Months. Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Mercury, red oxide of, in 1-oz. bottles oz- 1 1 2 3 4 4 Oil, croton, in 1-oz. bottles oz- 1 1 1 2 2 2 i Oil of anise, in 1-oz. bottles oz- 1 1 2 2 2 2 " of cinnamon, in 1-oz. bottles oz- 1 1 1 2 2 3 ... " of cloves, in 1-oz. bottles oz- 1 1 1 1 1 1 " of lemon, in 2-oz. bottles oz- 2 2 2 4 4 4 *• of male fern, ethereal, in 1-oz. bottles oz- 1 1 1 1 1 1 " of rosemary, in 1-oz. bottles oz- 1 1 1 1 1 1 '• of santal (sandal wood), in 4-oz. bottles oz- 4 4 4 8 8 - 8 " of theobroma (butter of cacao), in 8-oz. tins oz- 8 8 16 24 32 24 Opium, powdered, in 8-oz. bottles oz- 8 8 16 24 32 32 8 Tills of arsenious acid (V50 of a grain each), in bottles ....No. 200 200 200 400 400 400 400 " of iodide of arsenic (Vi00 of a grain each), in bottles.... .... No. 200 200 200 400 400 400 " of copaiba, compound, in bottles * No. 500 " of sulphate of quinine, 3 grains each (100 in a bottle).... No. 500 Plaster, belladonna, in tins yds. 4 4 4 6 8 8 4 *• porous No. 24 24 24 48 48 48 24 Podophyllum, resin, in 1-oz. bottles oz. 1 1 2 2 3 3 1 Potassa (caustic), in 1-oz. bottles oz. 1 1 1 1 1 1 Potassium, cyanide of, in % oz. bottles oz. X /g Z8 % Z8 . . . " nitrate of (powdered), in 1-lb. bottles oz. 16 16 16 16 32 32 " permanganate of, in 2-oz. bottles oz. 2 2 4 6 8 10 2 Rhubarb (powdered), in 4-oz. bottles oz. 4 4 8 8 12 12 Santonin, in 1-oz. bottles oz. 1 1 1 1 2 2 Soda, chlorinated, solution of, in 2-quart bottles .... bott. 4 6 8 12 16 20 4 Sodium, bromide of, in 1-lb. bottles oz. 16 16 32 ♦14 64 64 16 " salicylate of, in 8-oz. bottles oz. 8 8 8 16 16 16 8 " sulphite of, in 8-oz. bottles .... .oz. 8 8 16 24 32 48 8 Strychnine, sulphate of, in )^-oz. bottles oz. % z's M Sugar of milk (powdered), in 8-oz. bottles oz. 8 8 8 8 8 8 Sulphur (in roll) - washed, in 1-lb. bottles ' lb 12 12 12 12 12 12 oz. 16 16 32 32 48 64 Tar (wood), in 1-lb. w. m. bottles oz. 16 16 32 32 48 48 Tincture of belladonna, in 8-oz. bottles oz. 8 8 16 16 16 16 8 of cantharides, in 1-oz. bottles " of catechu, compound, in 1-lb. bottles oz. 1 1 1 1 1 1 .. .. .oz. 16 16 16 16 16 16 '' of cimicifuga (racemosa), in 8-oz. bottles oz. 8 8 8 16 16 16 *• of guaiac, ammoniated, in 8-oz. bottles oz. 8 8 8 16 16 16 of opium, deodorized, in 8-oz. bottles oz. 8 8 16 24 32 24 of sanguinaria, in 8 oz. bottles oz. 8 8 8 8 8 8 " of serpentaria, in 4-oz. bottles oz. 4 4 4 8 8 8 *• of veratrum viride, in 4-oz. bottles oz. 4 4 4 4 4 4 4 Tincture, Warburgs, in 1-lb. bottles oz. 16 16 16 16 16 16 16 Tolu, balsam of, in 8-oz. bottles oz. 8 8 8 8 8 8 Wax, white, in paper oz. 4 4 8 8 8 8 " yellow, in paper oz. 8 8 12 16 16 16 Zinc, acetate of, in 2-oz. bottles oz. 2 2 2 4 4 4 •• solution of chloride of, in 1-lb. g. s. bottles lb. 2 4 6 8 8 8 " oleate of, in 8-oz. bottles oz. 8 8 8 16 16 16 * The ''compound copaiba pill" consists of powdered cubebs (2 grs.), copaiba (1 gr.), sulphate of iron (X gr.), and Venetian turpentine (1>£ gr.). Dose, two to five pills. Articles. Allowance for Twelve Months. Allowance for Three Months. Post of one company. Post of two companies. Post of four companies. । Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Arrow-root, in tins lb. 5 5 10 15 20 20 25 20 Beef-extract lb. 10 10 20 30 30 Brandy, in 32-oz. bottles bott. 12 12 24 32 32 32 12 Candles. lb. 4 Chocolate, in Ji-lb. cakes lb. 4 8 12 16 20 12 4 Cinnamon (ground), in 8-oz. bottles oz. 8 16 24 32 48 24 Corn-starch, in 1-lb. packages lb. 8 12 16 20 24 . 12 4 Farina, in 1-lb. packages lb. 2 4 6 ' 8 10 12 Gelatin, in 2-oz. packages oz. 8 16 32 48 48 32 Ginger (ground), in 1-lb. bottles oz. 16 16 16 32 32 32 Lye, concentrated lb. 12 12 18 18 24 24 Meat-juice, Valentine's Milk, condensed lb. 12 12 18 24 36 36 lb. 24 24 36 48 48 16 Nutmegs, in 2-oz. bottles .. .oz. 2 4 6 8 8 2 Pepper, black (ground), in 8-oz. bottles oz. 8 8 24 24 32 48 8 " cayenne (ground), in 8-oz. bottles oz. 8 8 8 60 16 16 16 Soap, common, in bars lb. 30 30 60 80 100 io Soap-powder, in 1-lb. packages pkgs. 5 5 5 10 10 10 Sugar, white lb. 30 48 72 144 192 120 i2 Tapioca, in tins lb. 4 8 12 16 20 12 Tea, black, in tins or original chests lb. 20 30 50 80 80 100 5 Whiskey, in 32-oz. bottles bott. 12 18 32 32 48 32 12 Wine, sherry, in 32-oz. bottles bott. 12 12 18 24 32 24 Hospital Stores. 110 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Instruments, Dressings, Stationery, Furniture, and Appliances-Expendable. Articles. Allowance for Twelve Months. Allowance for Three Months. Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Instruments. Cupping-glasses, assorted sizes. No. 12 12 18 24 24 36 6 Nipple-shields No. 4 6 8 12 18 Probangs No. 12 12 18 24 32 24 6 Syringes, penis, glass, in case No. 32 40 60 80 96 48 12 " rubber, self-injecting No. 4 4 4 4 6 8 2 " vagina, glass No. 4 4 4 4 4 Thermometers, clinical * No. 2 2 2 2 2 2 2 Trusses, single No. 2 3 4 6 6 6 2 " double No. 1 1 1 2 2 2 2 Dressings. Antiseptic dressings for use with spray apparatus ; Gauze, antiseptic, 25 yards; gauze, hygroscopic, 25 yards; jute, salicylated, 5 lbs.; tissue, guttapercha (antiseptic), 3 yards set. 1 1 1 1 1 1 1 Bandages, roller, unbleached and unsized, assorted, in a pasteboard box; 1 dozen. 1 inch by 1 yard; 2 dozen, 2 inches by 3 yards; 2 dozen, 2X inches by 3 yards: 1 dozen, 3 inches by 4 yards; half dozen, 3X inches by 5 yards ; 1 dozen, 4 inches by 6 yards; half dozen, 4 inches by 8 yards doz. 24 36 48 64 96 96 32 Bandages, suspensory No. 4 8 12 16 16 10 4 Chamois skins No. 2 2 2 2 2 • 2 Cotton, absorbent lb. 1 2 2 3 4 4 " styptic, in 1-oz. packages oz. 1 1 1 1 1 2 2 Cotton-bats lb. 4 6 8 12 16 10 2 Cotton-wadding sheets. 8 8 8 12 16 10 2 Flannel, red. all wool. . yards. 10 15 20 30 30 20 4 Ligature, catgut for, carbolizea, three sizes, in bottles ; bott. 1 1 2 2 2 4 1 " silk for oz. X 1 IX 2 3 x Lint, patent lb. 4 8 12 16 20 24 4 Muslin, unbleached, unsized, 1 yard wide yards. 16 20 32 40 50 40 10 Needles, assorted papers. 2 2 2 2 2 2 1 " upholsterer's No. 4 4 4 4 4 4 2 Oakum or marine lint lb. 25 30 40 60 80 120 5 Pencils, hair, in vials No. 24 36 48 48 48 48 12 Pins, assorted papers. 4 6 10 12 12 12 3 " safety doz 6 6 12 12 12 24 4 Plaster, adhesive. India rubber yards. 20 30 40 60 60 60 10 " isinglass, 1 yard in case. yards. 4 6 8 8 8 8 4 Plaster-of-Paris, in 5-lb. tins lb. 10 10 20 20 30 50 5 Rubber sheeting, white yards. 6 8 12 16 16 24 2 Silk, gray, for shades yards. M % 1 1 1 2 X ' • oiled, in 5-yard pieces yards. 5 5 10 10 15 15 5 Splints . .. . . sets. 1 1 1 2 2 3 1 " anterior, Smith's No. 2 3 3 4 4 6 2 " felt for pieces. 4 8 12 16 16 12 2 Sponge, fine, small pieces oz. 12 20 ■ 32 40 . 48 48 5 Stenta book yards. 15 15 15 15 15 30 Tape, cotton pieces. 2 3 6 8 10 15 3 Thread, cotton, spools, assorted No. 4 4 4 4 4 6 2 " linen, unbleached oz. 1 2 3 4 5 6 1 Towels doz. 4 8 ■ 12 16 20 24 2 " roller doz. 1 2 3 4 5 6 Tubes, drainage. 3 sizes, 1 yard each yards. 3 3 3 3 3 6 Twine, half coarse oz. 64 96 48 8 Stationery. Blank books, cap, half-bound, 4 quires .' No. 6 8 8 8 8 10 2 " " octavo. 4 quires, with flexible covers No. 4 6 6 6 8 8 2 Blocks, memorandum •. No. 24 24 36 36 48 48 12 Elastic bands, gross, assorted No. 2 2 2 4 4 3 1 Envelopes, official, large ;....No. 150 150 200 200 250 150 25 " " letter No. 350 350 400 400 500 350 100 " " note No. 100 100 200 200 250 100 25 India rubber pieces. 4 4 6 8 8 8 1 Ink, black, in 2-oz. bottles bott. 16 16 20 24 28 24 4 " carmine, in 1-oz. bottles bott. 2 2 3 4 5 4 1 Mucilage bott. 4 4 8 8 8 12 Paper, blotting qrs. 1 1 1 2 2 4 X Paper, writing, legal-cap qrs. 8 8 12 16 24 24 2 " " letter qrs. 16 16 24 32 48 48 4 " " note qra. 8 8 12 16 24 24 2 Pencils, lead No. 18 18 24 24 36 48 6 Pen-holders No. 8 12 16 20 24 24 2 Pens, steel No. 96 96 144 192 192 120 48 Sealing-wax sticks. 1 1 2 3 4 6 Tape, red pieces. 1 1 • 2 2 4 Miscellaneous. Bowls, soup, delf No. 16 16 48 72 96 300 " wash, " (for office) No. 1 1 1 1 1 1 Boxes, pill, paper doz. 24 32 48 64 72 60 8 " powder doz. 18 18 36 36 48 48 4 Brooms . No. 12 20 30 40 48 50 2 4 4 4 4 6 " for stove blacking No. 3 3 3 4 4 4 * Clinical thermometers to be issued from the Surgeon-General's Office upon special requisition, accompanied by certificate of medical officer, in case of loss or breakage. 111 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Articles. Allowance for Twelve Months. Allowance for Three Months. Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Miscellaneous-Continued. Brushes, scrubbing No. 12 20 - 30 40 48 50 Clothes-line feet. 600 800 1200 1600 1600 800 Corks, velvet, best, assorted doz. 48 60 72 108 144 144 12 Cups and saucers, delf 18 24 36 60 84 200 Dishes, assorted sizes, delf No. 12 12 18 24 24 36 Fans No. 12 12 12 24 24 100 Feeding-cups, delf No. 2 4 6 8 10 24 Funnels, glass, X-pint No. 2 2 2 3 4 4 Green Holland, for curtains and bed screens.... .... yard.-.. 12 12 24 36 48 30 Labels, for vials gross. 2 2 4 4 4 6 Lantei n-glasses. extra No. 2 2 3 4 6 6 3 Measures, graduated, glass, 4-oz No. 2 3 4 5 6 6 1 " " " 8-oz No. 1 1 2 2 2 4 *• " " minim No. 1 1 1 2 2 2 1 Medicine droppers No. 12 12 24 24 36 36 12 " glasses No. 2 2 4 6 8 10 Mop handles No. 4 4 6 6 8 12 Mugs, delf No. 18 '24 36 60 84 200 " spit, delf No. 2 3 4 5 6 10 Paper, filtering, round, gray, 10 inches pkgs. 9 2 2 4 4 4 " litmus, blue and red, of each ... .sheets. 4 4 4 4 4 4 1 " wrapping, white and blue Percolator, glass . ... qrs. 4 8 12 16 20 24 2 No. 1 1 1 1 1 1 Pitcher, pint, delf No. 2 3 J> 5 6 10 " quart, delf No. 2 3 3 5 6 10 *• wash, " (for office) No. 1 1 1 1 1 1 Plates, delf No. 18 24 36 60 84 Salt-cellars, individual No. 12 12 12 15 15 30 6 Spirit-lamps, glass No. 1 1 2 2 3 6 Sponges, large, for bath No. 2 2 2 4 4 6 Spoons, medicine, delf No. 2 2 4 6 6 10 1 Stove-blacking, papers No. 6 6 12 16 20 12 Test-tubes No. 12 12 18 18 24 24 Tubing, glass, as-orted sizes " rubber, black, to match .. lbs. 1 1 1 2 2 2 ... .yards. 2 2 2 4 4 4 Tumblers, glass No. 18 24 36 60 84 260 Urinals, delf No. *) 3 4 6 8 12 Vials: six 6-oz.: twenty-four 4-oz.; twelve 2-oz.; sixl-oz.... doz. 36 48 60 92 120 100 "4 Instruments, Dressings, Stationery, Furniture, and Appliances-Expendable-Continued. Instruments, Books, Bedding, Clothing, Furniture, and Miscellaneous Articles-Not Expendable. To be renewed only as required. Articles. Outfit Allowance fob- Temporary । post. 1 Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 * beds. Five hundred men in the field. Instruments. Apparatus, electric " Politzer's, for the ear ....No. 1 1 1 1 1 1 ...No. 1 1 1 1 1 1 1 1 " spray , ...No. 1 1 1 1 1 1 1 1 Atomizers, steam, with three extra tubes Case, dental. (See list) ....No. 1 1 1 1 2 2 ....No. i 1 1 1 1 1 1 i " field. (See list) ....No. 1 1 1 1 1 1 1 1 " genito-urethral. (See list) ....No. 1 1 1 1 1 1 1 " obstetrical and gynaecological. (See list) ... No. 1 1 1 1 1 1 " pocket. (See list) ....No. 1 1 1 1 1 2 3 1 " post-mortem. (See list) 1 1 1 1 1 1 " stomach-pump and tube ...No. i 1 1 1 1 1 1 i Cutting pliers, for fixed bandages ....No. 1 1 1 1 1 1 1 1 Lancets, thumb ...No. 2 2 2 2 2 4 i Meteorological instruments as authorized by the Surgeon- General Ophthalmoscope, when required ....No. Powder-blower, for larynx ... .No. 1 1 i 1 1 1 1 1 Scarificators ... .No. 1 1 1 2 2 2 2 2 Shears .. .No. 2 2 2 3 3 3 10 2 Speculum for the ear " " rectum .. ..No. 1 1 1 1 1 1 1 1 .. .No. 1 1 1 1 1 1 1 1 Sponge-holders, for the throat ....No. 1 1 1 1 1 1 2 1 Stethoscopes ... No. 1 1 1 1 1 1 2 1 Syringes, hard rubber, 8-oz .. ..No. 2 2 2 2 2 4 4 1 " hypodermic ... No. 1 1 1 1 1 1 1 1 Tongue-depressors ....No. 1 1 1 2 2 2 4 1 Tourniquets and bandages, Esmarch's ....No. 1 1 1 1 1 1 2 1 Tourniquets, field ....No. ... 4 " screw with pad ... . ...No. o 2 2 2 2 2 4 2 Urinometer ....No. 1 1 1 1 1 1 1 Vision-test set. (See list) .... No. 1 1 1 1 1 1 1 112 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons, Field Surgeons. Articles. Book.#. Analysis, Volumetric-Sutton copy. Anatomy-Gray copy. Chemistry-Fownes copy. Children, Diseases of-Vogel copy. Color-blindness-Jeffries copy. Dictionary, English-Webster copy. " Medical-Dunglison copy. Dispensatory copy. Ear, Diseases of-Roosa copy. Eye, Diseases of-J. Soelberg Wells copy. Gymecology. Principlesand Practice of-Emmet copy. Histology-Stricker copy. Hygiene-Parkes copy. Medicine, Cyclopaedia of the Practice of-Ziemssen-20 vols copy. * ' Legal-Tidy-2 vols copy. " Practice of-Aitken-2 vols copy. " " -Flint copy. " " -Niemeyer-2 vols copy. " " -Wood-2 vols copy. " System of-Reynolds-5 vols copy. " Veterinary-Kirby copy. Meteorology-Loomis copy. Midwifery-Cazeaux copy. " -Lusk copy. Obstetrics, Principles ami Practice of-Hodge copy. Pathology, Surgical-Billroth copy. Physical Diagnosis-Delafield and Stillman copy. Physics-Ganot copy. Physiology-Flint-5 vols copy. " -Foster copy. Post-mortem Examinations-Virchow copy. Recruits, Examination of-Tripier copy. Skin, Diseases of-Fox copy. Surgery-Erichsen-2 vols copy. " -Gross-2 vols copy. " -Guthrie's Commentaries copy. " -Holmes-5 vols copy. Surgery, Operative-Stephen Smith copy. " Oral-Garretson copy. Therapeutics-Ringer copy. " -Stilld-2 vols copy. " -Wood (H. C.) copy. Therapeutics, Mechanical-Wales copy. Throat, Diseases of-Cohen copy. Urine, Analysis of-Fowler copy. Venereal Diseases-Bumstead copy. Bedding. Bed-sacks No. Blankets, gray, for the field No. " white No. Blanket cases, canvas No. Counterpanes, red striped No. Cushions, rubber, small No. " " with open centre No. Mattresses, felt No. " hair (when specially required) No. Mosquito-bars (when specially required) No. Pillows, feather No. *• hair ....No. Pillow-cases, cotton No. " " linen (when specially required) No. " ticks No. Quilts, white No. Sheets, cotton No. " linen (when specially required) No. Hospital Clothing. • Drawers No. Gowns, dressing No. Shirts, cotton No. Socks, woollen - pairs. Furniture. Bath-tubs No. Bedsteads No. Chairs No. " rocking No. Close stools No. Dispensing set. (See note) No. Earth-closet commodes No. Linoleum (when specially required) yards. Looking-glasses No. Refrigerators, size as required No. e o s ® £ 8. "i i i ' i "i i "i i * "i "i "i "i "i "i 1 20 40 "4 20 2 1 10 'io 4 10 40 '20 40 '26 6 1 10 12 i 1 "2 1 0 c . C >» _ c 0 § 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 "i 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 1 1 1 1 1 '46 2 20 2 2 15 i2 6 15 40 'i2 40 "2 20 6 20 1 12 18 1 2 2 1 1 "2 4 1 Ou 0 . > tn _ S 4J 2 § 0 <2° 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 1 1 1 1 1 60 2 30 2 2 20 is 8 20 60 24 60 "3 40 10 40 1 16 24 1 2 2 1 1 "4 4 1 tfit Allo 5 tn 0.2 s <*-< O a 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 1 1 1 1 1 80 2 45 4 3 40 '30 12 40 80 36 90 "4 80 18 80 2 30 36 2 2 4 1 1 "6 4 1 WANCE FO £ K ^'S O g s 2 0 - • 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 126 2 60 4 3 50 48 15 50 120 48 150 "6 100 30 100 3 40 60 2 2 6 1 2 "9 4 1 R- O G . O -U G <H O 0 s « Sb 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 150 4 90 6 4 60 60 20 60 150 60 200 "8 130 50 130 3 50 80 2 3 8 1 2 i2 6 1 IS a 0 £73 p c t- 2 JESS "i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 "i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 700 300 8 6 280 260 60 280 700 250 900 500 150 500 150 500 4 270 250 12 4 20 1 6 24 12 1 Five hundred Instruments, Books, Bedding, Clothing, Furniture, and Miscellaneous Articles-Not Expendable-Continued. 113 Field Surgeons, Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Instruments, Books, Bedding, Clothing, Furniture, and Miscellaneous Articles-Not Expendable-Continued. Outfit Allowance for- Articles. Temporary post. Post of one company. Post of two companies. Post of four companies. Post of six companies Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Furniture-Continued. Tables, bedside . No. Table-cloths yards. Trays, butler's No. Water-coolers. No. " filters (when specially required) No. Window-shades (when specially required) No. " shade fixtures (when specially required) No. 6 "i 10 15 2 2 16 15 2 2 30 15 4 2 45 30 6 3 60 30 8 3 250 60 20 3 List of Bottles, Jars, Etc., Contained in the Dispensing Set. No. of Bot- tles, etc. Size. Style. No. of Bot- tles, etc. Size. Style. 2 Tincture bottles. 24 8 ounce Salt-mouth bottles. 24 14 44 8 4 " 44 44 44 24 8 " 44 4* 8 2 " 44 44 44 8 4 " 44 44 2 4 " " " " blue. 8 2 " 44 44 2 2 " 44 44 44 44 2 4 " " " blue. 44 44 44 4 16 " White steeple-top jars. 2 2 " 8 8 " 44 44 44 24 16 " Salt-mouth bottles. 3 4 " <4 44 44 One set of labels. Articles. Outfit Allowance for- Temporary post. Bost of one company. Post of two companies. Post of four companies. 1 1 Post of SIX ! companies. | Post of one । regiment. j General hos- pital of 250 | beds. Five hundred men in the field. Basins, wash-hand No. 8 8 12 20 25 30 25 4 Bed-pans, delf No. 2 2 3 4 6 6 " metal No. 2 300 2 Bed-ticket frames No. Boilers, tin, size as required No. i i i i 1 1. 6 " double, for cooking No. 1 1 1 2 2 6 Bowl, chopping No. 1 1 1 1 1 1 Buckets, covered (6 quarts) No. 2 2 3 4 6 b 10 1 " fire (galvanized iron) No. 12 12 18 24 36 41 60 2 ' ' wooden No. 2 2 4 6 8 15 12 Candlesticks No. 6 0 10 18 24 36 36 3 Cans, milk (2-gallon) No. 1 1 2 2 3 6 Can-opener No. i 1 1 1 1 1 1 1 Casters . No. 1 1 1 1 1 6 Cleavers No. i 1 1 2 2 2 3 Clothes-pins No. 50 50 50 100 100 100 500 " wringers No. 1 1 1 1 4 Colanders No. i 1 2 2 3 4 6 1 Cork borers set. i 1 1 1 1 1 1 1 " extractor No. i 1 1 1 1 1 1 " presser No. 1 1 1 1 1 1 Corkscrews No. i 1 2 2 2 6 1 Cnspidores No. 5 6 8 15 24 3( 100 Dippers No. 3 4 6 8 12 11 24 2 Erasers No. 1 1 1 1 2 a 4 Fire extinguishers No. 1 1 1 1 2 2 2 Forks, carving No. 2 2 2 3 4 5 6 1 " flesh No. 1 1 1 1 2 2 1 " table No. 24 24 36 48 72 96 300 12 Funnels, pint No. 1 2 2 2 4 6 6 1 Graters, large " nutmeg No. 1 1 1 1 1 1 2 1 No. 2 2 2 2 2 2 4 1 Gridirons No. 1 1 2 2 2 3 4 1 Hatchets No. 1 1 2 2 3 4 4 2 Hone No. 1 1 1 1 1 1 1 1 Kettles, tea No. 2 2 2 2 3 4 4 1 Knives, bread 1 1 1 2 2 3 6 1 " butcher's No. 1 1 2 2 2 6 1 " carving No. 2 2 2 3 4 5 6 1 " chopping . " table No. No. 24 1 24 1 36 1 48 1 72 9( 300 1 12 Ladles .. No. 2 2 2 3 4 4 6 1 Lamps, hand . NO; 1 2 3 3 3 4 6 Lanterns No. 2 2 2 3 4 6 6 3 _ . _ . Miscellaneous Articles. 114 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Articles. Outfit Allowance for- Temporary post. Post of one company. Post of two companies. Post of four companies. Post of six companies. Post of one regiment. General hos- pital of 250 beds. Five hundred men in the field. Litters, hand ..No. 3 3 6 (i 6 6 6 4 Measures, gallon to pint 1 1 1 1 2 2 2 Medical saddle-bags, as required . .No. Medicine-cases, as required ...No. " panniers, as required. (See list) . .No. " wagons, as required. (See list) ..No. Mess-chest furnished by the list ..No. i i Mills, coffee ..No. i i i i i 2 2 i Mortars and pestles, wedgewood, 3)^ to 8 inches . No. 2 2 2 3 4 6 6 1 Pails, chamber , . .No. 1 1 1 2 2 2 6 Pans, dish . .No. 1 1 1 2 3 3 5 1 " dust . No. 1 2 4 4 4 4 6 " frying ..No. 1 1 1 2 3 3 5 i " milk . .No. 6 6 8 8 10 15 k ' sauce .. .No. 1 1 1 2 3 3 5 i Pill machine ..No. 1 1 1 1 1 1 " tiles, 5 to 10 inches ..No. 2 2 2 3 4 4 6 i Pitcher, britannia, 1-gallon .. .No. 1 1 1 1 1 1 1 Pots, chamber ...No. 5 5 8 12 12 12 24 ' • coffee ...No. 2 2 2 4 5 6 10 2 " pepper ...No. 1 2 2 2 2 4 8 i " tea ...No. 2 2 2 4 5 6 10 i Kazors . .No. 1 1 1 2 2 2 4 1 Razor-strops.. ... No. 1 1 1 2 2 2 4 i Retort-stand ... No. 1 1 1 1 1 1 Rulers ...No. 1 1 1 1 2 2 4 i Sadirons . .No. 2 3 4 5 6 8 12 Saws, butcher's ...No. 1 1 1 1 2 4 4 i " wood . .No. 1 1 1 2 2 4 6 Scales and weights, apothecary's (counter) ... . .No. 1 1 1 1 1 1 " " " balance, in glass case . ..No. ... 1 1 1 1 1 1 " " " grocer's . ..No. 1 1 1 1 1 1 " '' " prescription .. No. 1 i " platform .. .No. i Scoops . .No. 1 i i 2 2 2 4 Shaving-brushes ...No. 1 1 i 2 2 2 4 1 Spatulas, 3-inch and 6-inch ... No. 3 4 4 4 4 6 8 2 Spoons, table " tea...., . .No. 18 18 24 36 60 84 288 12 . .No. 18 18 24 36 60 84 288 12 Steels .. No. 1 1 1 1 1 2 4 1 Suppository moulds • No. 1 1 1 1 1 1 1 Tape measures . .No. 1 1 1 1 1 1 2 i Thermometers . .No. 1 1 1 2 2 4 5 Tools, small chest of . .No. 1 1 1 1 1 1 1 i Wash-boards ..No. 1 2 2 2 3 3 12 Wash-tubs No. Chemicals and chemical apparatus as required. (See list.) Microscopes and accessories as required. (See list.) 2 2 2 3 4 4 12 Miscellaneous Articles. 1 For Capital Operations. ...No. Saw, capital, long bow, two blades . .No. 1 Forceps, ball " dissection ..No. 1 Bistoury, straight 1 " chain . .No. 1 ..No. 1 Brush .. .No. 1 " Hey's . .No. J 1 " dressing . No. Case, mahogany, brass-bound, slide- " metacarpal . .No. 1 " oesophageal ..No. 1 catch ...No. 1 Scalpels ..No. 3 ! *• tracheotomy, Trousseau's.. ..No. 1 Chisel .. .No. 1 Scissors ..No. 1 Knife, amputating .No. 1 Drills (with one handle) . ..No. 4 Tenaculum . .No. 1 " finger ..No. 1 Elevator .. .No. 1 Tourniquet, screw, with pad " and bandage, Esmarch . .No. 1 " hernia ..No. 1 Forceps, artery " bone, broad-edged, s .. .No. 1 's.No. 1 Ligature silk .. oz. z4 ightly Trephine, conical... ..No. 1 Needle, artery " key, artery . .No. 1 curved, spring han- " small crown . .No. 1 .No. 1 die .. .No. 1 Trocar and canula, straight . .No. 1 Needles, surgeon's .No. 12 " " gnawing, spring han- Wax .. .oz. % " wire suture .No. 6 die .. .No. 1 Wire suture, silver . .yds. 12 Pins, suture, silvered . No. 24 " " Liston's, long, spring handle. sharp, .. .No. 1 For Minor Operations. Pliers, cutting, small Pouch, leather Probang, oesophageal • No. No. 1 1 " " sequestrum, sp ring Bistoury, curved " " probe-pointed ..No. J .No. 1 handle .. .No. 1 ..No. 1 | Probe, Nelaton's .No. 1 " lithotomy .. .No. 1 *■ straight . .No. 1 " Sayre's . No. 1 Gouge ... No. 1 Bougies, G. E., olive-pointed " steel, silvered, double-cu . .No. 3 Scalpels .... .No. 2 Knife, amputating, long " medium .. .No. 1 rved. Scissors, angular .No. 1 .. .No. 1 Nos. 1 and 2, 3 and 4. 5 ' ' curved ..No. 1 " cartilage .. .No. 1 and 6, 7 and 8, 9 and 10, 11 ' • straight .. .No. 1 " catling, long .. .No. 1 and 12 ..No. Serre-fines .No. 0 " " medium ...No. 1 Canula, Bellocq's . .No. 1 Sound, small, straight . No. 1 Ligature silk .. oz. % Case, mahogany, brass-bound, slide- Staff, grooved, large " " medium .No. 1 Needle, artery..;.. ... No. 1 catch ..No. 1 .No. 1 key, artery Needles, surgeon's .. .No. 1 Catheters, elastic, Nos. 1, 3, 5, 7, 9 and " Syme's .No. 1 ... No. 12 11 ..No. 6 Tenaculum .No. 1 " wire suture .. .No. 6 " prostate, silver . .No. 1 Tonsillotome .No. 1 Pouch, leather .. No. 1 " silver, Nos. 3, 6 and 9 . . .No. 3 Trocar and canula, curved . No. 1 Raspatory ...No. 1 Director ..No. 1 I Tubes, tracheotomy (double) .No. 2 Razor, small . No. 1 Ecraseur, wire . .No. 1 | Wax . .oz. Retractors .No. 2 1 Forceps, artery ..No. 1 Wire, suture, silver . yds. 6 Allowance of Surgical Instruments for Medical Officers-Personal Set. 115 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. For the Eye and Ear. Apparatus, Pulitzer's .. No. 1 Needles, cataract, straight " fine Ophthalmoscope No. No. No. 1 6 1 Case, Russia leather Catheter, silver, compound... Caustic-holder No. No. No. 1 1 1 Atropine, sulphate of (in g. s. bottles) Optometer, Thomson's No. 1 Director No. 1 scruples. 1 Physostigma (calabar bean), alcoholic ex- Forceps, artery No. 1 Brush-holder (silver), for larynx. ...No. 1 tract of (in g. s. bottles) scruples. 2 " dissection No. 1 Case, mahogany, brass-bound, slide- Pouch, leather . .. .No. 1 " dressing ..... No. 1 catch ...No. 1 Powder-blower for larynx ... .No. 1 Lancets, thumb No. 1 Catheter, Eustachian .. .No. 1 Probesand director, silver. Bowman's.set. 1 Ligature, silk oz. M Curette ...No. 1 Scalpel, small No. 1 Needles, artery No. 1 Cystotome . ..No. 1 Scissors, curved on the flat No. 1 " exploring No. 1 Forceps, angular, for removing foreign " iris No. 1 " surgeon's No. 6 bodies from the ear, Wilde's.... .. .No. 1 " strabismus .. ..No. 1 " wire suture No. 3 Forceps, cilia .. .No. 1 " straight No. 1 Probe No. 1 " fixation ...No. 1 Scoop and hook for removing foreign " N61a ton's No. 1 " iridectomy, angular .. .No. 1 bodies from the eye and ear.No. 1 Scalpel No. 1 ' • curved. .... ...No. 1 " lens No. 1 Scissors No. 1 " " straight 1 Silk, fine X Tenaculum No 1 Hook, sharp ...No. 1 Spatula, rubber No. 1 Tenotome No. 1 ' ' strabismus .. .No. 1 1 Wax 1 z " " small . ..No. 1 Speculum, eye No. 1 Wire suture, silver yds. "fl " Tyrrell's ...No. 1 " " Graefe's No. 1 Knife, cataract, Beers' ...No. 1 Spoon, Critchett's No. 1 for Local Ancrstnesiay Diagnosis, etc. " Graefe's linear ...No. 1 Spud, Dix's .... No. 1 Case, mahogany No. 1 " iridectomy, angular . ..No. 1 Styles, silver ....No. 2 Nebulizer, with two tubes-one single. " iris . No. 1 Syringe, Anel's No. 1 one double No. 1 Lid-holder, large .. No. 1 Test-types, Snellen's set. 1 Taper, litmus: red, six sheets blue, six " small ...No. 1 Wire suture, silver, fine yds. 1 sheets 12 Mirror, laryngeal, elliptical . ..No. 1 I Pouch, leather No. 1 " " square ...No. 1 For the Pocket Case. 1 Syringe, hypodermic No. 1 " laryngoscopic (reflector), with Bistoury, curved No. 1 Thermometer, clinical No. 1 head-band .. .No. 1 " " probe-pointed No. 1 j Urinometer No. 1 Needle, cataract, lance-headed.. . ..No. 1 " straight No. 1 Trunk, leather, for entire personal set. .. 1 Allowance of Surgical Instruments for Medical Officers-Personal Set-Continued. - '■ ■ - ■ I - - Dental Case. Raspatory . .No. 1 Forceps, long. Wallace's. ... . .No. 1 Elevators (Nos. 6 and 7), for lifting roots 1 Razor, small ..No. 1 " placenta, Loomis' . .No. 1 of bicusnidsand molars ....No. 2 | Retractors .. No. 2 short, Brickeirs, for premature Forceps, for extracting upper front root. Saw, capital, long bow, two blades ..No. 1 delivery . No. 1 No. 1 " chain ..No. 1 Funis clamp, Pulling's... ..No. 1 " " lower bicuspid and canine, " Hey's ..No. 1 Perforator. Thomas' ..No. 1 No. 1 ' ' Metacarpal ..No. 1 Probe, uterine, silver, and silver appli- " " " " and incisor. Scalpels . .No. 1 cator, with set-screw handle and cither side ... No. 1 Scissors, angular . No. 1 sponge tent expeller . .No. 1 " " molar, either side... .. ..No. 1 " straight . .No. 1 Scarifier, Buttles' . .No. 1 Tenaculum . .No. 1 Scissors, uterine, curved on flat ... . .No. 1 1 Tourniquet, screw, with pad . No. 1 Speculum, vaginal and anal combined.No. 1 Trephine, conical Trocar and canula, curved .. No. 1 Suppository tube, intra-uterine, hard No. 1 . .No. 1 rubber ..No. 1 " " upper bicuspid and canine, Wax .. .oz. X Syringe, rubber, self-injecting ..No. 1 either side ...No. 1 Wire suture, silver ..yds. Tampon, small ..No. 1 " " upper and lower back root, 1 Genito- Urethral Case. Tenaculum, Nott's . .No. . .No. .No. inted 1 No. " incisor and canine, 1 Bougies, a boule, Otis' " olive pointed, English .... . .No. ..No. 6 ' 6 " sea tangle Transfusion set, Fryer's (with pr 12 " " " wisdom, either side, 1 Case, rosewood Catheters, double current, silver... . .No. . .No. 1 1 directions for use) Vectis, with handle ..No. . .No. 1 1 Lancet, gum, ebony handle . ...Noi 1 " gum, Mercier's " Jaques' ;. . .No. . .No. 1 4 Pocket Case. Field Case. " tunnelled, Gouley's . .No. 1 Bistoury, curved " probe-pointed .... ..No. 1 ....No. 1 Catheter staff, grooved and tunnelled, ..No. 1 Bistoury, curved " " probe-pointed... 1 Gouley's ..No. 1 " straight .. No. 1 .. .No. 1 Crin de Florence ..No. 1 Case, Russia leather ..No. 1 Bistoury, straight ....No. Dilator, Thompson's, modified by Gou- 1 Catheter, silver, compound . .No. 1 Bougies, steel, silvered, double curve ley . .No. 1 Caustic-holder ..No. 1 (Nos. 1 and 2, 3 anil 4. 5 and 6 7 and 6 Director, silver, Gouley's . .No. 1 Director and artery needle . .No. 1 8, 9 and 10, 11 and 12) .. .No. 1 Forceps, urethral, Thompson's .... ..No. 1 Forceps, artery and needle " dressings ..No. 1 Brush .. .No. Gauge, steel ..No. 1 . .No. 1 Case, mahogany, brass-bound, slide- 1 Gauges, pasteboard . .No. 2 Lancet, thumb . .No. 1 catch ... .No. Guides, whalebone, Gouley's " " Otis' ..No. 12 Ligature, silk X Catheters, elastic (Nos. 1, 3, 5, 7, 9 and 6 ..No. 2 Needles, artery . .No. 1 ID . . .No. 3 Knife, beaked, Gouley's . .No. 1 " exploring 1 " silver (Nos. 3, 6 and 9) ....No. 1 Sounds, sets of four, fitting one handle " surgeon's ..No. « Director ....No. 1 set. 1 " wire suture 3 Elevator ....No. 1 " tunnelled. Gouley's ..No. 3 Probe . .No. 1 Forceps, artery " ball .. .No. 1 Tenaculum, Gouley's . No. 1 " Nelaton's ..No. 1 .. No. Urethrotome, dilating, with two points, Scalpel No. 1 " bone, broad-edged, s 1 ig h t J y - 1 Gouley's ..No. 1 Scissors ..No. 1 curved, spring handle .. .No. Yoke, rubber (catheter holder).... ..No. 1 Tenaculum . .No. 1 bone, sequestrum, spring han- dle No. 1 Obstetrical and Gynecological Case. Tenotome Wax ..No. 1 X u dissection ...No. Blunt-hook and crotchet, Gordon-Budd, Wire suture, silver .yds. 6 " dressing Knife, amputating, long " " medium .. .No. ...No. 1 guarded No. Bottle, glass stoppered and glass covered. 1 Post-Mortem Case. ....No. for Little's saline mixture. . ..No. 1 Blow-pipe ... ..No. 1 " catling, long " " medium ...No. " glass stoppered and glass covered, Box. mahogany ..No. 1 ...No. for styptic solution . No. 1 Chain and hooks . .No. 1 " finger . ..No. " glass stoppered and glass covered, Chisel ..No. 1 " hernia ...No. for ergot .. ..No. 1 Enterotome . .No. 1 Ligature silk ... .oz. Catheters, English, gum elastic ... . .No. 2 Forceps, dissection ..No. 1 Needle, artery .. No. " Sims' sigmoid, metal ... Dilators, Barnes', with stop-cocks.. ..No. 1 Knife, cartilage ..No. 1 " key, artery ...No. U ..set. 1 Needles and thread ..No. 2 Needles, surgeon's ...No. Dilator, uterine, small . No. 1 Saw ..No. 1 " wire suture ...No. 6 Elevator, uterine, Sims' . .No. 1 Scalpels ..No. 3 Pouch, leather ... No. 1 Folding sound, Simpson's . .No. 1 Scissors ..No. 1 Probe, Nelaton's....' ...No. 1 Forceps, craniotomy, Mundi's .... ..No. 1 Tenaculum ..No. 1 Contents of the Cases of Instruments, Medicines, Etc., to which Reference is made in the Standard Supply Table. 116 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons, Field Surgeons. Contents of the Cases of Instruments, Medicines, Etc., to which Reference is made in the Standard Supply Table-Continued. Vision-Test Set. 1. A pack of ten test-cards, in case, with a card of instructions. 2. A simple optometer, consisting of two lenses, one of 4-inch and the other of 10-inch focal length ; a brass holder with graduated bar and slid- ing test-type holder; six test-types numbered 1, for the measurement of defects of refraction and accommodation, and six test-types numbered 2, for the measurement of astigmatism. 3. A set of test-wools, for the detection of color-blindness, consisting of three larger skeins of " test colors" (one pale green, one rose color, called purple, and one bright red), and one hundred and forty-four small skeins of " confusion colors," as follows : Scarlet 8 shades, 1 skein each. Orange 8 " 1 " " Yellow 8 " 1 " " Yellow-green 8 " 1 " " Green 8 " 1 " " Blue-green 8 •* 1 " " Blue, No. 1 8 " 1 " " No. 2 8 " 1 " " Violet 8 " 1 " " Purple, No. 1 (Rose Victoria) 8 shades, 1 skein each. " No. 2 8 " 1 " " Olive-green 8 " 1 " " Olive-brown 8 " 1 " " Pearl-gray 8 " 1 " " Pure gray 4 " 2 skeins " Hair-brown 8 " 1 skein u Lion-brown 8 " 1 " " Wood-brown 8 " 1 " " All wrapped in a piece of muslin a yard square. 4. A small paper box in which to keep the extra lens and the twelve test-types. 5. A pamphlet of directions for using the Vision-Test Set. 6. A painted tin box containing all the foregoing. Medicine Pannieb. ... No. - Medicines. Pills of sulphate of quinine (grains two) 500 1 1 12 6 8 8 1 2 1 1 1 12 6 Bandages, suspensory 6 Acid, carbolic (pure, crystallized)... .oz. " citric oz. " tannic oz. Alcohol oz. Ammonia, stronger water of oz. Amyl, nitrite of pearls. Bismuth, subnitrate of oz. Capsicum (ground) oz. Chloral oz. Chloroform, purified oz. Copper, sulphate of oz. Cough mixture. (See note) oz. Diarrhoea mixture. Squibb's oz. Ether, spirit of nitrous (sweet smrit of 2 6 X 12 10 12 2 1 2 8 1 12 6 Plaster, blistering " mustard " porous Potassium, bromide of " chlorate of " iodide of " permanganate of ... Quinine, sulphate of Silver, nitrate of (crystals) ' " " moulded Soap Sodium, bicarbonate of •• salicylate of No. yd- yd. No. oz. oz. oz. oz. oz. oz. oz. ... piece. oz. oz. Binder s boards pieces. Ligature silk oz. Lint, patent lb. Muslin yards. Needle, upholsterer's No. Needles, 25; cotton, 1 spool; thimble. 1; in one case No. Pencils, hair, in vial No. Pins paper. " assorted, safety doz. Plaster, adhesive yards. " isinglass yard. Silk, oiled yard. Sponge, fine, small pieces '. No. 8 X X 3 j 1 1 4 nitre) Extract of colchicum seed, fluid. ... .oz. .... oz. 6 3 Squill, syrup of Tincture of aconite (root) oz. oz. 6 3 1 ape, pieces . Tow ...No. ....lb. 2 1 Extract of ergot, fluid " of eucalyptus, fluid .... oz. .... oz. 2 2 " of arnica flowers " of belladonna " of chloride of iron ... oz. oz. oz. 10 1 2 Towels Dool-s, Stationery, etc. ..No. 3 " of ginger, fluid " of ipecac, fluid Iodine Iodoform Ipecac (powdered) Iron, subsulphate of Lead, acetate of Liniment. (See note) .... oz. ... .oz. .... oz. ... .oz. .... oz. .... oz. ... .oz. ....oz. 10 3 1 3 4 1 8 " of digitalis " of opium (laudanum) . " camphorated Tincture, Warburg's Whiskey Zinc, oxide of " sulphate of oz. oz. oz. oz. oz. oz. oz. 1 6 6 10 10 2 1 Blank books Cases for books and stationery ... Envelopes Inkstand, traveller's, filled Paper, letter, ruled Pencils, lead Pen holders ...No, . ..No. .. .No. ...No. .. .qrs. ...No. ..No. 2 1 25 1 2 2 2 Magnesium, sulphate of .-. .. . .oz. 12 Instruments. Pens, steel .. .No. Mercury, corrosive chloride of (corrosive sublimate) oz. 1 Cupping tins No. 4 Miscellaneous. " mild chloride of (calomel) .. oz. 1 Probangs . ...No. 6 Basins, tin, small, for dressers... . ..No. 2 " oleate of .... oz. 6 Scarificator No. No. No. No. No. 1 Candle-holder ...No. 1 Morphine, sulphate of ... Oil, olive Oil of turpentine Petrolatum, 120° F ... .oz. .... oz. .... oz. .. . oz. % 12 8 16 Syringe, self-injecting Syringes, penis, glass Tourniquets, field 1 4 2 Candles, composition, half-length. Corks Corkscrew Measure, graduated, glass, 2-oz.. " " " minim ... No. . .doz. ...No. .. No. 6 2 1 1 Tills, compound cathartic . . .No. 600 Dressings, etc. .. .No. 1 Pills of camphor (grains two) and opium 300 Medicine measuring glass... ...No. 1 (grain one) ... No. Bandages, roller, unbleached and un- Mortar and pestle .. .No. 1 " of copaiba compound (dose, two to 600 sized : Pill boxes .nests. 6 five pills.) (See note) .... ... No. 1 inch by 1 yard long No. 6 Plates, for dressers .. No. 1 " of powder of ipecac and opium 2 inches by 3 yards long ... No. 12 Scales and weights, prescription. ... set. 1 (Dover's powder), five grains 2X inches by 3 yards long... No. 12 Spatula ... No. 1 each . . .No. 400 3 inches by 4 yards long No. 4 Spoon, tea . .No. 1 " of mass of mercury (blue mass).No. 500 3% inches by 5 yards long... No. 1 Vials ; 2, 4-oz.; 2, 2-oz.; 2. 1-oz... .. .No. 6 " of opium (one grain each) .. . .No. 700 4 inches by 8 yards long .... No. 1 1. The "Cough Mixture " consists of syrup of squill and camphorated tincture of opium, each four fluidounces, with two fluidrachms of fluid extract of ipecac. The dose is one teaspoonful. 2. The " Liniment" consists of equal parts of solution of ammonia, oil of turpentine, and olive oil. 3. The " Compound Copaiba Pill " consists of powdered cubebs (two grains), copaiba (one grain), sulphate of iron (one-half grain), and Venetian turpentine (one and one-half grain). Dose two to five pills. Medicine Wagon. Medicines. 8 Cerate, resin Chloral lb. OZ. 1 32 Flaxseed meal Glycerin .lbs. .oz. 4 16 Acacia (powdered) ... oz. Acid, carbolic (pure, crystallized). ... oz. 4 Chloroform, purified oz. 64 Iodine . .oz. 1 " citric ... oz. 8 Collodion oz. 4 Iron, subsulphate of .oz. 4 " sulphuric, aromatic .. .oz. 8 Copper, sulphate of oz. 2 " solution of subsulphate of.... . oz. 8 '• tannic ...oz. 8 Ether, compound spirit of (Hoffman's Lead, acetate of oz. 8 Alcohol . bott. 2 anodyne) oz. 8 Magnesium, sulphate of .lbs. 8 Ammonia, aromatic spirit of .. .oz. 8 *• spirit of nitrous (sweet spirit ot Mercurial ointment . oz. 16 " stronger water of .. .oz. 32 nitre) oz. 8 Mercury, corrosive chloride of (corrosive Ammonium, carbonate of .. .oz. 8 " stronger, for anaesthesia oz. 64 sublimate) . oz. 2 Antimony and potassium, tartrate of (tar- Extract of belladonna, alcoholic oz 1 " mild chloride of (calomel) . oz. 2 Lar emetic) ... oz. 1 of colchicum seed, fluid oz. 8 " mass of (blue pill) .oz. 8 Arsenite of potassium, solution of (Fow- " of colocynth. compound .oz. 8 Morphine, sulphate of Mustard, black (ground) . .oz. 1 ler's solution) ... oz. 4 " of ginger, fluid " of ipecac, fluid oz. 8 . lbs. 6 Bismuth, subnitrate of ... oz. 16 oz. 8 Oil, castor bott. 4 Camphor (refined) .. .oz. 8 of physostigma (calabar bean) oz. ' ' croton .. oz. 1 Note.-Medicine wagons will be distributed as the Surgeon-General shall direct. 117 Field Surgeons, Field Surgeons, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Medicine Wagon-Continued. Medicines- Continued. Oil, olive bott. " of peppermint oz. " of turpentine bott. Opium (powdered) oz. Petrolatum, 120° F lbs. Pills, compound cathartic No. Pills of arsenious acid ('/so of a grain each) No. " of camphor (two grains) and opium (one grain) No. " of opium No. " of sulphate of quinine (three grains each) No. Plaster, blistering yd. Potassium, acetate of oz. " bicarbonate of oz. " bitartrate of (powdered), .oz. " iodide of oz. " permanganate of oz. Potassium and sodium, tartrate of (pow- dered) oz. Quinine, sulphate of oz. Silver, nitrate of (crystals) oz. " moulded oz. Soap, castile lbs. Soda, chlorinated, solution of lbs. Sodium, bicarbonate of oz. Squill, syrup of lbs. Tincture of aconite (root) oz. " of chloride of iron oz. " of opium (laudanum) oz. " " camphorated (pare- goric) oz. " u deodorized oz. Wax, white oz. Zinc, solution of chloride of oz. " sulphate of oz. Hospital Stores. Beef-extract lbs. Brandy bott. Candles, sperm, half length lbs. Corn-starch lbs. Farina J lbs. Milk, concentrated..., lbs. Nutmegs oz. Pepper, black (ground) oz. " cayenne (ground) oz. Salt, table lbs. Sugar, white, crushed lbs. Tea, black .' . Ibs. Whiskey bott. Instruments. Case, dental No. " pocket No. Cupping tins No. Nebulizer (with two tubes) No. Probangs No. Scarificators No. Shears No. Sponge-holder, for the throat No. Stethoscope No. Syringe, hard rubber, 8-ounce No. 2 2 £ 3 200 200 300 200 200 1 8 8 16 16 4 22 15 1 1 8 2 32 4 8 16 16 24 4 2 32 1 16 12 4 10 10 16 4 8 8 15 10 24 1 1 10 1 6 I * 1 } 1 1 1 Syringe, hypodermic No. " rubber, self-injecting .......No. Syringes, penis, glass No. " rubber No. Tourniquets, field No. " screw No. Trusses, single No. Dressings, etc. Bandages, suspensory ... No. Binders' boards, 2)^ by 12-inch pieces.No. " " 4 by 17-inch pieces. .No. Cotton-bats , No. Cotton-wadding sheets. Flannel, red, ail wool yds. Lint, patent lbs. ' ' picked lbs. Ligature silk oz. Muslin yds. " oiled yds. Needles, cotton, spool, thimble, in one case No. Oakum or marine lint lbs. Pencils, hair No. Pins papers. Plaster, adhesive yds. " isinglass yds. Roller bandages, assorted doz. Rubber sheeting, white yds. Silk, gray, for shades <. yd. " oiled yds. Splints set. " anterior, Smith's ... No. " felt for pieces. Sponge, fine oz. Tape, pieces No. Tow lbs. Towels doz. Twine oz. Books, Stationery, etc. Anatomy-Gray copy. Blank books, quarto No. Elastic bands, assorted, gross No. Envelopes No. Ink, 2-ounce bottles No. Inkstand, traveller's No. Order and letter book No. Paper, blotting ....qr. " wrapping, white and blue ...qrs. " writing qrs. Pencils, lead No. Pen-holders No. Pens, steel gross. Portfolio No. Register of patients, small, flexible cover No. Surgery-Erichsen copy. U. 8. Dispensatory .copy Bedding. Blankets, in two cases No. Miscellaneous. Kxe No. Basins, tin, small, for dressers No. " wash-hand No. 1 1 6 2 4 1 8 ; 16 16 2 4 4 s 2 ! 2 15 4 1 5 12 6 10 10 36 4 X 4 1 6 10 4 10 2 : 2 1 300 6 1 1 X 2 8 12 6 1 1 1 1 1 20 1 2 3 ' Bed-pans, metal No. Buckets No. Camp kettle, small, with cover No. Corks, assorted doz. 1 Corkscrew No. Funnel No. Grater, nutmeg No. Hatchet No. Hone No. Lanterns, glass No. Measure, graduated, glass, 2-ounce ..No. Measures, graduated, glass, minim...No. Medicine measuring glasses No. Mortar and pestle, wedgewood No. Mugs No. Pill boxes doz. " tile No. Plates, dressing No. i Razor No. 1 Razor-strop No. Saw No. Scales and weights, prescription No. Scoops ........... . No. Shaving-brush No. Spade No. Spatulas, 3 and 6-inch No. Spoons, table.' No. " tea No. Tumblers No. Urinals, glass No. Vials, assorted doz. Mess Chest. Basins, metal, small No. " " wash-hand No. Box for pepper No. " " salt No. Canister for butter No. " " coflfee No. " " sugar No. " " tea No. Cleaver No. Cup, metal No. Dipper No. Dishes, metal (assorted sizes) No. Grater No. Gridiron No. Kettle, camp, with cover No. " tea, iron No. Knife and fork, carving, of each No. Knives and forks, of each No. Ladles No' Mill, coflfee No. Mugs, half-pint No. Pans, frying No. sauce No. Plates, metal No. Pot, coflfee, metal No. " iron No. " tea, metal No. Saw. butcher's No. Spoons, table No. " tea No. Tray, metal No. Tumblers, metal No. 2 2 1 12 1 1 1 1 1 3 1 2 2 1 12 8 1 4 1 1 1 1 3 1 1 12 12 12 2 8 12 2 1 1 1 1 1 1 1 1 1 6 1 1 1 1 1 12 2 1 12 1 1 6 1 1 1 1 12 12 1 12 The following is a list of chemicals and chemical apparatus from which will be issued to medical officers, on special requisition, such articles as may be approved by the Surgeon-General. Such requisition should set forth the special purpose for which the articles are desired and intended, and will be forwarded to the Surgeon-General through the Medical Director. Solid chemicals, in 2-oz. g. s. jars Acid, arsenious. chromic. " oxalic. " tartaric. Ammonium carbonate. " molybdate. " oxalate. Barium carbonate. " chloride. " hydrate. " nitrate. Calcium carbonate. " chloride. Cobalt nitrate. Copper oxide. Iron chloride. Iron sulphuret. Manganese binoxide. Platinum chloride. Potassium bichromate. " carbonate. '1 cyanide. " ferricyanide. " ferrocyanide. " hydrate. " sulphate. " sulphocyanide. Sodium acetate. " ammoniacal phosphate. " biborate, pure, dry. '• carbonate. *• chloride. " hydrate. Sodium hyposulphite. " phosphate. " sulphate. Tin chloride. Uranium nitrate. Liquid chemicals, in A-oz. g. s. vials Acid, acetic, c. p. " hydrochloric, c. p. " nitric, c. p. " sulphuric, c. p. Alcohol, absolute. Ammonia, solution of. Antimoniate of potassium, solution of. Benzol. Apparatus. Beakers, in nest nest. " 2, 4 and 6-oz No. Blow-pipe, with forceps and reagents.No. Bottles, g. s., n. m., 1. 2 and 4-oz. .. .No. " g. s., w. m., %, 1 and 2 oz.. .No. Burner (Bunsen's) No. Capsules (porcelain), nest of six... nest. " 4-oz .. .No. " 8-oz No. Casserol, with cover No. 1 6 1 18 18 1 1 6 3 1 Cork borers (set of six) set. " tongs No. Corks, assorted doz. " India-rubber, perforated ... .doz. Crucibles (porcelain), conical No. " Hessian, nest of three ....nest. Drying apparatus, sulphuric acid ... .No. Filters, cut, white (in packs of 100). packs. Flasks, flat-bottomed, with lip. .. . No. " round-bottomed, long-necked.No. " Schuster's, plain or stoppered. No. 1 1 3 1 4 1 1 3 6 6 Forceps, for handling small objects . .No. Funnel tubes No. Funnels, glass No. Mortar and pestle (porcelain) No. Paper, filtering, German or Swedish.. qr. " litmus, red and blue sheets. Tongs, crucible No. Measuring Apparatus. Alkalimeters. Schuster's No. Bottles, WoulfFs, 3-oz No. 1 2 2 1 1 12 1 2 2 118 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Measuring Apparatus-Continued. 1 Still, copper, half-gallon capacity... .No, 1 2 Burette, 50 c. c .. .No. Stop-cocks for rubber tubing. " 25 c. c No. 2 Sulphuretted hydrogen apparatus... .No. 1 " clips No. 4 Test glasses, on foot. No. 6 Cylinder, graduated, 200 c. c. No. 1 " tube brushes No. • " •* 100 c. c., stoppered, " " stand No. 1 No. 1 " tubes, assorted No. 12 " " 50 c. c.. No. 1 " " nests of six .... nests. 2 44 " 25 c. c. No. 1 Thermometer No. 1 Evaporating dishes, iron, porcelain-lined, Tubes, chloride of calcium.... No. 3 No. 3 44 u . No. 6 Flasks, 500 c. c No. 1 Tubing, glass lbs. 3 " 100 c. c No. 1 " rubber feet. 12 Glasses, Nessler's, 50 c. c No. 4 Wash-bottle No. 1 Pipe, block-tin, %inch, for condensing Watch-glass holder ; No. 1 distilled water feet. 20 1 ' glasses 1 No. 6 Pipette, 50 c. c No. 1 Water-bath for drying.k .. ..No. 1 44 25 c. c .. ..No. 1 " 10 c. c No. 2 Miscellaneous. 44 20 c. c., graduated... .... No. 1 Bone earth (as reauired) 44 5 c c., 44 No. 2 44 2 c. c.. 44 No. 2 Copper foil (as required) Platinum, capsule, 3-inch .... No. 1 Files, set of six set. 1 " crucible, 1-oz No. 1 Glass, blue .sq. inch. 1 Potash bulbs, Geissler's set. 1 4 4 green .sq. inch. 1 Retorts 8-oz. 32-oz No 2 Trnn wire fas renniredl Rods, glass.. No. 12 Magnesite in fragments (as required).... Scoop, horn .. No. 1 Paraffin oz. 8 Spatulas or spoons, porcelain No. 2 Platinum, foil.... . sq. inch. 2 Specific gravity bottle No. 1 44 wire i feet. 3 4 4 44 bulbs No. o Urea (as required) Spirit lamp, argand No. 1 Wire gauze . sq. feet. 2 " " simple No. 1 Zinc (as required) Medicine Wagon-Continued. The Microscope now issued consists of- Stand. Glass stage and slide-carrier. Two eye-pieces. Eye-piece micrometer. Concave and plain mirror. Three objectives-2-inch, % inch. and '/j-inch. Iris diaphragm, with sub-stage adapter arranged to take diaphragm or objective. Revolving diaphragm, ordinary. Bull's-eye condenser. Stage forceps. Camera lucida. Forceps. Six glass slides. " " covers (circles). In upright cherry-wood case, with handle, lock, and extra hook and post fastenings. List of Microscopical Accessories. 1 section cutter, with freezing apparatus. 1 razor, large, one side flat, with handle, in case. 1 syringe, injecting, X'oz-> brass, with four pipes and stop-cock, in case. 1 turn-table, self-centring. 4 dozen glass slides. 1 ounce glass covers (circles). X ounce carmine. 1 ounce Canada balsam. 1 balsam bottle. In cherry-wood case, with handle, lock, and hook and post fastenings. 1 copy Frey on the Microscope. A system of responsibility attaches to these and all other government supplies issued to military surgeons, who formally receipt for all articles, and become pecuniarily responsible for their preservation or proper use-unavoidable accidents excepted. All such property is accounted for at stated periods, on printed forms furnished for the purpose. Transportation.-When the army moves, food, tents, and medical supplies must all be carried with it, and for the limited supply to last for a few days the surgeon must procure transportation. Means of trans- portation are provided by the quartermaster department. When troops move by rail or boat, supplies will be car- ried on car and boat, with the troops. When the troops march, the supplies must be carried in wagons, rarely on mules. One six-mule army wagon is allowed to each regi- ment in the United States army, for the transportation of medical supplies. Habitually this will suffice, but will never be too much. In the confusion of campaigns, and the hurry of marches, the surgeon will sometimes find it difficult to obtain his wagon, and when obtained to re- tain it. With a moving army, means of transportation for supplies are always limited, and various accidents are liable to disarrange the surgeon's plans, and leave him destitute. Muddy roads delay the arrival of the wagons. Steam and other boats, railroad cars, and wagons as- signed to the transportation of medical supplies, are seized by the military authorities for the carriage of mu- nitions of war, or an advancing enemy captures the train and appropriates the contents. Such incidents are dis- couraging ; but in proportion as the medical officer over- comes this discouragement, and proves himself a man of resource, is his value proven. When the medicine wagon of the supply table is fur- nished, the surgeon must obtain from the quartermaster the animals to draw it, and if panniers are provided, the animal or wagon to carry them. The transportation of the sick and wounded, and their disposition in general, will receive attention elsewhere. III. Surgeon's Duties as Regards the Well.- The third duty of the medical officer is to watch over and recommend the proper steps to preserve the health of the well, and in this connection he will direct his attention principally to the soldier's diet, his dress, and his habita- tion. Diet.-The soldier's food is called his ration. It varies in different armies, and habitually the war ra- tion is greater than the peace ration. War makes exclusive claims upon the fighter's time, and to prevent Ins attention being diverted to any side issue, the Govern- ment proposes to supply all necessary sustenance. It is yet a moot question how much food a man must eat to preserve his functions in full activity. As eluci- dating the question of this sufficiency, I give below the rations of the British and Italian armies, and I select them because concerning them the facts stated are authoritative, being transmitted to the State Department in Washington by the United States ministers in England and Italy, re- spectively. Responsi- bility for property. C o m p o- nents of dif- ferent r a- tions. Transpor- tation. At Home. Except in tents. In camp. Bread .. 16 ounces. Bread. .. 16 ounces. Beef or mutton.... ..12 " Beef or mutton 16 English Army Ration. "On active service abroad, in the field, the ration is fixed according to the exigencies in each case, but the following scale is laid down as a guide, viz.: Meat - 1 pound. Bread 14 pound. Or biscuit 1 pound. Tea i/8 ounce. Coffee % " Sugar 2 ounces. Salt ounce. Pepper i/36 ounce. Fresh vegetables % pound. Or preserved vegetables, or rice, or peas 2 ounces. Lime-juice (when fresh vegetables are not issued)* 1,ounce. Rum % gill. "No special ration is given for working parties, they being remunerated by being granted working-pay. "The same ration is given throughout Great Britain and Ireland, and at most foreign stations ; at some of the latter, where the climate is specially trying, a special full health ration is given, calculated to be sufficient to keep the soldier in full health. "Ordinarily speaking, the government is supposed to supply the bread for the breakfast and dinner meals, and the dinner meat. The soldier provides, under regimental arrangements, the evening meal and the groceries, but- ter, and vegetables which he requires. His pay is calcu- lated to provide for this." Ration. * At the discretion of the general officer commanding, on the recommen- dation of the medical officer. 119 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Italian Army Ration. Type A. 150 grammes per diem. Of wine 25 centilitres, of cof- fee 15 grammes, sugar 22 grammes only, are allowed for each day. The distribution of these things is not made daily, but the regulation determined ad minimum-100- distribution of coffee and wine per annum. Of other arti- cles the quantity is not prescribed, but regard is had to the proportion of the necessary nutritive principles stated above. " The ration is equal in all circumstances, but according to the various services to which the troops may be called they are assigned more or less overpay, which the com- mander of the corps can keep wholly or in part for the augmentation and amelioration of the food." Regularly the ration does not vary in quantity or qual- ity ; "it is left, however, in the power of the corps com- mander to fix, always observing the principles above enunciated, whatever variety of food is demanded by cli- mate, season, the service of the troops, the products of the region, and other circumstances. " There are, however, other substances complementary to the ration, that are conceded in order to give to the food the necessary nutritive quality, the measure of which is left in the power of the commander of the corps to determine." It is not supposed that soldiers ought to procure for themselves food in addition to their ration, " because the soldier receives daily a quantity sufficient for his suste- nance ; if, however, he has money that he desires to spend for the acquisition of other comestibles, he is not forbid- den to do so in hours when he is not on duty. " There is a regulation forbidding the sale of rations ; moreover, it is prohibited to treat them contemptuously, or throw them away. Those to whom they come unex- pectedly deposit them in an appointed place for distribu- tion to the poor." The foregoing words in quotation marks are taken ver- batim, from the State despatches. Of the Russian army ration, Greene, in his " Report of the Russian Army," in 1879, states as follows : "In gen- eral, only the farinaceous portion of the ration is issued in kind, the rest being given in money, known as * soup- money ' (preevarzheny dengy), which is disbursed in each company, under direction of the captain, by an enlisted man having good talent as a marketer, and elected by the whole company. " The farinaceous ration, in time of war, is hard black biscuit, 2 pounds per man per day ; in time of peace, it is wheat or barley flour, and a buckwheat gruel much es- teemed by the Russian peasants. The ration of flour is 2.04 pounds; of gruel (in the grain), 0.31 pound for the line, and 0.42 for the guard. The bread is usually baked by the men in company bakeries. "The soup-money is intended to buy meat, vegeta- bles, salt, vinegar, tea, sugar, spirits, beer, and other arti- cles of food and drink. The amount of this money is determined by the price of meat. "The other portions of the soup-money are constant and invariable, and the whole sum is calculated to give the men half a pound of meat about four times a week (one hundred and ninety-six days in the year, the rest of the year being fast days), and a certain amount of vege- tables, tea, spirits, etc. . . . " There is no salt meat used in the Russian service." Articles of food. Grammes. Nitrogen. Carbon. Bread 918 11.00 285.0* Meat 180 4 37 18.0 Pasta (macaroni, etc.) 180 3.24 52.0 Vegetables 33 1.27 13.0 Bacon 15 8.0 Salt and pepper 20 Total 19.88 376.0 Bread 918 11 00 285 0 Meat 150 3 65 15 0 Pasta (macaroni, etc.) 200 3 60 58 0 Bacon 15 8.0 V egetables 50 1.90 20.0 Salt and pepper 20 Total 20.15 386.0 Type B. Bread 918 11 00 188 0 Pasta (macaroni, etc.) 350 6 30 101 0 Bacon 20 11 0 Cheese 23 1 66 13.0 Vegetables 25 0.95 10 0 Salt and pepper 20 Total 19.91 323.0 Type C. Type D. Bread 918 11 00 285 0 Meat 220 5.35 22 0 Vegetables 100 3 50 41 0 Bacon 15 8 0 Salt and pepper 20 Total 19.85 356.0 Type E. Corn meal 700 11.90 308 0 Meat 150 3.05 15 0 Vegetables 75 2 85 30 0 Cheese 33 , 1.66 13 0 Bacon 15 8.0 Salt and pepper 40 Total 20.06 374.0 Rye meal + 625 10 94 356 0 Meat 180 4 37 18 0 Pasta 180 3 34 52 0 Vegetables 33 1.27 13 0 Bacon 15 8 0 Salt and pepper 40 Total 19.82 374.0 Type F. * Errors in this and the subsequent Italian rations are in the original. The proportions of nitrogen and carbon estimated in these tables from Italy, are somewhat different from the proportions estimated in the other rations. t Six hundred and twenty-five grammes of rye flour are sufficient to form the bread ration. In Italy " it is established that for the maximum nutri- tion of soldiers, from eighteen to twenty grammes of (azote) nitrogen, and from three hundred and ten to three hundred and fifty of carbon are necessary," and to this standard the different types of ration must more or less conform. " It is in the power of each corps commander to make what modification of the rations he believes necessary, according to the locality, the season, and the services the troops are required to perform. " Owing to the latitude conceded to the commander of the corps to regulate the soldier's rations, he may order the requisition of other substances than those in the above table. ' ' Of bread is given about 918 grammes aday. Of flesh, 220 to the artillery, engineers, cavalry, grenadiers, ber- saglieri. and Alpine companies, and from 200 to 180 to the rest of the army. Of pasta (macaroni, etc.) and rice, Components of the United States Army Ration. Pork or bacon oz. 12 Or fresh beef or mutton *' 20 Or salt beef " 22 Soft bread or flour " 18 Or hard bread " 16 Or corn meal " 20 Beans or peas " 2.4 Or rice or hominy " 1.6 Coffee (green) " 1.6 Or coffee roasted and ground " 1.28 Or tea " 0.32 Sugar " 2.4 Vinegar gill, 0.32 Salt oz., 0.04 Pepper " 0.25 Candles and soap are also issued in the ration, and to troops in the field, when necessary, yeast powder, 0.64 120 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. oz.; rarely, dried fish, 14 oz.; or, pickled or fresh fish, 18 oz., may be substituted for the meat component. Mo- lasses or syrup may be issued in lieu of sugar at the rate of two gallons in lieu of fifteen pounds of sugar. To troops travelling or in the field, when it is impracti- cable to cook rations, may be issued, per 100 rations, in lieu of the usual meat portion of the ration, 75 pounds canned fresh beef, or 75 pounds canned corned beef ; in lieu of the dry vegetable portion of the ration, 33 one- pound cans baked beans ; or 20 two-pound cans baked beans ; or 15 three-pound cans baked beans ; or 5 one-gal- lon cans baked beans. Three pints of liquid coffee per man may be issued daily in lieu of the sugar and coffee component, to troops travelling upon cars, and having no facilities for cooking coffee, the cost not to exceed twenty-one cents per day. The component parts of the ration are subject to changes at the discretion of the President of the United States. The commanding officer of companies has discretion to sell such portions of his soldiers' rations as he deems best, and expend the proceeds of such sale for the bene- fit of the company. The ration, as above given, is issued by the Govern- ment on the belief that it contains ample material for the nutrition of the soldier. Does it ? Considering this ration in relation to the principles, nitrogen and carbon, it appears that the following is the most liberal ration of the alternatives offered. The following ration may be regarded as a type, that is nutritious, and generally to be obtained from the sup- plies accompanying the army. Typical Ration of United States Army. Article. Weight. Albuminates. 12 a QQ TJ 1 rt O Oz. Oz. Oz. Oz. nr *. (.X beef 8 3 1.245 0.6972 MeaL 1 Xbacon 6 0 0.53 4 40 Bread 1 flour 9.0 1 314 0 108 6.174 Ration f X hard bread 8.0 1.248 0 104 5 822 Beans 2.4 C.54 0 05 1 20 Sugar 2.4 2.316 Total 36.10 4.877 5.3592 15.512 These amounts equal- Grs. Grammes. Parts. Nitrogen 339 =• 22 1 The Italian authorities (see above) have concluded that the standard for the soldier's ration should be : Carbon 6,001 = 389 17-G8 Largest Ration of the United States Army in Weight. Nitrogen 18 to 20 = 278 to 309 Itoi Grammes. Grains. Parts. Article. Weight. Albuminates. Fats. Carbohydrates. Oz. Oz. Oz. Oz. Beef * 16.6 2.49 1.3944 Flour 18.0 2.028 0.216 12.348 Peas 2.4 0.528 0.048 1.272 Sugar 2.4 2.316. Total .... 39.4 5.646 1.6584 15.936 Moleschott, quoted by Parkes as the greatest authori- ty at present on this point (I have been unable to refer to the original), says that 243 grains (less than 16 grammes) of nitrogen is the least amount a working man ought to have, and gives the following table of components : albu- minates, 4.587 oz. ; fatty, 2.964 oz. ; carbohydrates, 14.247 oz.-which reduced, gives Carbon 310 to 350 = 4784 to 5401 17.22 to 17.5 * From the beef ration of twenty ounces is deducted seventeen per cent, for bone. Ten years ago I determined the amount of bone in a number of issues of beef. The number of separate issues was 65. The weight of beef issued, including bone, was 1,813 lbs. 5 oz. The weight of bone taken therefrom, 309 lbs. 3 oz., or seventeen per cent. Grs. Grammes. Parts. Nitrogen 319 20 x Parkes himself says, " a man of mean height, weight, and activity requires in twenty-four hours- Carbon 4860 315 15.24 The above ration equals: nitrogen, 392 grains, 1 part; carbon, 4.983 grains, 12.74 parts. A poor ration will contain the salt beef, when hard bread probably will be also issued. Grs. Grammes. Parts. Nitrogen, about.... 250 to 350 16 to 22 1 to 1 United States Army Salt Beef Ration. These amounts vary greatly, but not perhaps more than the appetite of different persons, or of the same person at different times. Dalton says, in " Human Physiology "From experi- ments performed while living on an exclusive diet of bread, fresh meat, and butter, with coffee and water for drink, we have found that the entire quantity of food re- quired during twenty-four hours, by a man in full health and taking free exercise in the open air, is as follows Carbon, about.... 3500 to 5000 227 to 324 14.19 to 14.73 Article. Weight. Albuminates. Fats. Carbohydrates. Oz. Oz. Oz. Oz. Salt beef* 14.66 1.82517 1.0221 Hard bread .... 16.0 2.496 0.208 11744 Rice 1.6 0.08 0.0128 1.3312 Sugar 2.4 2.316 Total .... 34.66 4.40117 1.2429 15.3912 * The salt beef ration is 22 ounces. Parkes gives the nutritious value of salt beef to fresh beef as perhaps two-thirds. I think this an under- estimate, but have taken it and deducted seventeen per cent, for bone. Meat 16 oz. or 1.00 lb. avoirdupois. Bread 19 oz. or 1.19 lb. avoirdupois. Butter or fat 3^ oz. or 0.22 lb. avoirdupois. Water 52 fluid oz. or 3.38 lb. avoirdupois. The above ration equals Nitrogen 3C6 gr. Carbon 4,444 gr. 1 14 In grammes these two rations contain : Supposing the meat to be cooked meat, this equals Gr. Grammes. Parts. Nitrogen 413 27 j Nitrogen. Carbon. 1st Ration 25 323 2d Ration 20 288 Carbon 5255 341 12.72 By the substitution of half bacon for half beef, or 6 oz. bacon for 8.3 oz. beef, the first ration will contain as follows : Gasparin calculates (I once more quote at second hand), a man weighing 141 pounds will require, in grains, Nitrogen. Carbon, During rest 198 4152 During exertion 395 4841 Nitrogen 342 = 22 Grs. Grammes. Parts. 1 Carbon 6,097 = 395 17.95 Now, for purposes of comparison, I place in juxtaposi- 121 Field. Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion the figures above collated, t quantity of food needed for the and purporting to be the j support of active life : given by the word typical, I do not wish to be under- stood as saying that the components entering into its composition are the best possible ; but rather that, of the materials ordinarily available-rendered available by con- siderations of ease of transportation and economy-this ration seems the best, i.e., seems to offer the most favorable proportions of azote and carbon, and give a sufficiency of nourishment. In this ration the amount of nitrogen is greater than in the British ration above given, than in the ration of the Italian army, than in the type given by Moleschott, and than in the type given by Parkes. On the other hand, it is less than in the type given by Gasparin for exertion, and the day's allowance given by Dalton. In regard to Dalton's ration, it must be remarked that the articles of food named are limited to meat, bread, and butter, or fat. Any other sufficient combination of food would have given a different analysis. In the amount of carbon present this ration of the United States army exceeds every other ration given above. As to the proportion of carbon and nitrogen in the dif- ferent rations described, the proportion of carbon to nitrogen in this typical United States ration is about the same as in the Italian army ration, and greater than in any of the others. Now as to weight or bulk. The United States ration, containing meat, bread, beans, and sugar, weighs a little more than 2£ pounds; the British ration, containing meat, peas, bread, and sugar, weighs a little more than 2| pounds; Dalton's ration, consisting of meat, bread, and butter, or fat, weighs a little more than 2^ pounds ; the average of the Italian army rations given, containing generally bread, meat, maccaroni, and vegetables, weighs 1,206 grammes, or a little more than 2| pounds. The weight of the food itself is not given for the other rations, but only the weight in albuminates, fats, and carbohydrates. A consideration of the above rations and their consti- tution seems to the author to point to the conclusion that, theoretically considered, the ration of the United States sol- dier is ample. A few of the most judicious army sur- geons in the United States believe that, in practice, the ration thus constituted has proved insufficient for the sustenance of soldiers on a campaign or doing hard work. The majority, however, of those largely familiar with the practical workings of the question, are of the opinion that the amounts above stated will suffice. If a certain combination of the above-given components can be made so as to insure the soldier the smallest possible amount of nutrition, that is no reason to make such a combination; on the contrary, if a combination can be made that will give the soldier an abundance, that is the combination to be effected, and it is one of the surgeon's duties to show it, and urge it; and from the foregoing it appears that this can be done. In almost every instance where complaint has been made of the insufficiency of the ration, it has appeared that the soldier did not receive the whole of his ration, but that a portion was diverted from its legitimate pur- pose. As before stated, at the discretion of the company commander, parts of the ration may be sold, and the pro- ceeds used for the benefit of the company. This discre- tion is liable to be unwisely exercised, and so in time of peace the soldier's food is wilfully taken from his mouth, while on a campaign circumstances will occur where the soldier is necessarily put on short ration. As to the latter, nothing need be said ; but against the wilful diversion of the soldier's food it is the duty of the medical officer to protest. Even if temporarily unsuccessful in his pro- test, he must repeat it in the hope of final Success. The quality of the articles of diet furnished, and the mode of cooking them, requires the surgeon's watchful inspection attention. Together with the company officers, of food. the surgeon must inspect before and after cook- ing, and give such general instructions on the subject as may secure to the soldier the best-prepared food. Constitution of Various Rations. Nitrogen. Carbon. Remarks. Grs. Gms. Grs. Gms. Parts. 1 Nitrogen. British army ration given as 1 a guide f 343 22 4481 290 13.1 Carbon. 278 18 4784 310 1 Nitrogen. Italian army, standard ration} to to to to 17.4 Carbon 309 20 5401 350 First United States army ra- 1 tion in this paper J 392 25 4983 323 1 Nitrogen. 12.71 Carbon. Second United States army I ration given f 306 20 4444 287 1 Nitrogen. 14.52 Carbon. United States army ration I given as typical i Type given by Moleschott... j- 339 22 6001 389 1 Nitrogen. 17.7 Carbon. 319 20 4860 315 1 Nitrogen. 15.24 Carbon. 250 16 3500 227 1 Nitrogen. Type given by Parkes to 350 to 22 to 5000 to 324 14.16 Carbon. Type given by Gasparin for 1 exertion [ 395 26 4841 314 1 Nitrogen. 12.25 Carbon. Day's allowance of food, ex- 1 413 341 1 Nitrogen. perimentally determined by > Dalton j 27 5255 12.72 Carbon. . All tables known to me as professing to give the chem- ical composition of food vary. The figures here given are calculated from such tables (those found in Parkes' " Manual of Practical Hygiene"); and for them absolute accuracy cannot be claimed. The same data, however, serve as bases for every cal- uitimate culation, and any error in one must be com- analyses of mon to all, so that, though still approximate m°a°themat- ouly, these figures are sufficiently near the icaiiy cor- truth to serve the purposes for which here used, rect. and certainly for comparison. At any rate, if we are not permitted to use (with the foregoing explanation) such figures as these of doubtful ac- curacy, we would be debarred from further research in this direction ; because it is doubtful whether we shall ever attain rigorously exact knowledge of the weight of the ultimate elements composing given quantities of or- ganic compounds used as food. The identical portions used as food, it is manifest, can neither be eaten first and then analyzed, nor analyzed first and then eaten, so that the composition of such articles must be inferred from average analyses of other speci- mens, similar or analogous. Now, setting aside the un- certainties attending the ultimate analyses of organic compounds by our present chemical processes, it is quite certain that different specimens, comprising equal weights of the same article of food, will, on final analysis, give different results, and this because their composition is not the same. Two specimens, say of beef, weighing fifty pounds each, will vary in the proportions, respectively, of bone, muscular fibre, cellular tissue, nerves, veins, arteries, lymphatics, and perhaps other solids and fluids. Slight differences must then exist between different ta- Sufficient- hies, f°un(led as they are on different analyses, 1 y correct and professing to give the weights of nitrogen to r e a s o n and carbon per pound of food ; these differences from. or inaccuracies are not so great, though, as to interfere with useful study and deductions therefrom. This table is confined to the elements nitrogen and car- bon, because, so far as I know, the salts are admitted by all to be in abundance. It must be remembered, too, that coffee is to be added to the above-about one and a quarter ounce per day. The exact value of coffee is undetermined as an article of food; but it is quite certain that, taken in proper propor- tion, it increases the nutritive value of other food taken. It must also be said that in some European armies the war ration is greater than the peace ration, and that in the United States army it has been customary in time of war to add to the peace ration. In designating the third United States ration above 122 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field. Surgeons. Concerning the variety in the ration, I say only that it is sufficient; if for no other reason, because its exchange for other kinds of food is effected daily. On an Arctic exploring expedition, or other simi- lar duty, men may be restricted to the components of the ration furnished, because other food is exhausted or abandoned. This contingency might happen, were every known article of food originally supplied. As this does not pretend to be an exhaustive treatise on food, I will only mention the additional fact that climate and age affect "the demands of the system for food, as well as violent exertion. I am of the opinion that the ration issued to the United States soldier is sufficient to nourish him under any circumstances that are not so extreme as to forbid any provision against. Salt meat in some shape forms a large portion of the soldier's diet in a campaign, and this on account of its availability ; easily obtained in the market, it is easily transported and preserved, while fresh meat is often difficult to furnish to a moving column. Weight for weight, the nutritive value of salt meat is less than that of fresh meat; in this all authorities agree. However, it is difficult, if not impossible, to maintain the health of any body of men upon a diet whose meat component is exclusively salt. Scurvy will make its appearance. It has not been proved that any one or more toxic ingredients contained in the salt meat cause the scurvy. In almost every instance where salt meat is the important element of diet, it also happens that there is a lamentable absence of other kinds of food, notably fresh vegetables, and generally a status of suffer- ing and deprivation in those thus illy nourished as to food. These positive and negative influences combined are the determining causes of scurvy. So it becomes an im- portant part of the military surgeon's duty to see to the frequent issue of fresh meat in lieu of salt meat. In time of peace, ordinarily, seven days' issue of fresh meat and three of salt pork or bacon, are made every ten days. When the meat of recently killed animals cannot be obtained, dried or canned meat may be substituted; to the use of these the greatest objection is their expense. Of these the amount mentioned in the ration of the United States army is the correct proportion. Green vegetables are prophylactics against, and cure for, scurvy. Of these potatoes and onions are the most effective, and where equally cheap and plenty, the only choice between them is that of flavor. When green vegetables are unattainable, the surgeon must insist on the liberal allowance of desiccated and canned vegetables and pickles. Their use in Arctic expeditions, particularly the Greely, has preserved the men in perfect health for long periods. Lime-juice, citric acid, and pickles-inferior to vegetables, but more or less efficacious as antiscorbutics-must be issued in the absence of the vegetables. But the surgeon must insist that fresh vege- tables be supplied. On the march hard bread is issued often because of its facility of transportation. Dutch ovens are issued to troops, and company cooks soon learn to/make a very palatable bread from flour, with or with- out yeast-powder. As soon as any permanence of camp is attained, the surgeon should initiate measures for the construction of ovens and bakehouses by the subsistence and quartermaster's departments. Two and four-tenths ounces of beans or one and six- tenths ounce of rice are issued as alternatives. They are in no sense equivalents. Rice may now and then be allowed to furnish variety, but the sur- geon will urge the habitual issue of beans or peas as the more valuable food generally. Hot infusion of coffee should be issued morning and evening, especially before early morning marches. It fortifies the body and enables it to resist the in- jurious influence of so-called malaria and fa- tigue. Coffee is preferable to tea as a regular ration. Its value as part of the ration is far greater than can be accounted for by its carbon and nitrogen elements. The habitual issue of alcohol to the soldier is unad- visable. Sometimes of great value as a prompt stimulant, it should be kept on hand. Space is wanting to describe the physical characteris- tics of healthy and unhealthy food. In the case of meat, the surgeon may notice whether it is putrefied or infested by organisms harmful to man, and this, though it must be admitted that the use of both putrid and diseased meat has been in some instances followed by no appreciable evil result. As regards vegetables, staleness and decay are to be watched against, and the use of stale and decayed vege- tables and unripe fruit forbidden. In cooking, the soldier is apt to select the easiest mode, which as to meat is to fry it, and the soldier's fried meat is apt to be a hard, indigestible article. Roast- ing, baking, boiling, or broiling, rather more inconvenient as modes of cooking, are preferable to fry- ing. Vegetables should be thoroughly cooked, and un- ripe fruit (generally to be avoided) sometimes becomes innoxious by cooking. On shipboard, troops are habitually crowded. A pas- sive life is substituted for an active life, and the ration of the troops so situated may be reduced, even when sea-sickness does not show the propriety of such reduction on short voyages. Drink.-Drink should be treated of with food. Pure cold water is a great desideratum, and the use of impure stagnant water is to be avoided. The precaution of promptly posting a guard over the source of water-sup- ply, be it spring, river, well, or pond, will often prevent pollution-stopping the entrance of animals, and prevent- ing the soldiers themselves from wading, or swimming, or washing clothes in the source. Free drinking of water on the march is no advantage. Soldiers, and recruits particularly, are prone to drink as often during the day as they approach potable water. Canteens are issued to troops, and should be carried filled with water. Even if not drunk during the march, the water may be necessary if no water is found at camp. Those soldiers who take a good drink before starting out in the morning, and then habitually abstain from drinking during the day until camp is reached, soon learn to feel no discomfort from the.failure to drink; while their comrades who frequently drink on the march, not only suffer more when the scarcity of water necessitates abstinence, but even when water abounds, do not seem to march with the same ease and elasticity as those who drink less. Sometimes it happens that the water is muddy, turbid, and impure ; in such case filters are of advantage. Small portable filters are attainable, are sometimes is- sued as part of his outfit to the soldier, and are easily carried. Where the water may be expected to be impure, these filters should be carried by the soldier. On a larger scale, sand is often used as a filter. In the lower portion of a barrel with a perforated bottom sand is well pressed. The barrel is then filled with the turbid water, which passes through the sand, and, guided in some convenient mode, passes through and out more or less purified. For the purification of water alum is often used, drop- ped in in the proportion of half an ounce to the barrel (five grains to the gallon is sufficient). In the southern parts of the United States, bruised cactus or prickly pear is thrown into the barrel of muddy water, which before long becomes clear. Water is often purified by boiling. Wells may be dug, particularly in those sections of country where water may be found near the surface, such as sandy edges of river-channels and the sea-coast. Armies should be provided with a tubular pump, with pointed and perforated end, to be pushed into the ground below the water-level, which is generally followed by abundant water on pumping. On the peninsula on which stands Fortress Monroe, pumps of this kind sunk Very near the ocean yielded water so slightly brackish as to be not ungrateful to the palate. Alcohol. Variety. Cooking. Salt meat. Scurvy. Food on shipboard. Free drink- ing not an advantage. Antiscor- butic food. Filters. Hard and soft bread. Purifica- tion of wa- ter. Beans or rice. Cofiee and tea. 123 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The solution of ice in water tends to clarify, and now that ice is manufactured by machines at small expense, this is worthy of consideration. When the campaign is in inhabited country, or in the vi- cinity of navigable water, an ice-machine can always be operated-in the latter case in an air-chamber prepared for the purpose on shipboard. If the water is salt, it may be distilled before freezing. In these times of ad- vancing civilization it will be expected that every army will be supplied with machines sufficient to provide ice, if not for all, at least for the sick ; and this is one of the charges of the surgeon peculiar to modern times. Under certain circumstances it may become necessary to issue water in limited quantities. The maximum sup- ply of water is measured only by the drinker's desire when water is abundant; but what is the minimum necessary for health ? The amounts of water taken in with solid food, and imbibed as drink, are complementary. Both amounts together range be- tween four and five pounds-about the latter. Professor Dalton, by experiment, found that, with an ordinary suffi- cient diet of meat, bread, and butter, fifty-two fluid ounces more were required as drink. The statutes of the United States require that the masters of vessels transporting passengers between Europe and this country ' ' shall deliver to each passenger at least three quarts of water daily." This of course is for all purposes, drink- ing included. In the United States navy, one gallon of water is allowed to each person daily. The surgeon should see that this latter is the minimum allowance to be provided for troops upon transports or expeditions where scarcity of natural water makes it necessary to carry a full supply. Where it becomes necessary to reduce the allowance, the above will indicate the principles of effecting such reduction. Clothing.-A soldier's clothing is an element of im- Weightof portance in maintaining his health and military clothing, efficiency. The weight of different articles of his dress (recently weighed for me) now is as follows : Fifty pounds is not such a heavy weight to lift, but by the time a man has carried it for fifteen miles, it becomes more than perceptible. Hermant gives the weight carried by the Belgian sol- dier as follows: Ice and ice- machines. Kilos. Vetements 5.5S0 Armemen t et equipement 7.206 Sac charge 17.393 Total 66.53 pounds = 30.179 Morache gives the weight of the equipment of the French as 77.16 pounds = 35 kilogrammes ; of the Prus- sian, as 62.26 pounds = 28.240 kilogrammes ; of the Rus- sian, as 68.93 pounds = 31.268 kilogrammes. Parkes gives the weight carried by the British foot soldier of the line as a " trifle over 60 pounds," of which a little more than half is clothing, including blanket. It will naturally suggest itself that this weight may be occasionally diminished. The soldier, particularly if a recruit, starts out with a full supply of clothing, includ- ing duplicates of most garments. Soon he considers some superfluous, and disposes of them. No advice of the surgeon, or anyone else, will now persuade him to carry aught save what he knows to be immediately needed. The clothing retained by him he wears until filthy or worn out, and trusts to his ability to obtain from Government new clothing to replace that no longer fit to wear. As to clothing, the surgeon's advice will be often of ad- vantage. He will cause flannel or woollen garments to be the habitual dress of the soldier in the field, to protect against the danger of sudden cooling. He must advise that garments be worn loose around the neck and chest. Not so many years ago, officer and sol- dier alike wore around the neck a stiff stock of leather or pasteboard, from two to three inches in height, and scooped out at the chin, which not only kept the head in a constrained position, but constricted the neck and in- terfered with the free circulation of the blood. Such stocks are no longer worn, neither are shakos nor heavy helmets, and bullet-proof cuirasses no longer envelop the chest. Helmets, light in color and material, are made and issued to troops, and weigh from seven to sixteen ounces. They are the best head-coverings in tropical climates. The flannel blouse is an admirable garment, scarcely to be improved on, and the pantaloon is excellent. The great-coat is loose and still sufficiently warm, and when worn with the kepi leaves little to be desired ; most sol- diers prefer to trust for warmth to their blanket, twisted and tied over the shoulder for carriage. Cotton shirts are preferable to linen. When the sol- dier wears the flannel shirt over the cotton shirt, the former does not so easily show dirt, in consequence of which, and the difficulty of having washing done in the field, it is very apt to escape washing. Soldiers should be specially charged by the surgeon to change their clothes according to temperature, more es- pecially as regards falling of temperature ; no one cause is more prolific of soldiers' diseases than inattention to such climatic change. Leggings or gaiters are not issued as uniform to the United States soldier. They, however, should be issued, of cloth or leather, buttoned up the side. As far as the author's observation goes, all soldiers like them. After a day's march through rain or mud, regiments may be observed coming in, every man having his pantaloons tucked into his boots or stockings, which is his nearest substitute for gaiters. Concerning the mode of carrying the soldier's load, much has been written, and more than one apparatus devised. The surgeon must remember that the back, shoulders, and hips must bear the brunt, and straps for shoulder and breast and waist fur- nish the means of distributing most advan- tageously the burden. Knapsacks and haversacks are furnished the soldier which in convenience can hardly be excelled. Habitations.-Permanent barracks will not here be treated of. A m ount of water needed. Clothing, kind of. Article. Pounds. Ounces. Forage cap or campaign hat, either 0 5# Overcoat 5 8 Undershirt (knit) 0 15# Drawers 0 12# Socks (wool) 0 4# Shoes .... 2 11 Knapsack (clothing bag) .... 1 14 Blouse 2 X Trousers 1 14# Shirt (blue flannel) 1 0 Blanket (wool) 5 0 Blanket (rubber) 2 14 Haversack includes meat-can, tin-cup, knife, fork, and spoon .... 4 8 - Total .... 29 11# If the soldier wears or carries a uniform coat instead of a blouse, 1 pound and 1| ounce additional must be added. If a pair of boots instead of shoes, 12| ounces additional; if he carries an india-rubber pouch, an ad- ditional 2 pounds and 11 ounces. Besides the clothing worn on his person, the soldier carries a number of duplicate articles in his knapsack, and his shelter-tent weighs 2 pounds and 6 ounces. In addition the soldier must carry his arms and ammunition, as follows : Weight of equipment. Pounds. Ounces. Carbine 7 8 Carbine sling and swivel 1 1 Belt for cartridges (in field) 0 15 Cartridges, forty rounds 2 9 Total 12 1 Cavalry Soldier. Infantry Soldier. Springfield rifle with bayonet Pounds. 9.43 Cartridges, forty-five rounds 4 539 Total 13.969 Soldier's load, mode of carrying. Frequently the soldier will carry also his day's ration of 2| pounds, and 2 pounds of water in canteen-and so carry on his person 50 pounds. 124 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. In the field, troops occupy cantonments or camps. Cantonments are the inhabited places which troops occupy for shelter, when not put into bar- racks. In camp, troops are established in bivouacs, tents, or huts. Bivouacs are camps without artificial shelter, and gen- erally occupied but for a single night. Ordi- narily the tent is the residence of the soldier in the field. It may be necessary to select a site for camp on purely military grounds, or else on account of fuel, water, and grass for the animals. Where these considera- tions are not paramount, the surgeon should be consulted in regard to the camp site ; or, if not consulted, it is his duty to volunteer his opinion to the proper authority. He must remonstrate against low, marshy grounds and bottom lands, and favor dry, porous soils and elevated ground. Sufficient slope to carry away surface-water is desirable, and a position sheltered from objectionable winds by trees or elevated ground. The north wind in winter, and malaria-bearing breezes from marshes, are objectionable. Old camping-grounds should be avoided, and the ground should be disturbed as little as possible in preparing it to receive the tents or huts. Ordinarily, tents or huts in camps are located by military rule, which crowds the camp, rendering its population more dense than a thickly peopled city. While it is true that dis- ease often follows crowding, yet it may be said that the open-air conditions in camp are such as to minimize this danger, the air entirely surrounding and blowing upon each habitation. Most surgeons agree that the distance between tents or huts should be at least one and a half time their diameter. The surgeon's efforts should be to separate them as far as possible, and in encamping a large army he need never fear that they will be too far apart. The Regulations of the United States Army say: "In active campaign troops must be prepared to bivouac on the march, the allowance of tents being limited as fol- lows : for every two soldiers one shelter-tent." The shelter-tent consists of two canvas pieces, 66 x 65 inches each, so provided with buttons and button-holes that several may be united into a continuous cover. By means of uprights they can be made to assume a tent-like form, and by tent-pins and ropes be secured to the ground. In the campaigns of 1861-65, they speedily became the favorite tent of the American soldiers, and still are so. The weight and amount of shelter given being considered, it is doubtful whether anything better can be devised. During the advance, re- treat, or pursuit, in warm, pleasant weather, the soldier will use no shelter. He sleeps sub Jove. The time comes, however, when storm and cold forbid military operations ; when camps are occupied for longer periods, and even for the whole of the winter months; and it is now that the surgeon must interest himself to guide the efforts and ingenuity of the soldier. Now, other tents are provided, habitually the wedge or com- mon tent, and the Sibley, or their congeners. The common tent, at the bottom, is 6 feet 10 inches by 8 feet 4 inches, with a ridge-pole on two uprights, 6 feet 10 inches high. The tent is wedge-shaped, and has a capacity of about 192 cubic feet. One tent is occupied by six foot, or four mounted, soldiers. This latter is supposed to keep in his tent saddle and bridle and horse accoutrements. The Sibley tent is a cone of canvas 13 feet high, with a diameter at the base of 18 feet, and open at the top for ventilation. Its cubic capacity is about 1,103 feet, and it is designed to shelter 17 mounted men or 20 footmen. The air space thus given to each man is, strictly speak- ing, insufficient, ranging from a minimum of 29 feet per man in the wedge-tent, to a maximum of 62 feet per man in the Sibley ; in either case 3 feet being deducted for the body of each occupant. The tents are, however, never fully occupied, not far from one-fourth of the authorized inhabitants being ab- sent on guard or otherwise. Thus ameliorated, the cubic air-space per man ranges from 35 feet per man in a wedge- tent occupied by infantry, to 82 feet per man in a Sibley tent occupied by cavalry troopers. This mode of tent life does not last long. So soon as the soldier learns that his camp is established for some time, he takes steps to promote his comfort, and one of the first steps is to improve his residence. He raises artificial walls, surmounting them with his tents for a roof, or he builds a hut which may be wooden en- tire. His shelter, wedge, and conical tents may all be utilized for roofs, while he builds his walls of the height desired, with vertical or horizontal timbers, chinked with mud or plaster, with stone ce- mented in the same way, or entirely of mud. Doors, windows, and floors are generally in some way procured, while stoves, or fireplaces of stone or mud serve for warmth. In these extemporized houses bedsteads are soon constructed of old boxes or barrels, forked sticks, brush, or canvas, which raise their owner from the ground. The surgeon must not rest contented here, but will now recommend that lumber be furnished to make the walls of these tent-houses, or erect entire huts. The question has been raised whether tents or huts are more desirable as winter quarters for troops in camp. The nearer a hut approaches to a well-built barrack, the greater its superiority to tents ; but a hut may be so con- structed and occupied as to be inferior to a tent. In determining the size of these quarters the medical officer must realize the fact that, to give the air-space re- quired in theoretically perfect huts for a large army, more lumber would be needed than the means of transportation of even the most liberal govern- ment could supply. He must therefore content himself with the best that is practicable, remembering that thor- ough ventilation may prevent the evils threatened by crowding. Where the roofs are to be constructed of the tents, man- ifestly the size of the huts must depend on the size of the canvas. While Medical Director of the Army and Department of Arkansas, in the winter of 1863-64, the author saw excellent temporary quarters occupied by troops of that army. Trunks of trees were planted in the ground, side by side, on a circumference the size of the tent to be used as a roof, proper openings being left which were closed by a door and windows. On the tops of the trees, levelled off about six feet from the ground, were secured the tents used as roof-generally the Sibley tent. Mud was chinked in between the tree-trunks. Board floors were laid in some, in others the earth, covered with gravel or clay, was well tamped down, and around the outside earth was heaped a foot or more in height. The ground in most instances was cleared, when necessary, for a few feet around each tent, and a trench led the surface-water to a distance. To most of them fireplaces were built, though some were heated by stoves. Chimneys were made of the best ma- terial attainable-stone, mud, old stovepipes, pieces of tin, or a framework of sticks covered with mud. It must be confessed these latter did not always prove fire- proof. To each of these huts were assigned fifteen to twenty men. The cubic capacity of a hut thus built, with perpen- dicular walls six feet high and eighteen feet in diameter, with a conical Sibley tent on top, equals 2,629 feet, and it is not difficult to determine the air-space enjoyed by each occupant according to their number. These tent-huts were habitually well ventilated. The line of junction of wood and canvas was far from air- tight, the canvas itself admitted air through its interstices, and in many cases the tents were secured on the top of the tree-trunks in such a manner that they might be easily removed, to admit air and sunlight. In fact, habitually, the ventilation was so excellent as to obviate or compensate for the ill effects of limited air-space. In the various reports of American military surgeons published in Appendix of vol. i., "Medical and Surgical History of the Rebellion," it is remarkable how little is Canton- ments. Bivouacs. Huts. Site for camp. Size of huts. Descrip- tion of huts used in 1863. S h e 1 ter- tent. Tent, wedge or common. Sibley tent. 125 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. said concerning the camp quarters of the troops. Ihe medical director of the army of the Potomac says that in the winter of 1863-64 these quarters consisted "for the most part of log huts about eight feet square, the walls four feet high, and roofed with shelter-tents." These were occupied by three to four men. He further says, " the beds of the men were in all cases raised from the ground, and the huts were all warmed by open fireplaces." This same officer reports, the next winter, a "nearly uniform system of huts, generally six by ten, and not less than five and a half feet to the eaves." These were roofed with shelter-tents and assigned to four men. Dr. Calhoun says his division built " new, large, well-ventilated, and well-warmed huts." Dr. C. F. Haynes says, "the artil- lery brigade built log huts warmed by open fires, save two instances, where Sibley stoves gave heat." With these exceptions, scarce a word can be found in the re- ports referred to as to the winter quarters of the army. In the Crimean war the size of the huts varied. The largest were 74 x 16.5, with ten feet to the eaves, and five feet eight inches above the eaves. They were occupied by forty-eight soldiers. The Portsmouth huts were 27 x 15 feet inside measurement, six feet to the eaves, and twelve to the ridge. They were intended to give about one hundred and forty-six cubic feet space to twenty-five men. Generally, the surgeon will consider that the size of winter huts for troops must be determined by the dimen- sions of the material available for their con- struction, as well as the size of the companies or squads who are to occupy them, remembering the general rule that twenty to twenty-five is the maximum number who should be permitted to occupy one hut. The site and size of huts having been determined con- formably to the foregoing principles, the site should be cleared to about three feet around. The ground to be embraced within the walls should be smoothed, slightly raised (never excavated), pounded, or hardened, and the tents, or huts, or their combination erected. Trenches should be dug surrounding the hut, and thence in a direction and to a distance suitable to carry off all drainage. The ground outside may be slightly raised, but an embankment should never be erected around the bottom for the sake of warmth, but instead the hut may be lined to a convenient height with- in, to ward off currents of cold air. The cleared space outside should be paved or covered with gravel. Wooden floors should be laid if possible, and suitable provision made for the entrance of the air from outside through either the floors or the lower part of the walls. Eaves should carry the rain from the roof to a sufficient dis- tance, and, if practicable, porches should be built, as add- ing much to the comfort of the inhabitants. Ventilation must be secured at ridge, end, and sides. Ridge ventilation consists of an opening at the ridge through the roof, running the whole length of the building, or less, according to the severity of the climate. A hood, or cap, covers this at a distance from the roof varying also with the climate, and ex- tending far enough over the edges to prevent the entrance of rain or snow. Hinged shutters may be so arranged as to close these openings, but their manipulation should never be left to the discretion of the soldier, to whom warmth is more desirable than ventilation. Side and end ventila- tion should be effected by doors, windows, and specially constructed openings. These huts may be warmed by stoves or fireplaces, which should be placed at one or both ends. The pipes of stoves may be carried along the inside of the hut, near the roof, for the entire length, to thus aid in heating, and the chimney, in case of fireplaces, erected at one end. Allusion has heretofore been made to the bizarre material utilized at times in the construc- tion of fireplaces, and the ingenuity of a frigid soldier is wonderful and reliable. As ventilators, fireplaces fur- nish the best mode of heating huts; as economizers of fuel, stoves. The stove may be surrounded with a jacket of zinc, or sheet-iron, between which and the stove fresh air from outside, introduced through openings in the floor, is heated before entering the general apartment. The surgeon will now see that the huts are whitewashed outside and inside, and that the soldiers' beds are raised above the ground. The latrines and sinks will demand the surgeon's attention. He must locate them to leeward of the huts, not less than a hun- dred and fifty feet, and cause their disinfection daily, with lime or carbolic-acid compounds preferably. For sinks trenches in the ground should be dug, about two feet wide, eight to ten feet long, and six to eight feet deep, surrounded by screens of brush, with a pole sup- ported at either end by uprights, and running longitudi- nally to serve as a seat. When lime, charcoal, or carbolic acid are unattainable-in fact, ordinarily-the earth from the excavation piled up near by is thrown into the fossa daily, covering its contents. When the trench is filled thus to within eighteen inches of the surface, it should be entirely filled up with earth piled above the level of the surrounding ground. Charred tubs or half-barrels may be placed at some con- venient place nearer than the sinks, if they are distant, to be used as urinals, to be emptied daily at a distance and dis- infected. It can scarcely be too often repeated, that the ventilation and cleanliness of these quarters will demand the surgeon's constant watchfulness. The soldier must be prevented from banking with earth the outside of his tent to keep out the cold. Although the interstices of the canvas are not air-tight, the ventilation of a closed, crowded tent is poor, as may be readily recognized by any one from the open air entering a tent which all night has been closed and occupied. The manipulation of the ridge ventilators must be entrusted only to some trusty person previously instructed on the subject. Where possible, the tent-roofs of the huts must be opened or entirely removed, and the doors and windows opened, so that air and sunlight, nature's great purifiers, may be admitted. When all in this direction has been done, the hut floors are apt to become saturated with human emanations, and the surgeon's duty is imperative to recommend the removal of the houses from the foul spot to a clean one, and at all events, all re- fuse and filth must be moved away, burned, or buried at a distance. Chloride of lime, charcoal, and lime are furnished as disinfectants by the quartermaster's department-the lat- ter in the form of whitewash-and must be freely used. But the fact cannot be too emphatically impressed upon the surgeon, that disinfectants will not supply the place of cleanliness and removal. In military parlance, the removal of filth and refuse is called policing, and after thorough policing the surgeon must continually look. The work thereof is performed by soldiers detailed for the purpose. Where it is not done without the surgeon's interference, he must interfere, making such representa- tions to the commanding officer as will cause it to be done. When travelling by sea, all parts of the ship may be oc- cupied as soldiers' quarters. From the nature of the case, the soldiers are crowded, and the surgeon must particularly guard against the neglect of thor- ough policing, or such resources for securing ventilation as may be practicable. Duties of Surgeon other than Routine.-The foregoing are more or less routine duties of the surgeon ; but there is a class of duties which he is re- quired to perform, connected with the habits of the soldier, which it is extremely difficult to formulate. The effect of aggregation or massing, on a large num- ber of men, is a strange psychological problem. A mob may so easily be induced to perform acts the most illegal and irrational, and an army, if I may use a contradiction of terms, is a disci- plined mob. Men who at home are correct, dignified, and sensible members of society, when gathered into an army, and removed from home restraints, will speak and act in violation of propriety, decorum, and law. In- discriminate disregard of law, hygienic as well as other, becomes the rule rather than the exception. The lapse of time and the power of discipline may di- Latrines. Crimean huts. Best size for huts. Huts, pre- paration of. Disinfect- ing. Ventila- tion of huts. Sea travel. Surgeon's duties other than rou- tine. Heating of huts. Aggrega- tion of men, effects of. 126 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. minish this tendency to lawlessness, but it never entirely disappears in an army of volunteers or militia, i.e., an army where fighting is not the business adopted for life. For these soldiers a full sense of his own responsibility never prevails and becomes his constant rule of action. These facts increase the responsibility of the surgeon, and add to his duties, for the whole life of the soldier needs super- vision, and it would be difficult to name a circumstance or condition of his military career when he may not be benefited by such watchful care as it is the province of the surgeon to give, in his capacity of conservator of the public health ; and in this connection it is mainly to ex- erting an influence upon the personal habits of the sol- dier that the efforts of the surgeon must be directed. So the surgeon will impress upon the soldier that per- sonal cleanliness must be enforced, lice and other vermin kept at a distance, and contagion of every kind warded off or neutralized. Bathing of the person will prevent many diseases ; of the eye, ophthalmia. Vaccination must be rigorously enforced to prevent small-pox, as to whose prevention thereby the author's experience forbids him to doubt. The washing of the feet at the end of the day's march, and the soaping of the socks, or greasing the feet on putting on the socks, will often prevent sore feet. Examination of the gums from time to time will detect the advent of scurvy, and isolation of con- tagious diseases must be promptly enforced to prevent their spread. Excess in the use of tobacco, as in civil life, is productive of numerous evils, and the continual presence of syphilis and gonorrhoea in military camps, constantly point out to the surgeon the propriety of warn- ing against exposure to their cause. The necessity of ex- ercise in moderation ; the avoidance of exposure to ex- cessive heat, cold, fatigue, or excitement of any kind ; the need of sufficient sleep and food, and the evils of gluttony in food or drink ; the danger of unnecessary exposure to night air, especially in malarial regions ; the good effects of discipline, and the evils resulting from disobedience ; the danger of neglecting the first symptoms of disease, and the perils of intoxicating drink-all these are subjects whose importance is to be impressed by the military surgeon upon the soldier, of whom he is the na- tural sanitary adviser. Correlatively, of all these subjects with every other affecting the soldier's health and life, the importance must be impressed by the surgeon on those military authorities who permit or enforce the soldier's modus vivendi. IV. Duties as Medical Historian.-The military surgeon's duties of record will next be considered. These duties interest the sick and wounded and their families, the Government, and science. In many countries the sick and wounded who are per- manently disabled in the line of duty are entitled by law to pensions or other allowances, such as artificial limbs, admission to soldiers' homes or hospitals; and the evi- dence on which these allowances must be granted or graded is to be found in the records kept by the military surgeon. These records must therefore be suf- ficiently minute, giving a description, topo- graphical and other, of every wound, the his- tory of such wound, and of every case of sickness, with its beginning, end, and name, and a full report of the conditition of the subject when dis- charged from observation or from the service. Upon these same records the families of those who die in the service, from sickness or wounds, must also depend for evidence to secure them the pensions habitually granted in such cases. In many armies the greater part of this information is consolidated in certain reports of sick and wounded. These are either stated and periodic, or special, and made from time to time as rendered nec- essary by battle or epidemic. In the United States army this regular report is stvled the " Consolidated lieport of the Medical Department." It should, however, rather be called (as regards soldiers) a " Report of Cases Excused by the Surgeon," for surgeons are instructed habitually not to enumerate therein cases not excused from duty by them. Now, cases of disease of a grave nature not unfrequently occur which are not excused from duty by the surgeon. To illus- trate by cases occurring in the author's experience: In- guinal hernia has occurred in the person of a company clerk. The nature of the clerk's duty did not require that he should be excused therefrom by the surgeon on account of his rupture. He never was so excused, nor his case reported. Cases of tumor, malignant and other, and of haemorrhoids, have occurred in soldiers who were discharged the service in consequence of expiration of term of service, while yet their disease was incipient or immature, and not necessitating excuse from duty. These cases are not of record. The general commanding has been sick and treated by the surgeon, and has excused himself from duty; his case is not reported. Cases of skin dis- ease, venereal and other diseases, are presented for treat- ment, in consequence of which the patient is never ex- cused by the surgeon from any duty; his case is not reported. It is manifest, then, that in the United States army, the report of sick and wounded cannot be held to represent the whole number of cases occurring in the army. For this report, however, "a threefold object" is claimed : " first, to collect through qualified observers reliable statistics relative to diseases and injuries occur- ring among troops of different races and nationalities, and subject to the conditions of locality and climate inci- dent to the military service ; second, to show the effects of similar conditions upon women and children accompany- ing the army, and upon the civil population in the imme- mediate vicinity of military posts and stations; and lastly, to aid in the establishment of the rights of soldiers and their dependent heirs in the matter of pay, bounty, and pension." This paper, and the directions regarding it, are highly elaborate, and it seems very possible that the multiplicity of details required may now and then interfere with their accuracy. The paper is of recent introduction, and has not yet been submitted to the test of a war or large aggregation of sick and wounded, and it is to be feared that it necessitates more clerical labor than can ordi- narily be given in a large military hospital. In every case of transfer of a patient, a careful and full history of the case should accompany him, as thus only can the continuity of the history of each case be preserved. From the hospital records are also determined the cur- rent account of individual inmates with Gov- ernment, that is, of allowances fixed by statute or regulation, and of which the chief are monthly pay, and food and clothing. In a diametrically opposite way the interests of Govern- ment are affected. While governments have granted more or less liberal allowances to their soldiers, it is evidently to their interest that these be not granted to those who have not earned them and are not entitled to them. The trustiness of- hospital records is here the Government's chief reliance. The surgeon is re- quired, in every detachment or large body of troops, to Morning make a daily written report of the number dis- report. abled from duty by sickness or wounds. He is further required to make special report of all epidem- ics occurring, and from these reports, alto- gether, may be estimated for future wars the probable percentage of men who during a cam- paign will be unfitted for duty by sickness, and also may be prophesied the probable effective strength of an army. Hence also may be inferred not only the most probable diseases to be apprehended during a campaign, but ra- tional grounds are supplied for the application of pre- ventive measures. The medical officer is required to report and record the amount of public property of all kinds obtained and ex- pended by him. These reports and records not only serve to maintain responsibility and enforce economy in the use of public property, but from a con- sideration of them for many years and many wars, valu- Def ects in. Surgeon's advice to soldier. General advice con- tinued. Correlative- ly, surgeon must advise high author- ities as well as rank and file. Transfer of patients. Accounts of patients (money, etc.). Govern- ment i n - terested i n accurate hospital records. Records' accuracy advantage- ous to sol- dier. Epidem- ics, report of. Report of sick and wounded. Property reports. 127 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. intervals if directed by the commanding officer, by whom it must be approved. 4. Requisition for Medical and Hospital Supplies. This is made for such period as may be directed, or when ne- cessary in consequence of emergency. This requires the approval of the medical director. 5. Requisitions for Quartermaster's Stores. These are made when needed, and require the commanding officer's approval. 6. Returns for Medical and Hospital Property and for Quartermaster Property. These are made at such stated times as may be directed, or when the officer is relieved from duty with, and responsibility for, the property em- braced in the return. 7. Hospital Fund Statement. This is practically a re- turn of subsistence stores. It accounts for part of the ration consumed as food; for part as sold, giving the amount received for such sale, and accounts for this amount by regularly receipted vouchers. Articles of a durable nature purchased from this money (i.e., the hos- pital fund) is regularly accounted for by 8. Invoices, Receipts, and Return for articles of a dura- ble nature purchased from the hospital fund. These are made at such time as may be directed, or at the time when responsibility for such property ceases by transfer. 9. Register of Patients. This is a ruled book, in which are entered the names and history of all cases treated. The information is the same as a part of the Consolidated Report of S. and W. (Vide 18.) 10. Case, Diet, and Prescription Book. This is a rec- ord of the diet and prescriptions of each case. 11. A Report of hired Nurses aud Cooks made monthly in duplicates, where nurses and cooks are hired ; one copy for the medical director, and one for the surgeon- general. 12. Register of Patient's Effects. A book containing opposite the patient's name a list of his effects, which must be returned to the patient in case of recovery, or to his legal representative in case of death. 13. A Book of Transfers, recorded in a book, the leaf of which is torn out to accompany the patient, while the stub in the book contains the same information as the leaf sent. 14. Book of Certificates of Disability. This book con- tains the retained copy of certificates given patients to secure their furlough or discharge on surgeon's certifi- cate. The original surgeon's certificate is sent to the military authority who is able to grant discharges or furloughs. 15. Record of Deaths and Interments. A book con- taining ruled forms to be filled up in cases of death, and sent to the quartermaster's department who provides the grave. A stub is left in the book containing a dupli- cate. 16. Muster and Pay Rolls. These are ruled forms on which are entered the names of soldiers, and the amounts due or stopped against them, on which the soldier is paid. In the United States army they are made every two months. 17. Descriptive Lists. These are transcripts from the muster and pay roll (16), and are made for the benefit of soldiers sent elsewhere. They give the data for calcu- lating his pay. 18. Consolidated Report of the Medical Department. This is a monthly report previously commented on. It is very elaborate, giving for each case the full name and hospital number, age, race, nationality, and birthplace, with reference to former admissions to sick report. It must state whether the disease originated in line of duty, and give explicitly the name and anatomical location of disease and injury, and all complications and intercur- rent diseases. Transfers must be noted fully, and the results and disposition of the case. Ex-officers and sol- diers under treatment must be accounted for on this re- port, which must also include the cases of civilians at- tached to the command, and a report of births, marriages, and deaths occurring among them or the military. Under General Remarks must be noted ' ' matters of interest per- taining to the medical, hygienic, or sanitary condition of able information is obtained as to the probable amount of hospital accommodation, as to the probable amount of transportation that must be provided for the sick of an army, and as to the probable amount of medical and hos- pital supplies and food that they will need. These are all elements that aid in the calculation of war's expenses. Science also is interested in these records. Collective investigation is a wrell-recognized source of knowledge, and an observer can scarcely record a fact that will not at some time or other prove useful, or that will not find its place when some other correlative fact is recorded. Statistics are of interest in a double sense. They con- tain in a concrete form the past history of a subject (and the history of every subject interests its student), and they contain the germs of knowledge as to the future. Averages obtained from statistics are not, in isolated cases, exact and absolute guides, but they become so more and more in proportion to the magnitude of the interests involved. Thus, if statistics show that in a large army, under unex- ceptional circumstances, any percentage whatever require monthly hospital treatment, the man may well err who affirms, in regard to a single hundred, that that identi- cal number in the future will be sent to hospital; never- theless he will err but little, if at all, if he affirm that from the thousand hundreds composing a large army, a thou- sand times that percentage will require hospital treat- ment. From the voluminous reports and records of military surgeons, valuable information has been and will be ob- tained as to the health of armies, their prevalent diseases, and the results of treatment-including in the term disease ■woundsand injuries-for the future repeats the past. As disease and wounds occur in civil as well as military life, and often identical in form, so the civil surgeon is often under obligation to the military surgeon (as wTell as the opposite) for knowledge thus contributed. And while military surgeons of all civilized nations have not been backward in this direction, it may be truly said that the American military surgeon has not failed to contribute his full quota. For convenience and uniformity all hospital records that may be, are made and kept on printed forms fur- nished for the purpose. They embrace public property of all kinds, in the shape of "requisitions," which are printed requests for articles needed, and " returns," which are printed forms to be tilled up with the amounts of property received and its disposition. In the form of special and other reports is found the meteorological and sanitary history of the country in which is operating the army, as well as the sanitary his- tory of the army itself. But enough has been written to show that this is not the least important part of the military sur- geon's duty, and it goes without saying that copies of all reports made by the surgeon must be retained, with his hospital records or regi- mental records, where there is no hospital. Below are given the reports and records required to be made and kept by the military surgeon of the United States army. 1. Personal Reports. These are made at the end of each month, or at the date of change of station. They must narrate the duties performed during the month, the journeys travelled, and the writer's station at date. They are made in duplicate, one copy to the medical director, and one to the surgeon-general. 2. The Morning Report. This is made daily in a book ruled for the purpose. It contains the number, the com- pany, and regiment of those excused from duty by the surgeon on account of wounds or disease, the duties from which excused, and whether in hospital or quarters for treatment. This book is sent by the surgeon to the com- manding officer for his information, and by him returned to the surgeon to be tilled up with the next day's report. 3. Requisition for Rations for those in Hospital. Not only patients, but hospital steward, nurses, and cooks. This is made on a ruled form, every ten days, or at other Statisti- cal reports advanta- geous to science. List of re- po r t s r e- quired from military Burgeon. 128 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. the troops and post, prevalent diseases of the vicinity, etc. One copy of this report is sent to the medical di- rector and one to the surgeon-general. They are made monthly, or for a fraction of a month when necessary. In the field, sheets ruled accordingly are stitched to- gether to the requisite size. This report is of such im- portance as to be worthy of the closest attention of the surgeon. 19. Lists of Wounded after Battle. This report is re- quired within two days after an engagement. It must be made to the medical director on Form 18 (see 18 above) and under Remarks. Should give place and date of en- gagement, troops engaged, and losses on both sides. 20. Order and Letter Books. All letters sent and re- ceived, and all indorsements, must be copied in a book devoted to that purpose, and indexed. 21. Register of Medical Examination of Recruits. This is a book containing the retained copy of a monthly re- port to be made to the medical director and the surgeon- general, giving the number, names, and description of re- cruits examined, their acceptance or rejection, and cause for the latter. 22. Report of Epidemics. Whenever an epidemic occurs, special report thereof is to be made to the sur- geon-general through the medical director ; this must be full. 23. Medical History of Post. This is a book in which must be entered a mention of all things affecting the sanitary condition of the post. 24. Sanitary Report. Medical officers are required monthly, at least, to formally examine, note, and re- port to the commanding officer, the sanitary condition of the quarters, the character and cooking of the ra- tion, the amount and quality of water-supply, the drain- age, and the clothing and habits of the men, with such recommendations as he may deem proper. If the rec- ommendations be approved and carried out, the medical officer will so note in the Medical History of the Post (23). If the commanding officer does not deem the rec- ommendation practicable or desirable, he will indorse his objections on the report and forward to the department commander, and his indorsement shall be copied in the Medical History of the Post. 25. Special Reports. The surgeon must make special reports on all subjects in his opinion requiring them, and whenever he deems them necessary. 26. Report of Hospital Matrons. Where hospital ma- trons are on duty with a command, the medical officer, at the end of each month, will report to the medical direc- tor their names and date of appointment. 27. Building Estimates. Annually, on the first of May, medical officers in charge of hospitals will prepare and forward to the War Department, through the com- manding officer, detailed estimates of repairs, alterations, or additions required for their hospital during the suc- ceeding year. If new hospitals are needed, this report will include plans and estimates therefor. 28. Meteorological Reports. Certain medical officers at certain places are specially directed to make and record meteorological observations, and forward monthly re- ports thereof to the surgeon-general. Temperature, weight, and movements of the air, amount of clouds and rainfall are embraced in these reports. Not infrequently complaint is heard against the num- ber of the reports required from medical officers, with sneers at " red tape." But medical officers cannot long serve without being convinced of the necessity of every report required. V. Hospital Surgeons.-Military surgeons are liable to duty in military hospitals. In these their strictly pro- fessional duty differs in nothing from the same duty in similar cases of diseases and injury else- where, and therefore here it will receive no com- ment. But in the military hospital much other than professional duty devolves upon the sur- geon in charge, much of which is indicated above ; and of this duty much must be delegated to, and performed by, subordinates. In connection with the foregoing pages, it is only neces- sary here to repeat that medical and hospital supplies, furniture, food, fuel, lights, and luxuries, cooks and nurses, must all be procured by the surgeon in charge in modes or in accordance with the principles heretofore enunciated. Books, reports, and records must be made and kept as above directed. Assistant surgeons, hospital stewards, and all other aids and subordinates, must be assigned by the surgeon in charge to their specific duties; while obe- dience must be enforced and discipline maintained by him among patients and all other residents or frequenters of his hospital. VI. March and Battle.-The military surgeon is called a non-combatant. Still he is exposed to the dangers of the battle-field, and in every war are published the names of surgeons who have been killed in battle, as well as of officers whose function is purely to fight. I will quote from the " His- tory of the Medical Department of the United States Army," a work published from the surgeon-gen- eral's office, Washington, in 1873. Of medical officers, during the War of the Rebellion, " thirty-two were killed in battle, or by guerillas, or par- tisans, and nine by accident; eighty-three were wounded in action, of whom ten died ; four died in rebel prisons ; seven of yellow fever; three of cholera; and two hundred and seventy-one of other diseases, most of which were in- cidental to camp life, or the results of exposure in the field ; making a roll of honor embracing four hundred and nine names of those whom it is a common error to consider not exposed to the dangers and chances of war." Marches are generally preliminary to battle. Concern- ing the rapidity and proper length of the march each day, I say but little, because, ordinarily, these are regulated by military necessity. The soldier will not be pressed to make great efforts in either speed or distance, unless necessity demands it, and then he must make the effort. A body of men is unable to make the same speed that a single man can; nevertheless armies have made marches of forty to fifty miles in the twenty-four hours. Cavalry, for limited periods of time, can cover more ground than infantry, but for long pe- riods foot soldiers are able to outmarch and break down mounted soldiers. On the march the medical officer should be mounted. The greater part of his duties will have to be performed after arrival in camp, and therefore lie should arrive there not too weary to perform them. If the three regimental medical officers are with the regiment, one should be near the head of the column, one near the centre, and one at the rear with the ambulance, in which should be permitted to ride only those specially designated by the surgeon. The surgeon should be accompanied on the march by a mounted orderly, carrying a medical knapsack or case, and a pocket case. Medical cases and knapsacks are issued by the medical department of the United States army, of different patterns, di- vided for convenience into compartments, and containing materials for provisional dressings, and such stimulants, restoratives, and other medicines as the surgeon may choose. Some surgeons prefer medicine saddle-bags, which are also issued. The near approach of battle puts new responsibilities upon the surgeon. The expected unexpected has come. An indefinite number of wounded are about to need care from (in proportion to numbers) a small number of surgeons, with insufficient means of removing the hurt to a place of ref- uge, and but poor refuge often when reached. Precision and rapidity of firing, in modern battles, fur- nish a large number of wounded in a short time. Here it is necessary to speak only of the first care of the wounded, which must be given on the field by the surgeon serving with the troops, who sends the wounded as speedily as possible to the place in the rear provided for fuller treatment-which places, and the means of transporting the wounded, are directly con- Mil itary surgeon exposed to war's vio- lence. March, length and rapidity of. S u rgeon on march must be mounted. P o s ition on march. O r d erly n e eded by surgeon. K n a p- sack, medi- cal. Battle, sur- geon's r e- s p onsibili- ties in. H ospital surgeons li- able to oth- er than pro- f essional duty. Wounded, first care of. 129 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trolled by the medical director. One of the regiments' medical officers is always expected to accompany the regiment into battle, and to be well in front to give prompt aid where needed. In the writer's experience, and, so far as he has heard, in the experience of other medical directors, the junior medical officers have never avoided danger, or needed urging to expose their persons and lives when a wounded soldier demanded succor. Such wounded as are able to walk, the surgeon must promptly direct to the hospital or depot at the rear ; those who are unable to walk he must despatch to the same place by litter, ambulance, or most convenient mode. It is not proposed to perform capital operations on the battle-field ; but the surgeon must be prepared and will be expected to apply appropriate remedies for collapse ; to check haemonhage, generally by pressure ; to apply simple dressing to flesh- wounds ; to apply some sort of temporary splints in cases of fractured bones-sufficient at least to facilitate and render less dangerous and painful the removal of the so-injured from the field of battle. It is worth repeti- tion to say, that at this time the surgeon must see that his orderly be present with his knapsack and some sort of material as may serve for splints, if not the splints themselves-branches or twigs of trees may often serve as substitutes. It will be well also for the surgeon to see that field-tourniquets are carried to the battle-field by about one-sixth of the soldiers, and some sort of material for dressing by about one-third. The field-tourniquet is not often of service on the field, still the author knows of one instance where life was saved thereby; but they will do no harm, and are of light weight, and when they do good, they do great good. The dressings should be antiseptic-oakum, carbolated tow, or cotton wool, are convenient forms, or materials soaked in a solution of corrosive sublimate ; or some- thing similar to the first field dressing devised by Es- march. During, and after, a battle of any great magnitude, the surgeon's opportunity for rest is small. Night ar- rives, and the field is covered with the mingled mass of wounded, dying, and dead. The separation of the living from the dead, and the search for those whom he may hope to relieve, will occupy the time of some of the medical officers; while the labors of the operating room or tent, and the prepara- tion of large hospitals with small means, will put to the test the endurance and capacity of every medical officer. After a big battle, many weary hours will elapse before the wounded are all picked up, and more than one de- tail of exhausted surgeons will have left the operating room, and their places been filled by other relays, be- fore even the primary operations will have all been per- formed. The responsibility for the care of the wounded at this time does not rest upon the regimental surgeon, but on his superiors. VII. Medical Purveyors.-The Purveying Depart- ment furnishes to the army medical and hospital supplies. While the higher ranks of the purveyor's corps are, in most armies, filled by permanently ap- pointed incumbents, the majority of the pur- veyors are officers of lesser rank, temporarily assigned to such duty by army commanders or higher authority. Much of the successful supplying of an army with medical stores will depend on the intelligence and energy of these officers. They procure supplies from the base and distribute them at the outposts, and they procure them as directed by higher authority, either by purchase or by requisition on depots, where they have previously been notified that supplies would be stored subject to their order. It is part of their duty to notify higher authority of their prospective wants. They issue supplies to the medical officers on requisitions ap- proved by the medical director, or as they may be di- rected by this last-named officer. Law and regulations hold purveyors to strict responsibility for public property in their hands. VIII. Medical Inspectors.-In some armies a dis- tinct corps of officers permanently appointed perform in- spection duty. In other armies, for such duty, officers are temporarily specially assigned on account of qualifications supposed to constitute suitability. Medical inspectors make periodical tours of inspection of the command to which they are attached, or they make special tours, as and when directed. They in- spect military camps, barracks, forts, and hos- pitals, and the troops occupying these places. Through the reports of inspectors, superior authority habitually learns the existence of evils before unknown to them, but requiring remedy, as well as the truth concerning special evils reported through other channels, and is thus able to minimize, prevent, and correct the faults for which they might be held responsible. Familiarity with regulations, orders, and the wants of an army will suggest to the inspector the points requiring his particular attention. The most important will here be named. Regarding the medical officers, the inspector should notice their number with regiments or in hospital, their sufficiency, presence, or ab- sence, reason of absence and prospect of return ; their activity, competence, and attention to duty. The same points demand attention as to hospital stew- ards, nurses, and cooks. The number of sick must be ascertained, the mode of caring for them, and the disposition made of them ; the nature, cause, and preventability of the diseases occurring ; the food, drink, camps, and cook- ing of sick and well, and their supply of am- bulances ; the hospital tents, hospital supplies, and records ; the hospital itself, in which the sick are cared for, whether regimental or otherwise, and its man- agement. Regarding the camp, the inspector must inspect the abodes of the soldiers, whether tents or huts ; their heat- ing, ventilation, and policing ; their latrines, sinks, and urinals ; the regulations in force for the preservation of health, and the observance of those regulations and of regulations in general. The inspection here treated of must include not only all things directly under the control of the military sur- geon, but every irregularity, every violation of law, orders, or regulations, influencing in any way the health of the army. Hence men, manners, mind, body, habitation, diet, dress, and discipline all fall legitimately within the purview of the medical inspector. Reports of these inspections must be made to the medi- cal director or other authority ordering the inspection, by whom alone the evils discovered can be remedied. In different armies the practice varies as to the author- ity possessed by inspectors. Generally it has been found best for inspectors to exercise no absolute au- thority on their inspecting tours. Manifestly the exercise of supreme authority by two heads in the same place may lead to a conflict of authority. The inspector is rather the eye to see than the tongue to com- mand, or the hand to act; nevertheless, he should inform local commanders of evils discovered in their commands, and advise with subordinate medical officers as to the ex- istence of the same, and the best mode of remedying them, and very seldom will it happen that faults in the power of the subordinates to remedy will not be cured before the report of their existence can reach higher authority. IX. Medical Directors.-The chief medical officer of an army corps, of a separate army, or of a military department, is the medical director. Large armies are organized into brigades, consisting of two or more regiments ; divisions, consisting of two or more brigades ; and army corps, consisting of two or more divisions. To each of these organ- izations it has been found convenient and ad- vantageous to assign a chief medical officer, who is Inspectors, how ap- pointed. Inspection tours. Informa- tion gained from in- spection re- ports. Surgeon's duties on field. Facts about medi- cal officers to be learn- ed by in- spectors. Facts to be ascertaine d about the sick. Concern- ing camp. After bat- tle. All points embraced by inspec- tion. Inspection reports, to whom macle. Pur v e y- ors, how ap- pointed. Authority o f inspec- tors. Duties of purveyors. Chief medical officers. 130 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons, styled, for the brigade, " Brigade Surgeon ; " for the divis- ion, " Surgeon-in-Chief," and for the other organizations, " Medical Director." The duties of these officers are spe- cial, and to a large extent supervisory. Mutatis mutandis, a description of the duties of one may apply to all, and as the duties differ in degree rather than in kind, they will all be treated of under the head- ing of Medical Director. So far as human responsibility carwextend, this officer is responsible for the health of the army. In other words, he is held responsible that knowledge, fore- sight, and well-directed effort shall do all that can be done to avert sickness, and properly care for those who, notwithstanding such efforts, are taken sick. Armies have been decimated by preventable disease. Campaigns have failed, rather from sickness than from opposition of a recognized, tangible foe. For these reasons, habitually, commanding generals receive with respect the opinions and recommendations of the medical director, and treat them with the consid- eration to which their importance entitles them. Rarely has it been otherwise, in the armies of the United States especially. But when it is otherwise-when the precau- tions and warnings of professional wisdom are slighted- the responsibility of the medical director ends, though not his grief, his regret, and his efforts in the same direc- tion. To the humane and intelligent it is sad to see his comrades perish in spite of timely warning. Ordinarily the officers of whom we are treating are the ranking medical officers on duty with their organiza- tion. The medical director is habitually selected and assigned to his duty by the War Depart- ment of the Government. Such is the regula- tion in the armies of the United States. In some armies, that selection may not be embarrassed, an increase of rank goes with the assignment. In the army of the United States, by law, medical directors of every corps, ipso facto, rank as lieutenant-colonels, and medical directors of armies and military departments rank as lieutenant-colonels or colonels, according to the size of the army or department. Speaking in the most general terms, the duty of the medical director is to supervise and administer all mat- ters affecting the health of the army, making, from time to time, to the commanding general the proper recommendations therefor. To do this the medical director must of course be fa- miliar with sanitary science, and familiarize himself with military regulations, as published by the general Govern- ment in a book-avade mecum-styled "Army Regula- tions." Subordinate medical officers will frequently require from him instruction in their duties, and control in their performance by advice and orders. By personal inspection and the reports, verbal and written, of his inspectors and other subordinates, the med- ical director, as speedily as may be after joining, must learn the sanitary condition of the army, and thereafter, by the same means, keep himself well informed of all changes in such condition. He must ascertain the number of medical officers, hos- pital stewards, and other employes serving with the army, and if insufficient procure more by request from higher authority. Ascertaining in all ways the capacity of his medical officers, he will take steps to weed out the incapacitated and ignorant. In the armies of the United States he is authorized to order examining boards, on whose adverse report the disqualified are obliged to vacate their office. He must recommend to the commanding general the assignment of medical officers to such duties as they have demonstrated their peculiar fitness to perform, such as sanitary officers, inspectors, purveyors, and hospital sur- geons. Requiring from regimental surgeons regular sick-re- ports, from which he may learn the health of the army, he must recommend proper precautionary measures against the loss of health-such as the removal of troops from unhealthy to healthy sites, the enforcement of vac- cination, and of obedience to police and general regula- tions regarding food, water,- camps, and clothing, and he will never falter in his watchfulness against epidemics. Armies are specially subject to typhus, typhoid, and paroxysmal fevers ; to small-pox and measles ; to scurvy, to ophthalmia, and venereal diseases ; to cholera, diar- rhoeas, and dysenteries, according to latitude and sea- son. For these he must watch, and against them recom- mend precautionary measures before their appearance, and measures to mitigate their severity and mortality when prevalent, at the same time superintending in a general way (the only way permitted him by want of time) the practice in camp and hospital. He must direct the mode of the treatment of the sick, as regards the proportion in regimental, brigade, division, corps, or general hospital, and decide the important ques- tion of the amount of hospital accommodation to be pro- vided. The general hospitals belonging to the army are estab- lished at suitable places more or less near to the army, and should be under the sole control of the medical di- rector. In the army of the United States the control is so vested. The question of amount of hospital accommodation required is one to be determined only by the soundest discretion. The organization of a large hospital is not an inexpensive affair, and the transportation of its material is sometimes a very difficult matter. The percentage of those requiring hospital treatment varies greatly in different armies, and in the same army at different times and places. In the winter of 1861-2 the Medical Director of the Army of the Potomac, for four different months, reported the per centage sick as 7, 6.07, 6.50, and 6.18, of whom he reports less than half in. hospital. In November, 1864, of the same army, he reports 4 to 5 per cent. sick. In January, 1862, the present Surgeon-General of the army reported in the army of which he was medical di- rector, in the West, 13| percent, excused from duty, and a little over 12 per cent, in March. In August, 1861, of some troops on the flats near Ar- lington, on the Potomac, 33 per cent, were reported sick with diarrhoea and malarial fever. The proportion need- ing hospital accommodation is not given. Of the British army in the Crimea, on the week ending April 7, 1855, the reported sick and wounded were a little more than 12 per cent., of whom 5 per cent, were wounded. During the five weeks ending May 5th, the number averaged nearly 11 per cent., of whom but 1 per cent, were wounded. June 2d, a twelfth part of the army were on the sick list. June 9th, the sick amounted to 10 percent.; June 30th, nearly 14 per cent. During most of the time above referred to. from May 5th to July 14th, the cholera pre- vailed. The same dates comprehend a period of harass- ing and dangerous duty in the trenches and one terrible assault. The report does not state that 14 per cent, was the maximum of sick at any one date, but it gives no greater number. The total admissions to the hospital were 58 per cent, of the force. During the five weeks ending May 5, 1856, the sick are reported to have averaged 10 per cent, of the whole force. The Transvaal, Afghanistan, and Egypt are all con- sidered unhealthy for European troops. For the war in Afghanistan, 1878-79-80, the Brit- ish Medical Department provided field-hospital accommodation for 5 per cent, of the force, and base-hospital accommodation for 7 per cent. For the Transvaal war, 1880, they pro- vided hospital accommodation for 19 per cent. For the war in Egypt, in 1882, the same department provided field-hospital accommodation for 12 per cent., Respon- s i b 1 e for health. Rank and assignment of medical directors. Ratio of sick in ar- mies of U. S. Duties of medical di- rector. Ratio of sick in Brit- ish army. The ratio of British troops for whom hos- pital a c - commoda- tions are provided. 131 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and base-hospital accommodation for 6 per cent, of the force, in addition to a system of transport ships. I have before stated that the figures representing the number of sick in the United States army refer to all excused from duty by the surgeon, and consequently in- clude many not requiring hospital treatment. The statistics of the British army refer to the number admitted to hospital. The British reports for the ten years 1863-72 show that of the force in the United Kingdom the "mean daily sick, per 1,000 of the strength," was 41.55. Among the European troops in China, the same re- ports, for the nine years 1864-72, give the "ratio for 1,000 of strength constantly sick " as 79.35. Boudin calculates that in an expedition lasting ninety days, the daily changes of the sick will average about 3 per cent, of the force. This does not include the wounded. Now, besides the regular tide of sick, with its daily ebb and flow, it must be remembered that epidemics may swell the list, and a battle suddenly add its indefinite number of helpless victims ; the enemy's wounded being often added to the burden of the victors. In 1863, after the battle of Gettysburg, 14,193 of the wounded of the Union army were left on the battle-field requiring professional care, and 6,802 of the opposing forces, in all 20,995. The strength of the Northern army which provided hospital accommodation for these wounded may be considered as 90,000, so that by one coup a number equal to more than 23 per cent, of its strength suddenly required succor and professional care, shelter and transportation. Enough has been said in the foregoing to show how varied must be the estimate of hospital supplies needed by an army. In making his decision on the subject the medical director must consider the country, the season, the climate, the nature of the contest, and, above all, the provisions for the removal of the sick and wounded to the hospitals in the rear The minimum hospital accommodation for a campaign, in an army making any pretence to care for its own sick and wounded in its own limits, and without which the medical director must not rest content, is for fifteen per cent, of the army's strength. Besides, there must always be a reserve sup- ply somewhere available, to promptly make good losses by capture, fire, shipwreck, or ordinary use. It is part of the business of the medical director to see that regiments are always ready to enter into active operations, as far as the medical department is concerned, and he must, therefore, cause them to be always provided with hospital tents, medical supplies, and the means of transporting them. He must direct the regimental sur- geons what amount of hospital supplies it is desirable that they keep on hand, and how and when to renew them ; and, on the other hand, he must inform the medical purveyor as to the nature and quantity of these supplies probably needed by the regiments. The requisitions of medical officers for such supplies must be submitted to the medical director for his exami- nation and approval before issue. Recommendations for sick leaves for officers, and fur- loughs for soldiers, and certificates of disability for dis- charge, are submitted by the commanding general to the medical director for his approval. They merit very care- ful attention, for it surely happens that, tired of the war and anxious to escape from the fatigues and hardships of the campaign to their homes and families, a certain num- ber of soldiers will always be found desirous of magnify- ing their infirmities. The medical director will find it necessary to take steps to enforce the prompt rendering by medical officers of the stated and other reports heretofore mentioned; and he must receive the reports of his inspectors and other re- ports due at his own office, and act appropriately thereon. Reports received by him, and intended for the Surgeon- General or commanding general of the army, he must for- ward with the remarks and recommendations needed. Then the medical director has his own reports to make. He serves in a dual capacity, being responsible both to the Surgeon-General and the commanding general, who must depend upon the medical director for in- formation concerning the medical department of the army, and for advice as to all sanitary matters affecting it. Certain needs of the army can only be supplied by agencies outside of its limits, while others can be better supplied by the mediation of the medical bureau. These wants should all be embraced in the reports of the med- ical director, together with information of the army's movements and every other item of interest that may serve to give information of its needs to the power able to sup- ply them. When timely notice is given to the medical director of a proposed military movement, he must disembarrass the army of its sick and wounded by sending them to the hospitals in the rear. If the movement is to take place by water, the transports are to be examined as to suita- bility, particularly as to space. The army being freed of its sick, when warning of im- minent battle is given, the medical director must, by re- newed inspections and reports from his subordinates, assure himself that the troops and the medical depart- ment are in possession of all that it is his business to see provided, viz., food, stimulants, mess-chest, and hospital stores ; blankets, bedsacks, cots, or bedsteads; hospital knapsacks, medicine wagons or chests, medicines and instruments ; tents and stoves, and the means to trans- port them; stretchers, ambulances, an organized am- bulance corps, and a sufficiency of surgeons, each one in- structed as to his place and duty. He is now at liberty to devote himself to his final duty- the supervision of the transportation of the wounded on and from the battle-field, and their care during, and im- mediately after, the battle. And here it may well be said that, although some of the duties above described have been treated of as appropriate to such and such officers, yet it must be remembered that each and every of- ficer is likely to be called on to perform each and every duty heretofore mentioned. X. Cake and Removal of the Wounded in Battle.-The care of the wounded in battle will be treated of under three headings : 1. The attention and aid to be given them on the field. 2. Their removal from the field. 3. A second removal from the temporary hospital to the permanent hospital. This last may be called their service of evacuation. It will be well here to define our terms. "Ambulance" is a word used in many foreign armies to comprehend the whole field organization for the care of the sick and wounded, and has been applied, rather indifferently and indefinitely, to the field hospitals themselves, the surgeons, and the porters of the wounded, whether men, animals, or vehicles, taken as a whole. In France and Germany the terms " ambulances vo- lantes," " Noth-Verbandplatz," have been used to comprehend that most movable part of the means of succor which follows the troops to the very front lines, and from there carries the wounded to their first place of temporary treat- ment, and cares for them there. The terms "ambulances divissionaires," or "ambu- lances permanentes," "la grande ambulance," " Haupt-Ver bandplatz," are in the above-named countries applied to the depot established for the immediate reception of the wounded car- ried from the field. In England the word ambulance has fre- quently been used to signify a wagon used for the carriage of the sick and wrounded. Longmore speaks of this use of the word as a misap- plication of the term. In the army of the United States the word ambulance signifies a wheeled vehicle for the transportation of the sick and wounded. M edica1 dire c tors act in dual capacity. Number of the wound- ed in battle. Duties may be common to all officers. Minimum for whom hospital ac- commoda- tion must be provided. Meaning of ambulance. Ambu- lance vo- lante, Noth- V e r b a n d- platz. Ambu- lances di- vissionaires o r perma- nentes, la grande am- bulance, Haupt -Ver- bandplatz. 132 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. The term "ambulance corps," in the United States, comprehends ambulances, stretchers, and appliances; horse and mule litters; medicine and other wagons, for the carriage and care of the sick and wounded, and medical supplies ; horses, mules, harness, and other furniture or fixtures pertaining thereto ; together with the officers and men necessary for the management of the same. This meaning of the terms "ambulance" and ambu- lance corps, being that well understood in the United States, will be the meaning in this article unless other- wise specified. Succor on the Battle-field.-This is given by medical officers and their assistants, by porters, and by animals and vehicles. In the armies of most civilized nations a certain pro- portion of the medical officers share with the combatants the full dangers of the battle-field and the skirmish line. In the Prussian service it is the rule for one-half of the military surgeons to accompany the troops un- der fire, anil the remainder to assemble in a suitable place out of reach of projectiles. An analogous custom prevails in the English service. During the recent active operations of the British army in Egypt the principal medical officer reports medical arrangements from front to base as follows: "In the first line of assistance there were the medical officers of corps, one to each unit, and in the case of the Guards two to each unit, provided with fielcj companions, water-bottles, and regimental stretcher-bearers. The regiments which were sent to Egypt from the Mediterranean garrisons in advance of the force were, besides, furnished with field panniers on pack mules. " Next, two bearer companies with mountain equip- ment, supplemented by sets of medical comfort-boxes and the canteens taken from the surgery wagons, by a considerable number of the new pattern field-stretchers, and by six light two-wheeled carts. " The second line of assistance consisted of five mobile field hospitals, each provided with the usual equipment, double circular bell-tents, and furnished with twenty light two-wheeled carts. In place of pharmacy wagons field panniers on mules, medical comfort-boxes, and can- teens. " The third line of assistance consisted of three station- ary field hospitals, similarly equipped to the mobile, except that they had marquees instead of bell-tents, med- ical chests instead of field panniers, and double the amount of hospital clothing ; each was also provided with twenty light two-wheeled carts. In addition to the regulated number of paillasses, each field hospital was equipped ■with sixty stretchers (with feet), and feather pillows to form beds for the more serious cases. The articles of equipment of all hospitals were packed in handy-sized boxes, screwed, not nailed, down, for carriage in two- wheeled carts, every package marked with the general hospital sign, a red cross on a yellow square, and each bore the number of the hospital to which it belonged. "A number of special articles were provided to meet special requirements and exigencies which were to be an- ticipated in a country like Egypt, such as goggles, veils, ophthalmic napkins, wire bed-cradles covered with gauze, mosquito nets with frames, bamboo chicks, wire dish- covers to protect the food from flies, machines for mak- ing ice, refrigerators for cooling food and drinks, and filters. Very large supplies of medical stores and sur- gical appliances were held in reserve at Ismailia and Alexandria ; among these were all the modern appliances for the treatment of wounds antiseptically, discs of all kinds for subcutaneous injection," etc. In the armies of the United States, during the war of 1861-65, the general custom was for one medical officer to accompany the regiment into battle. The remainder assembled either at the division hos- pital or at the place of dressing, provisional hospital, am- bulance depot, or corresponding place (by whatever name called), which it was the endeavor to establish in some place secure from fire, and about five hundred yards in the rear of the line of battle. Habitually between the field of battle and the more or less permanent division hospital there was but one inter- mediate place, whose location was made known to those interested by the hospital or Geneva flag. Where the line of battle rapidly advanced or retreated, the fluctuation was attended with a corresponding change in the depot for wounded. Longmore believed that there should more than one station intervene between the line of battle and the division hospital, and he names the sta- tions "field station," "transfer station," "dressing sta- tion," and " field hospital station." The experience of medical officers of the United States army during the war of secession was, that one station was both necessary and sufficient, in most cases, between the front and the division hospitals. The surgeon in the front was accompanied by the hos- pital steward, when this latter was not more urgently needed at the depot for the wounded or at the division hospital; also by his orderly, with hospital knapsack, provisional dressings, instruments, etc; and, after the organization of an ambulance corps, by such members of that corps as were ordered to the front by the medical director. In March, 1863, the arrangements for the care of the wounded in battle were quite fairly systematized, and Surgeon-General Hammond in that month issued a cir- cular prescribing the duties of the military surgeon in battle. In this circular, except the operating staff and surgeons assigned to specific duty in the division hospitals, it was directed that ' ' the remaining medical officers of the divis- ion, except one to each regiment, will be ordered to the hospitals to act as dressers and assistants generally. Those who follow the regiments to the field will establish them- selves, each one at a temporary depot, at such a distance or situation in the rear of his regiment as will insure safety to the wounded, where they will give such aid as is immedi- ately required ; and they are here reminded that, while no personal consideration should interfere with their duty to the wounded, the grave responsibilities resting upon them render any unnecessary exposure improper." It may be considered, then, the established rule, that one medical officer, to be designated by the regimental commander, when not previously designated by higher authority, shall accompany the, regiment on to the field of battle, and selecting, as far as his duties will permit, the least exposed location, shall there establish himself and give the wounded such immediate aid as they may require. A hospital or Geneva flag should indicate the spot where the surgeon may be found. The hospital steward should accompany the surgeon, and so should the orderly, with knapsack, and all men of the ambulance corps who are available. Litters or stretchers should be carried by the men of the ambulance corps, and in those cases where they have been issued to the troops, and the military authorities permit their approach to the battle- field, the mule litters, cacolets, and light ambu- lances, and carts carrying supplies, should be within the surgeon's call. The surgeon's horse should also be at hand. A pocket-case, or field-case at most, will cover the in- struments needed ; opiates, styptics, and stimulants the drugs. Anaesthetics will seldom be needed. The above- named drugs, with materials for dressing, should be car- ried in the knapsack, or carts, or panniers, when furnished. Materials for antiseptic dressing should always be at hand. It is all very well to enumerate the desirable contents of panniers, comfort-boxes, medicine-cases, field medical companions, carts, wagons, and ambulances ; but in point of fact the commanding general is very little apt to permit the jeopardizing of public property, especially horses and mules, by letting them go where they must be more or less in danger of capture by the enemy. The surgeon on the battle-field must, then, be habitually A m b u - lance corps, meaning of the term. Surgeons on the bat- tle-field. In the Prussian service. In the English army. H o spital or Geneva flag, to show sur- geon's pres- ence. Aids to the surgeon. In the U. S. army. 133 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. limited to such instruments and supplies as can be car- ried on the persons of himself, his steward, orderly, and men of the ambulance corps. Per contra, the presence of these may be generally re- lied on, because among most civilized nations the sur- geon and his assistants, with what they carry on their persons while engaged in the care of the wounded, are exempt from capture or molestation. By the terms of the convention signed at Geneva, in 1864, their neutrality is guaranteed among the signatories. The absence of elaborate supplies here is the less to be regretted, because the succor demanded of the surgeon on the field is necessarily of the simplest character. Save in undoubted cases for treatment by primary antiseptic occlu- sion, the dressing of wounds on the battle-field should be avoided, as dressing there would interfere with prompt and more careful examination at the division hospital. The surgeon on the field should confine himself to measures against collapse ; to the simplest dressings of the few wounds that he may see will benefit by such treatment at once ; to the application of temporary splints to broken bones ; to the stopping of haemorrhage (ordi- narily by pressure); and to the supervising of the move- ments of the wounded from the field. Transportation of Wounded on and from the Field.-It is obvious that the general care of the wounded after a battle must devolve upon the medical department, and it needs but little argument to show that the control of the means of their im- mediate transportation should rest with the same department. Nevertheless, difficulties have arisen connected with this control. It was so in the armies of the United States until an ambulance corps was formed by law. In a previous part of this paper it has been stated that at the battle of Gettysburg nearly twenty-one thousand wounded were added to the sick report of the Northern army-over twenty-three per cent, of the strength of the army. A few more figures and facts, taken from the report of this battle made by the medical director of the Northern army, will serve to illustrate further the subject of which we are now treating, and the difficulties of the case. It was fought on the 1st, 2d, and 3d of July, 1863, nearly nine months before the ambulance corps was es- tablished by law. The medical director says that on the previous 19th of June the transportation of the medical department was cut down, "in opposition to my opinion expressed ver- bally and in writing. This reduction necessitated the turning in of a large portion of the supplies, tents, etc., which were necessary for the proper care of the wounded in the event of a battle. Three wagons were assigned to a brigade of one thousand five hundred men, doing away with regimental wagons. This method, in its practical working, is no system at all, as it is liable to constant changes, and proved to be, what I supposed at the time it would be, a failure, as it did not give the department the means necessary to conduct its operations. " On the 1st of July the trains were not permitted to come farther, and on the 2d were ordered to the rear, near Westminster. On the 1st it was ordered that 'corps commanders and the commander of the artillery reserve will at once send to the rear all their trains, excepting ammunition wagons and ambulances.' " On the 2d these trains were ordered still farther to the rear, and parked near Westminster, nearly twenty-five miles distant from the battle-field. The effect of this order was to deprive the department almost wholly of the means for taking care of the wounded until the result of the en- gagement of the 2d and 3d was fully known. I do not in- stance the effect of this order, except to show its influ- ence upon the department ; the expediency of the order I, of course, do not pretend to question, but its effect ■was to deprive this department of the appliances neces- sary for the proper care of the wounded, without which it is as impossible to have them properly attended to as it is to fight a battle without ammunition. In most of the corps the wagons exclusively used for medicines moved with the ambulances, so that the medical officers had a sufficient supply of dressings, chloroform, and such arti- cles, until the supplies came up, but the tents, and other appliances which are as necessary, were not available un- til the 5th of July. ' ' I had an interview with the commanding general on the evening of July 3d, after the battle was over, to ob- tain permission to order up the wagons containing the tents, etc. This request he did not think expedient to grant but in part, allowing one-half of the wagons to come to the front; the remainder were brought up as soon as it was considered by him proper to permit it. To show the result of the system adopted upon my recom- mendation, regarding transportation and the effect of the system of field hospitals, I may here instance the hospi- tal of the Twelfth Corps, in which the transportation was not reduced, nor the wagons sent to the rear at Gettysburg. Surgeon McNulty, medical director of that corps, reports that ' it is with extreme satisfaction that I can assure you that it enabled me to remove the wounded from the field, shelter, feed them, and dress their wounds within six hours after the battle ended, and to have every capital operation performed within twenty-four hours after the injury was received.' " Over six hundred and fifty medical officers are re- ported as present for duty at that battle. These officers were engaged assiduously, day and night, with little rest, until the 6th, and in the Second Corps until July 7th, in attendance upon the wounded. The labor performed by these officers was immense. Some of them fainted from exhaustion induced by over-exertion, and others became ill from the same cause. " Notwithstanding the great number of wounded, amounting to fourteen thousand one hundred and ninety- three, I know, from the most reliable authority and from my own observation, that not one wounded man of all that number was left on the field within our lines early on the morning of July 4th. A few were found after daylight be- yond our farthest pickets, and these were brought in, al- though the ambulance men were fired upon, when engaged in this duty, by the enemy, who were within easy range. In addition to this duty, the line of battle was of such character, resembling somewhat a horseshoe, that it became necessary to remove the most of the hos- pitals farther to the rear, as the enemy's fire drew nearer This corps did not escape unhurt; one officer and four privates were killed, and seventeen wounded, while in the discharge of their duties. A number of horses were killed and wounded, and some ambulances in- jured. . " It is unnecessary to do more than make an allusion to the difficulties which surrounded the department at the engagement at Gettysburg. The inadequate amount of transportation ; the impossibility of having that allowed brought to the front; the cutting off our communication with Baltimore, first by way of Frederick, and then by way of Westminster ; the uncertainty, even as late as the morning of July 1st, as to a battle taking place at all, and, if it did, at what point it would occur; the total inade- quacy of the railroad to Gettysburg to meet the demands made upon it after the battle was over; the excessive rains which fell at that time, all conspired to render the management of the department a matter of exceeding difficulty, and yet abundance of medical supplies were on hand at all times. Rations were provided and shelter obtained as soon as the wagons were allowed to come to the front, although not as abundant as necessary, on ac- count of the reduced transportation. " Medical officers, attendants, ambulances, and wag- ons were left when the army started from Maryland, and the wounded well taken care of, and especially so when we consider the circumstances under which the battle was fought, and the length and severity of the engage- ment. The conduct of the medical officers was admirable. Their labors not only began with the beginning of the battle, but lasted long after the battle had ended. When other officers had time to rest, they were busily at work, and not merely at work, but working earnestly and de- votedly." Control of .rightly be- longs to the medical department. Transport of wounded at Gettys- burg. 134 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. The foregoing interesting remarks illustrate several points connected with the care of the wounded. And the battle of Gettysburg was fought in the midst of a well-settled country, where houses of various de- scriptions were at once used as temporary places of shelter for the wounded, and a railroad was already constructed on which trains could bring supplies, and take the wounded away. On many battle-fields, both in Europe and the United States, the wounded have been far less promptly cared for, and in some cases days and nights-six to ten-have inter- vened between the reception of the wound and the re- moval of the wounded. Plenty of comrades have always been found ready to carry the wounded from the field, some of them actuated by humanity or affectionate friendship, others making their duty to the wounded a pretext for their own escape from the dangers of the battle. This sort of aid was manifestly neither best for the wounded who left, nor for the unhurt who remained. The former were liable to careless handling ; the latter to be weakened in numbers by the loss of their able-bodied comrades, plus the disabled. An organized plan for taking from the field the wounded suggested itself to many as the only remedy for this state of things, and accordingly the prompt removal from the battle-field of the wounded is the sufficient and real raison d'etre for an ambulance corps. The first systematic effort in this direction of which I have knowledge was the organization by Percy, in 1800, of a company of brancardiers, or litter-bearers. Seven years previously Larrey had only par- tially solved the problem by his " ambulances volantes ; " but habitually up. to 1800, and for many years subse- quently, in most armies, the drummers, the lifers, and the musicians of the band, were called on to carry the wounded from the field. Within the last half century, in many countries, or- ganized bodies of men have been attached to the army, whose sole function is the carriage and care of the wounded and sick. At present, in the French army, one " infirmier regi- mentaire " per company is trained to become a skilled nurse and dresser, while four " brancardiers re- gimentaires " to each battery and company, commanded by non-commissioned officers in the proportion of one sergeant to each regiment, and one corporal to each battalion, carry the wounded from the field of battle or the front line of fighters. In the Prussian (German) army this body of men is divided into " Lazareth-Gehulfen " and " Kranken-War- ter," who, during time of peace, arc more or less instructed in their duties. The first-named receive thorough instruction in the care and handling of sick and wounded. In his report of the Russian army, etc., made in 1879, Lieutenant Greene reports that in that army " there are in all 84 field hospitals and 64 division hospitals (one for each division of infantry and cavalry)." To each division hospital belongs one company of stretcher-bearers, consisting of 1 officer, 9 non-com- missioned officers, and 200 privates. These are in addi- tion to the regular attendants in hospital. The strength given of the whole army on war footing is given by Lieutenant Greene as, total combatants, 835,467. Ac- cording to these figures the ambulance corps numbers almost four per cent, of the combatant strength of the army. In the Austrian army the " Sanitats-Soldaten " and the "Kranken-Trager" receive special instruction. They serve in the hospitals in time of peace, and in war, organized into companies, accompany the ambulances. The " Kranken-Trager," or litter- bearers, number four to a company. In Belgium the men attached to the army in such ca- pacity are termed "soldats panseurs." They number two to each company, with a non-com- missioned officer to each regiment. The Italian army possesses an organization (in this par- ticular) which is almost analogous to that of the Prussian army. The British army possesses its companies of stretcher- bearers and its hospital nurses, generally included in the hospital corps. These men are more or less educated in their special functions, the Royal Warrant of February 22, 1875, providing that "the ranks of our army hospital corps shall be tilled by non-commissioned officers or soldiers, . . . with a view to their undergoing a course of probation at our Royal Hospital, Netley, preparatory to their being transferred to our army hospital corps, if deemed eligible for service therein." The same warrant further reads: "Such men as may from slight ailments be considered unfit for service in the ranks of our army shall be allowed the option of volun- teering for service in our army hospital corps, before being brought forward for final discharge." The wisdom of the last-quoted clause will be more than doubtful to all who have seen the continuous and difficult work required of hospital nurses and bearers of wounded ; none but able-bodied men can perform it. The control of the means of transportation in the Brit- ish army is at times rather mixed ; the ordnance, the com- missariat, and the medical department all being at times more or less powerful and responsible. Practically the number of men assigned to these duties in different armies serving in the different parts of the British empire is variable, and determined by conjecture as to the probable number of sick and wounded to be cared for. For the war in Egypt, in 1882, commanding officers were ordered to detail two stretcher-bearers per company to carry wounded, under the medical officer in charge of each unit ; these men to be trained and practised at every opportunity in their special duties, and not removed save by special sanction of the general officer commanding. At the battle of Tel-el-Kebir "half a bearer company was attached," and for the cavalry "a special cacolet corps, consisting of twenty-five cacolets, carried on horses." Sir J. A. Hanbury, the principal medical officer of the British army in Egypt, reports, as attached to that army, eight field hospitals, the organization of each consisting of 1 officer, 15 non-commissioned officers, and 22 privates, all from the hospital corps. Also, two bearer companies with an organization to each of 2 officers, 1 warrant offi- cer, 20 non-commissioned officers, and 124 privates, all from the hospital corps. The whole hospital corps attached to this army num- bered 820 men, and ' ' from their ranks the hospitals at Gozo, Cyprus, and Alexandria, the field hospital and bearer companies attached to the fighting force, convoys of sick from front to base, and invalids proceeding in transports, were supplied, as well as batmen for the medi- cal officers." This hospital corps was attached to an army whose average strength, as given in its returns, of sick and wounded, was 13,554. This system in the British army is not considered by its medical officers as perfect. Hanbury, making recommendations deduced from his own experience in the field, says : " In my opinion an army in the field should always be accompanied by a large and well-organized ' sanitary or conservancy corps,' under an officer of rank with supreme power, subject only to the general officer commanding ; and that such an or- ganization as this will be found to be the best and most effective mode of keeping men in the fighting line." " One of the most important reforms called for in the present organization of the army medical department in the field is that relating to the land transport of hospitals and bearer companies." The following conclusions, among others, -were derived from the experience of the Afghan campaigns, by Sur- geon-General T. Crawford, principal medical officer: " Sick carriage should be under the orders and at the dis- posal of the principal medical officers of divisions." "The doolie-bearers, now separately employed under In Italian army. In the British ar- my. Primitive mode of re- moving the wounded. Necessity for ambu- lance corps. A m b u - lance corps. In the French army. In the P ru s sian army. In the Russian ur- my. In the A u s t r ian army. In the Belgian ar- my. 135 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the commissariat and medical department, should be con- solidated and instructed for a given period during each year; the men so trained should take the field and be re- placed by others employed temporarily, and not the re- verse." " The doolie-bearers should not only be organized, but have native non-commissioned officers attached to them for carrying out the orders of the medical officer or transport officer in charge, acting under the principal medical officer or senior medical officer present." The army of the United States inherited the traditions of the British army ; for a long time its mil- itary surgeons were without rank or authority, and almost without place in the military hie- rarchy. During its early years the sick and wounded were probably as well cared for as the contemporaneous sick and wounded in other armies, but, owing to illy directed effort, only at the cost of much unnecessary labor, not to speak of personal and professional pride entirely put aside. In 1861 began the war between the Northern and South- ern States-a war of such magnitude as to magnify all imperfections. During the progress of this war the disadvantages of divided control of the wounded and their means of trans- portation became so manifest and unbearable that Con- gress legislated on the subject, organizing an ambulance corps whose absolute control was with the medical de- partment. The law' organizing the ambulance corps was the out- growth of the experience of the war. It codified the orders issued from time to time on the subject, in the va- rious Northern armies, the necessity and usefulness of which had been proved on many hard-fought battle-fields. It became a law in March, 1864. Precisely wdiat directions regarding the care of the sick and wounded existed at the beginning of the war, and how unequal to the necessities of the case, will appear from the following, which embrace all army regulations on the matter in force in 1861. Army Regulation 497 directed that the grand depots of the army having been established where they would not be broken up by the military operations, the hospitals and depots for convalescents, as far as possible, should be there. 703-4 directed that the sick march with the wagons, and the general designates the position in the column to be taken by the ambulances. 734-740 forbade soldiers to leave the ranks to help the wounded, stating that "the highest interest and most pressing duty is to win the victory, by winning w hich only can a proper care of the wounded be in- sured ; " directed the division quartermaster, before the action, to make all necessary arrangements for the trans- portation of the wounded, to establish the ambulance depots in the rear, and instruct his assistants as to the service of the ambulance wagons and other means of re- moving the wounded ; directed " the ambulance depot, to which the wounded are carried or directed for immediate treatment, to be generally established at the most con- venient building nearest the field of battle ; " its place, or the way to it, to be marked by a red flag "to the con- ductors of the ambulances and to the wounded who can walk ;" the "active ambulances" to "follow' the troops engaged, to succor the wounded and remove them to the depots, " for which purpose the necessary assistants to be detailed ; directed the medical director, " after consul- tation with the quartermaster-general, to distribute the medical officers and hospital attendants to the depots and active ambulances to "see that the depots and ambu- lances are provided with the necessary apparatus, medi- cines, and stores "-the medical director himself to " take part and render his professional services at the principal depot; " directed the quartermaster to remove the depot when endangered, and the wounded in the depots and the sick to be removed, as soon as possible, " to the hos- pitals that have been established by the quartermaster- general of the army on the flanks or rear of the army." 1099 and 1100 directed tlie medical director to make estimates for the necessary transportation of the hospital service, which will be provided by the quartermaster, and directed the sick to be transported on the application of the surgeon. 1103 provided that ambulances and all the means of transport continue in charge of the quartermaster. 1329 fixed the allowance of ambulances to a regiment " on marches and in campaigns against Indians" as two four-wheeled and ten two-wheeled ambulances. 1330 fixed this allowance in "a state of war with a civilized enemy" as two four-wheeled and ten two- wheeled ambulances, and four two-wheeled transport carts to a regiment. 1331-32 forbade the use of ambulances for aught save the transportation of the sick and wounded, and directed them and transport carts to be made after the patterns to be furnished by the Surgeon-General. 1333 authorized horse litters where required for service on ground not admitting the employment of wheeled vehicles, "said litters to be composed of a canvas bed similar to the present stretcher, and of two poles, each sixteen feet long, to be made in sections, with head and foot pieces constructed to act as stretchers to keep the poles apart." 1334 fixed the allowance of hospital attendants in the field as one hospital steward, two cooks, and ten nurses to a regiment. 1335-36 fixed the dimensions of the hospital tent (wide page 107) and the allowance of tents to a regiment as three hospital tents, one Sibley tent, and one common tent. 1337 directed medical officers on the march or in battle to be habitually attended by an orderly carrying a hospi- tal knapsack. The foregoing are the only regulations, applicable spe- cially to the sick and wounded in the field, which were in force early in 1861. Under these regulations it is seen the quartermaster controlled the movements of the -wounded and the means therefor, established the depot for the wounded and the hospitals in the rear of the army, and must even be con- sulted by the medical director before the latter could dis- tribute his medical officers. The regulations now in force on these same subjects are as follows : Par. 1067 is the same as 497, above quoted. Par. 1249 allows, independent of the wagons authorized by the ambulance corps law, two wagons for hospital supplies to each brigade of infantry, cavalry, and artillery, of not less than 1,500 men ; and Par. 1252 allows one wagon to each regiment to transport exclusively hospital supplies, under the direc- tion of the regimental surgeon. 1261 directs that all ambulances for the transportation of sick and wounded be painted, the woodwork dark olive green, the ironwork black-the letters U. S. in yel- low, six inches in height, being painted on certain panels, and the red Geneva or Greek cross on a white ground on other panels. 1262 establishes the ambulance depot, to which go the wounded for immediate treatment, generally at the most convenient building nearest the field of battle ; and 1263 declares the hospital and ambulance flags of the army of the United States as follows : For general hospitals, yel- low bunting, nine by five feet, with the letter H, twenty- four inches long, of green bunting, in centre. For post ami field hospitals, yellow bunting, six by four feet, with letter H, twenty-four inches long, of green bunting, in centre. For ambulances and guidons to mark the way to field hospitals, yellow bunting, fourteen by twenty-eight inches, with a border, one inch deep, of green. 1289 forbids soldiers to leave the ranks to aid the wounded, and 1290 enjoins that all the necessary arrange- ments be made, before the action, for the transportation of the wounded, and that the ambulance depots also be then established in the rear. 1821-22 directs that hospitals be built, and ambulances, In the army of the United States. Care of the wound- ed in Unit- ed States ar- my previous to 1862. Care of the wounded in U n i t e d States army at present. 136 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. harness, and wagons be provided by the quartermaster's department, and that medical and hospital (like other) stores be transported by the same department. 1924 directs that the same department furnish the necessary transportation by ambulances for the sick and wounded, upon the requisition of the medical officer, and 1948 directs the necessary transportation for the hospital service to be furnished by the quartermaster upon the duly approved estimates of the medical director. 2327 directs that the medical officer, upon the march, be attended by a mounted orderly carrying a medicine case and the necessary instruments. Finally, the important law organizing the ambulance corps of the army is republished in Regulation 1260 as follows: The following are the rules for a uniform sys- tem of ambulances in the armies of the United States : The medical director, or chief medical officer of each army corps shall, under the control of the medical direc- tor of the army to which such army corps belongs, have the direction and supervision of all ambulances, medi- cine and other wagons, horses, mules, harness, and other fixtures appertaining thereto, and of all officers and men who may be detailed or employed to assist him in the management thereof, in the army corps in which he may be serving. The commanding officer of each army corps shall de- tail officers and enlisted men for service in its ambulance corps, upon the following basis, viz. : One captain, who shall be commandant of said ambulance corps ; one first lieutenant for each division ; one second lieutenant for each brigade ; one sergeant for each regiment; three pri- vates for each ambulance, and one private for each wagon. The officers and non-commissioned officers of the ambu- lance corps shall be mounted. The officers, non-commissioned officers, and privates detailed for each army corps shall be examined by a board of medical officers of the same as to their fitness. Such as are found to be not qualified shall be rejected, and others detailed in their stead. There shall be allowed and furnished to each army corps two-horse ambulances, upon the following basis : Three to each regiment of infantry of five hundred men or more ; two to each regiment of infantry of more than two hundred and less than five hundred men ; and one to each regiment of infantry of less than two hundred men ; two to each regiment of cavalry of five hundred men or more ; and one to each regiment of cavalry of less than five hundred men ; one to each battery of artillery, to which it shall be permanently attached ; to the headquar- ters of each army corps, two such ambulances ; and to each division train of ambulances two army wagons. Ambulances shall be allowed and furnished upon the same basis to divisions, brigades, and commands not at- tached to any army corps. Each ambulance shall be provided with such number of stretchers and other appliances as shall be prescribed by the Surgeon-General. Horse- and mule-litters may be adopted or authorized by the Secretary of War, in lieu of ambulances, when judged necessary, under such rules and regulations as may be prescribed by the medical director of each army corps. The captain shall be the commander of all the ambu- lances, medicine and other wagons in the corps, under the immediate direction of the medical director, or chief medical officer of the army corps to which the ambulance corps belongs. He shall pay special attention to the con- dition of the ambulances, wagons, horses, mules, harness, and other fixtures appertaining thereto, and see that they are at all times in readiness for service ; that the officers and men of the ambulance corps are properly, instructed in their duties, and that their duties are performed, and that the regulations which may be prescribed by the Sec- retary of War or the Surgeon-General, for the government of the ambulance corns are strictly observed by those under his command, it shall be his duty to institute a drill in his corps, instructing his men in the most easy and expeditious manner of moving the sick and wounded, and to require in all cases that the sick and wounded shall be treated with gentleness and care, and that the ambulances and wagons are at all times provided with at- tendants, drivers, horses, mules, and whatever may be necessary for their efficiency; and it shall be his duty also to see that the ambulances are not used for any other purpose than that for which they are designed and or- dered. The first lieutenant assigned to the ambulance corps for a division shall have complete control, under the captain of his corps and the medical director of the army corps, of all the ambulances, medicine and other wagons, horses, mules, and men, in that portion of the ambulance corps. He shall be the acting assistant quartermaster for that portion of the ambulance corps, and will receipt for and be responsible for all the property belonging to it, and be held responsible for any deficiency in anything appertaining thereto. He shall have a travelling cavalry forge, a blacksmith, and a saddler, who shall be under his orders, to enable him to keep his train in order. He shall have authority to draw supplies from the depot- quartermaster upon requisitions approved by the captain of his corps, the medical director, and the commander of the army corps to which he is attached. It shall be his duty to exercise a constant supervision over his train in every particular, and keep it at all times ready for ser- vice. The second lieutenant shall have command of the por- tion of the ambulance corps for a brigade, and shall be under the immediate orders of the first lieutenant, and he shall exercise a careful supervision over the sergeants and privates assigned to the portion of the ambulance corps for his brigade ; and it shall be the duty of the ser- geants to conduct the drills and inspections of the ambu- lances, under his orders, of their respective regiments. It shall be the duty of the medical director, or chief medical officer of the army corps, previous to a march, and previous to and in time of action, or whenever it may be necessary to use the ambulances, to issue the proper orders to the captain for the distribution and management of the same, for collecting the sick and wounded, and conveying them to their destination. And it shall be the duty of the captain faithfully and dili- gently to execute such orders. The officers of the ambulance corps, including the medical director, shall make such reports, from time to time, as may be required by the Secretary of War, the Surgeon-General, the medical director of the army, or the commanding officer of the army corps in which they may be serving ; and all reports to higher authority than the commanding officer of the army corps shall be trans- mitted through the medical director of the army to which such corps belongs. The ambulances in the armies of the United States shall be used only for the transportation of the sick and wounded, and, in urgent cases only, for medical supplies ; and all persons shall be prohibited from using them, or requiring them to be used for any other purpose. It shall be the duty of the officers of the ambulance corps to re- port to the commander of the army corps any violation of the provisions of this paragraph, or any attempt to violate the same. And any officer who shall use an am- bulance, or require it to be used, for any other purpose than as provided in this paragraph, shall, for the first offence, be publicly reprimanded by the commander of the army corps in which he may be serving, and for the second offence shall be dismissed from the service. No person, except the proper medical officers, or the officers, non-commissioned officers, and privates of the ambulance corps, or such persons as may be specially as- signed, by competent military authority, to duty with the ambulance corps for the occasion, shall be permitted to take or accompany sick or wounded men to the rear, either on the march or upon the battle-field. The officers, non-commissioned officers, and privates of the ambulance corps shall be designated by such uniform or in such manner as the Secretary of War shall deem proper. Officers and men may be relieved from service, and others detailed in the ambulance corps, subject to Law organ- izing ambu- lance corps. 137 Field Surgeons, Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the examination provided in section 3 of this paragraph, in the discretion of the commanders of the armies in which they may be serving. It shall be the duty of the commander of the army corps to transmit to the Adjutant-General the names and rank of all officers and enlisted men detailed for service in its ambulance corps, stating the organizations from which they may have been detailed. When officers and men belonging to volunteer organizations are detailed for such service, the Adjutant-General shall thereupon notify the governors of the several States in which such organi- zations were raised. It shall be the duty of the commander of the army corps to report to the Ad jutant-General, from time to time, the conduct and behavior of the officers and en- listed men of the ambulance corps, and the Adjutant- General shall forward copies of such reports, so far as they relate to officers and enlisted men of volunteer or- ganizations, to the governors of the States in which such organizations were raised. Nothing in these regulations shall be construed to diminish or impair the righful authority of the com- manders of armies, army corps, or separate detachments, over the medical and other officers, and the non-com- missioned officers and privates of their respective com- mands. A comparison of these regulations with those above quoted as in force in 1861 shows a marked contrast. Under these latter now in force the quartermaster builds hospitals, and furnishes transportation for hospital stores and the hospital service generally when needed. The system and means of transporting the sick and wounded on the battle-field are placed under the sole control of the medical department, while no power is given to any other department to interfere with the selec- tion of hospitals, or the care of the sick and wounded, which therefore naturally falls to the medical depart- ment. It must be added that since the care of the sick and wounded has thus devolved upon the medical de- partment, the service of caring for them has been more efficiently performed ; this not owing to any want of ability on the part of officers of the quartermaster's de- partment-to whose ability and good-will no one can more cheerfully bear testimony than the writer-but be- cause the special knowledge of the medical man is re- quired for such work, and because under the former system divided power and responsibility halved the ability manifested. And here one thing is worthy of comment. General hospitals, although at once of prime necessity in war, in the United States army are not organized or used in peace. Strange to say, directions concerning them are not to be found in the Army Regulations of 1881, which is also true for 1861. After the beginning of the war in 1861, it soon became evident that for the good of the service the control of these hospitals must be explicitly fixed. An additional paragraph was, therefore, added to the regulations published in 1863, saying, that " the general hospitals are under the direction of the Surgeon-General," who was also authorized by this same regulation to transfer parties of sick and wounded from one general hospital to another. . This regulation, however, did not suffice. The dis- position of various lesser military commanders to inter- fere, without legal authority, in the affairs of the hospi- tals was so uncontrollable that, in December, 1884, the War Department issued an order, declaring the general hospitals to be under the exclusive control of the Surgeon- General, and investing the surgeons in charge of these hospitals with the powers of post commanders. For similar reasons, in February, 1865, a similar order of the War Department announced that "properly as- signed hospital transports and boats" were "exclusively under the control of the medical department, and will not be diverted from their special purposes by orders of local or department commanders, or of officers of other staff departments. The regulations now in force, have, however, omitted these provisions, and are silent concerning general hospi- tals as such. Sec. 1238, Revised Statutes of the United States, how- ever recognizes general hospitals by name. Par. 1161, Regulations of 1881, now in force reads, " The medical director establishes the hospitals, and or- ganizes the means of transporting the wounded to them." This doubtless must be construed to include general hos- pitals. Par. 2289 reads : * ' The senior medical officer of a post is charged with the management" . . . "of the hospital." The authority of the medical officer is largely derived from these regulations last quoted. In the United States army, the size of the ambulance corps is determined from the regiment as an unit, with 500 men as its strength. With two such regi- ments to a brigade, two brigades to a division, and two divisions to an an army corps, the strength of the latter would be 4,000. To one army corps of this strength the law allows as a maximum 26 ambulances with four attendant wagons ; and 7 officers, 8 non-commissioned officers, and 82 privates of the ambulance corps. The privates of the ambulance corps equal about two per cent, of the strength of the army corps. When no fighting is going on this strength is greater than needed, but in battle is less. It is difficult to compare the strength of the United States ambulance corps with the strength of the corps de- tailed for the same duty in foreign armies, absolutely, be- cause, first, in many foreign armies the numbers given include all hospital attendants, while in the United States army the numbers given embrace only litter-carriers and drivers ; and second, because of the difference of the size of the units on which the allowance is based. This size, it is often difficult to determine. As stated above, the proportion of litter-bearers is vari- able at different times and places in different British armies. In the most recent war in which the English army has been engaged, in Egypt, 1882, the privates of the hospital corps equalled a little more than four per cent, of the strength of the army. In the Belgian army the number of " soldats panseurs" is about one and a half per cent, of the strength of the army (36 to 2,500). Foran "ambulance" (in the foreign signifi- cation of the term), the French regulations al- low to an army of 10,000 men, 1 principal med- ical officer, 4 battalion surgeons, 1 apothecary, and 10 assistant surgeons; while for purposes of ad- ministration are allowed to the same, 1 hospital director and 4 assistants, 6 chief nurses, 8 cor- porals, and 90 nurses. For smaller bodies of troops Boudin gives the personnel of the ambulances (in the foreign sense) as follows : For 5,000 men : 9 surgeons or assistants, besides the chief surgeon, 1 director or chief administrative officer, and 66 infirmiers or nurses. For 2,000 men: 7 surgeons, 1 administrative officer, and 49 nurses. In the Prussian army the men organized to care for the wounded in war are divided into three sec- tions. The first section consists of 6 surgeons, 12 aids, and 48 litter-bearers to an army corps. One-half of these surgeons accompany the troops under fire ; the remainder serve between the battle- field and the hospitals (Noth-Verband und Haupt-Verband Platz). The second section, for a corps d'armee, is divided into three parts, one of which is in reserve, and one serves with each of the two divisions of the corps. Each of these three parts consists of 206 persons, viz., 8 skilled nurses, 8 ordinary nurses, 7 medical officers, 1 apothecary, 4 officers for administration, and 178 soldiers and litter-bearers, of whom 25 are subofficers and non- commissioned officers. The third section comprises the personnel of the Feld- Size of ambulance corps in the United States a r- my. Size of ambulance corps in British ar- my. Strength of a m bu- lance corps in Belgian army. Strength of a m b u- lance corps •in French army. Hospitals, control of in medical de- partment. Strength of a m b u- lance corps in Prussian army. 138 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons, Field Surgeons. lazareth, of which there are twelve in a corps d'armee, each capable of accommodating two hundred wounded. The organization of each comprises 5 medical officers, 1 apothecary, 23 nurses and cooks, and 27 subofficers and soldiers. The duties in battle of all these parties is de- tailed in an order issued by the Prussian War Department in 1875 ; for the cavalry a special, slightly different, or- ganization prevails, the men being mounted, for the more rapid movements of mounted troops. In the Austrian army, besides the specially instructed " Kranken-troeger," or litter-bearers, four to a company, the Sanitats-detachment provides nurses who are attached to hospitals, but who, when not actually engaged in the hospitals, serve with the ambulances. To make as complete a comparison as possible between the organizations heretofore described of foreign armies, for the succor of the wounded in battle, and that of the United States army, it will be necessary to say a few words regarding the forces that may be considered directly aux- iliary to the ambulance corps in the latter army. First, the regimental musicians. To a regiment of 10 companies are allowed 20 field musicians, and 16 musicians of the band, with 3 non-commis- sioned officers to infantry and artillery. Allow- ing for absentees, temporary aid to the wounded in battle may be expected from about two hundred and fifty privates to each army corps. A certain amount of aid may be also expected from the officers, non-commissioned officers, and privates detailed for duty in the regimental, brigade, and division hospi- tals. Before a battle these hospitals will ordinarily have been emptied by the transfer of their occupants to the permanent hospitals in the rear. Their personnel, there- fore, may often be made useful on the battle-field while the hospitals are awaiting new occupants. These nurses and cooks equal 10 nurses and 2 cooks to a regiment in the field, or 96 to the army corps. To fully illustrate the subject a word must also here be said concerning the field hospital ; and the individual views of the author concerning them will be given, which will be emphasized by a few facts, gathered from the " Report of the Medi- cal Director of the Army of the Potomac." The first division of the second army corps in the Army of the Potomac is reported by the medical director of the army to have numbered 8,000 men, in 21 regiments, or- ganized into 4 brigades. To it there were allowed, for medical purposes, 22 hospital tents, 14 army wagons, and 4 medicine wagons. Six of the army wagons were loaded with regimental medical property, four with brigade sup- plies, two with hospital tents, one with cooking utensils and three hundred rations, and one with blankets, beef- stock, whiskey, chloroform, bandages, lint, etc. An operating-table was established for each brigade, with cor- responding wagon beside it; otherwise brigade and regi- mental organizations were ignored. The surgeons-in- chief were, ex officio, the operating surgeons. Thirty-six regular hospital attendants in a distinctive uniform pre- pared and distributed food, dressed wounds, and gener- ally cared for the patients. During battle the drum corps of the division, 350 men and boys, organized into companies, and properly officered, was put on duty in the hospital; from these, details were made to pitch and strike tents, move the wounded, procure water and wood, bury the dead, and do general police duty. A provost guard was present with the hospital during an engagement to arrest malingerers and restore stragglers to their com- mands. In a few divisions of the army the hospital tents were pitched by brigades, and it is stated that the divis- ion hospital could be pitched or taken down and packed in the wagons in forty-five minutes. Owing to the pe- culiar service of the cavalry such a system of division hospitals was not put into operation for them. The nearest available house was occupied as their hospital. In addition to the above-named wagons, a general sup- ply of medicines for the army was carried in a reserve train of thirty-five wagons. The medical staff of this division hospital consisted of a surgeon in charge, a recorder, three operating surgeons, with two or more assistants to each, and one assistant to provide shelter. The strength of the division hospital staff, here and elsewhere, had been directed by the Surgeon-General, in March, 1863, who prescribed a surgeon in charge, with one assistant to provide food, fuel, and water, undone as- sistant to keep the records ; three surgeons as operating staff, with three assistants to each ; additional medical officers, hospital stewards, cooks, and nurses as many as may be. This distribution was intended to include all medi- cal officers on duty with the regiments, save that one in the front; and in those cases where a place of first dress- ing was selected near the front, and distinct from the more distant and permanent division hospital, the same medical officer Served at the place of temporary dressing until his services were needed at the division hospital. The division hospital is here spoken of because from some of its personnel a certain amount of aid may be ex- pected in the carriage of the wounded from the field of battle ; and because it is the great centre where the wounded first receive relief and treatment worthy of the name of permanent ; and it is from this point of view that its superiority is especially manifest over the regi- mental hospital, the only other system pretending to com- pete. The views of military surgeons who bore a part in the great American civil war of 1861-65 are almost unani- mous in favor of the system of division hospitals. A few were in favor of regimental hospitals, because they claimed that the soldier of the regiment there received better care, besides that of an ordinary professional nature a purely personal attention due to relations of personal acquaintance and friendship. The additional advantage was claimed that the soldier, being with his regiment, was directly under the control of regimental officers, and, therefore, less apt to remain long absent from duty. Cases are conceivable where certain advantages may render the regimental system of hospitals in an army the most desirable, and. in these cases, the inherent power of the medical director will enable him to adopt said system. But economy and efficiency of administration are al- ways with the system of division hospitals, and in large armies fighting great battles the superiority of this sys- tem is incontestable as regards both quickness and thor- oughness in the care of the wounded. In regard to the system whose organization is given in this paper, it need only be added that its details were adopted as the results of much experience in actual war- fare ; that they enabled the best aid and care, professional and extra-professional, to be given to hundreds of thou- sands of sick and wounded, and that no better system has yet been discovered, so far as is known to the writer. Besides the aid above enumerated, help in caring for the wounded after battle may be expected, when operat- ing in civilized regions, from the various chari- table aid associations, and from volunteer citi- zen physicians and nurses. Where these come, as they now generally do, amenable to discipline, obedient to orders, and prepared to undergo hardship, the value of the aid that may be expected from them is almost be- yond expression ; not only as measured in physical work, but by the moral effect of their presence upon the over- tasked surgeon and the suffering wounded. A word regarding female nurses. It may be said that they are out of the question on the battle-field. In the permanent hospitals their presence is exceed- ingly grateful to the patient, and some func- tions of the nurse can be far better discharged by them than by the male nurse. Their presence should be en- couraged in hospitals. Exclusive of female nurses it must be admitted that soldier nurses are generally preferable to citizen nurses in military hospitals, and this because they are more obe- dient and subject to discipline. Means of Transport of the Wounded.-The primitive modes of carrying the wounded must doubtless have been by carriage in the arms or on the back, or by leaning on a single aid ; on the Strength of ambu- lance corps in Austrian army. Auxiliaries to ambu- lance corps in United Statesarmy. Aid to ambulance corps from field - hospi- tal organi- zation. Aid asso- ciations. Fem ale nurses. Primitive transporta- tion. 139 yield Surgeons. Pield Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hands of two persons joined, or leaning on or being borne by two assistants. Hand-litters, wheeled litters, horse or mule litters (and other animals), cacolets, and ambulances, are the modes now adopted for the transporta- tion of the wounded on and from the battle- field. Each of these modes of transport has its appropriate use. In a limited number of cases a man is so shattered by wounds that any other than man carriage seems out of the question. Frequently litters and cacolets only are available, either on account of the topography of the country, which may interfere with the movement of wheeled vehicles, or on account of military reasons, the danger of capture, which may forbid the approach of these vehicles too near the enemy. Hand-litters or Stretchers.-The terms hand- litter and stretcher are used almost indiscriminately in the United States. Ordinarily they are made of canvas, from six feet to six feet six inches long, and nineteen to twenty-two inches wide. The canvas is attached to side-bars of wood, bam- boo, or similar material, -which are long enough to pro- ject at each end, forming handles, between which the bearers walk. The canvas may be fastened to the side- bars by tacks or nails, or the canvas may be doubled over and sewed so as to form a tube on each side, into which the bars are thrust and removed at pleasure. Cross-bars of iron or wood are so arranged as to keep the side-bars apart without incommoding the occupant. Sometimes the handles are attached by hinges, so that they may be bent down at right angles and serve as legs. If not, legs should be attached, which for convenience of packing should be arranged to fold up underneath. By means of these legs the litters may serve for a bed, with- out changing the occupant. Sometimes the longitudinal side-bars are hinged in the middle, to admit of more com- pact packing. The ambulance seats are sometimes removable, to serve as litters. In this case the seats are longitudinal, and consist of two pieces-the seat proper, horizontal, and a piece attached by hinges to this and hanging to the floor. Handles are attached in a suitable manner, hinged under- neath, that may also serve as legs. This litter must be properly upholstered. The wood used in litters in the United States army is ash. A sufficiently strong litter must weigh not far from twenty pounds. The great objection to the hand-litter is the amount of help required for its use. Two men at least are needed for every wounded man carried, and their rate of loco- motion must be slow. On the other hand, this very slow motion, with the reg- ulated step of the drilled carrier, renders this mode of transportation the least painful and the safest. Besides, the hand-litter can be carried right to the front, and al- most anywhere that a man can go, while its simplicity and consequent ease of repair tit it for campaign uses. No authoritative drill for litter-bearers has ever been published in this country, nor, so far as the author knows, in any country. Such a drill, however, was devised and used experimentally by the author in 1864, in the army of which he was medical director. It included the move- ments of raising a man's body and placing it without shock, of raising and setting down the loaded stretcher, of marching with regular step, and of placing and remov- ing the loaded litter in and from the ambulance. Contrary to the statement of Woodward, in the " Hos- pital Steward's Manual," the movement of the wounded was found to be the smoothest when the carriers kept step, each moving their right or left foot at the same time. In the Prussian army, part of the outfit of each Feld- lazareth consists of two hundred stretchers. The English Commission considered the proper allowance per 1,000 men to be about thirty-two hand-litters, of which one-half were in the ambulances. The " Report of the United States Army Medical Board," published in General Order, No. 1, from the Adjutant- General's Office, series of I860, is silent as to the number, necessity, or kind of hand-litters. Their accompanying supply table for field service mentions them merely. The first ambulances, however, recommended by this board contained hand-litters. The supply table of the United States army, issued in 1883, gives the allowance of hand-litters as 8 per 1,000 men. As 12 hand-litters are included in the furniture of the ambulances allowed to 1,000 men, the supply is at the rate of 20 per 1,000. This allowance is sufficient, save in the actual time of battle. Then no supply within the prob- able resources of any army can so fully meet the case as to allow every wounded man to be moved so soon as he falls. Present modes of transporta- tion. Fig. 1177.-Halstead's Folding Litter. Fig. 1177 represents Halstead's folding litter. It was the favorite model of a very large number of medi- cal officers during the war of secession. Its weight is nearly twenty-four pounds. It is not worth while to multiply descriptions or drawings of the various hand- litters devised, which, finally, do not differ from each other in essentials. Wheeled Litters.-The same, or a modified pattern of a litter, has been mounted on two wheels, to be pulled or pushed by one man; occasionally useful it will be but rarely that this form of litter cannot advantageously be replaced by some other form. It has happened to the writer to have seen wounded men borne on the common wheelbarrow, and it seems very possible that a litter on springs, on a wheelbarrow base, may be perfected into a not disadvantageous form of transportation for the wounded. It might be made to combine cheapness, strength, quickness of movement, and comfort for the wounded, and economy of labor, one man being able eas- ily to propel it. The forms of wheeled litter heretofore used have nearly all of them failed to commend them- selves to the judgment of the military surgeon. Horse-litters.-Where horses or mules are plenty, and men few, these litters find their place. The first were suspended from two horses, one in front of the other, the Fig. 1178.- Extemporized Horse-litter. (From a drawing by Dr. Hart- sufif.) length of the litter. They have met with greater favor for the transportation of both well and sick in Oriental countries. In the " Report of the Medical Board of the United States Army," before referred to as published in 1860, we read: "The board also resolved that horse-litters be pre- pared and furnished to posts where they may be required for service on ground not admitting the employment of two-wheeled carriages, said litters to be composed of a canvas bed similar to the present stretcher, and of two poles, each sixteen feet long, to be made in sections, with head- and foot-pieces constructed to act as stretchers to keep the poles apart." The report of the board fails to fix the number of litters to be allowed. We may infer that they regarded the same number necessary, as they stated ambulances to be, viz., enough to carry forty per thousand. The weight of such a stretcher or horse-litter is nearly ninety pounds. Although recognized in the United States army as a mode of transporting sick and wounded, but two in- stances of actual use (save in Indian hostilities) are known Number of hand-lit- ters needed. 140 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. to the writer. One of these is referred to in Dr. Otis' re- port, made in 1877 ; the other was the case of an infantry officer wounded at the battle of Churubusco through the hip and elbow-joint. The limbs were preserved, and the officer carried on a litter, such as here described, from the city of Mexico to Vera Cruz. The officer stated that he was carried in absolute comfort, the day's march be- ing limited not by his fatigue or inability to proceed, but by the powers of the animals bearing the litter. These litters have been repeatedly used in hostilities in the rough country occupied by the Indians, and concern- pack-train. Every officer of any practical experience in scouting on the frontier knows that, before the pack- mules or cavalry horses can be made to work satisfac- torily in the double-horse litters now issued in the army, every such animal requires, in each case, a special and more or less prolonged system of training and daily drills in these litters. Several litters are usually broken to pieces before the animals can be made to work steadily. It is nearly always found impracticable to give the ani- mals such special training, for the reason that on an In- dian campaign transportation is always cut down to the minimum, and consequently no extra animals can be taken for use in the litter-train. It is seldom possible to obtain the quartermaster's pack-animals for such pre- paratory drills, as they are forced by the circumstances of the case to carry packs all day, and when the camp is reached at night there is no time, and the animals are in no condition for any such drills. The consequence is, that when the urgent necessity for the use of the litter-train actually arises, among all the animals turned over to the medical officer for such service there will not be more than one or two that can be used ; the others all refuse to work in the litters, and ultimately some other means has to be resorted to for the transportation of the wounded. Only one animal is required for use with this litter, and consequently there is no useless expenditure of labor, as when two horses are required for the trans- portation of one man. The litter can be folded com- pactly together, so as to permit a load of grain, pro- Fig. 1179.-McElderry's Single Mule-litter. ing their use nearly every United States army surgeon reports favorably. The objection to their use in general is the number of animals needed. In the effort to economize, the experiment of substitut- ing one animal for two would naturally be soon at- One-horse tempted. The ordinary hand-stretcher was so litter. arranged as to be secured to the top of a saddle specially prepared to receive the attachments, and other litters were invented to be so secured, but hinged so as to permit the carriage of the occupant in other than a recumbent position. Figs. 1179 and 1180 represent the single-horse litter devised by Assistant Surgeon McEl- derry, U. S. A., which, taken all in all, is as good as any that has yet been produced. Concerning this litter its inventor says as follows : "The following are some of the advantages of this form of litter. As was demonstrated by experience in the held during the Modoc campaign in the lava-beds in Southern Oregon and Northern California in 1873, the Fig. 1181.-British Crimean Mule-litter. (After Weir.) visions, etc., to be packed upon it. The animal having arrived at its destination, the load is removed, the litter is unfolded, and becomes available for the transportation of the wounded back to the base of supplies. By the use of the adjustable iron support, which may be raised up over the lower end of the litter, a wounded lower extremity can be suspended in the anterior or other splint, and the patient thus carried with much greater ease and comfort than when the wounded member is simply laid upon or fixed to the litter. Used upon the Mexican aparejo, which is now universally found in the pack-trains upon the Pacific coast and Texas frontiers, this litter, being well balanced, is easily and comfortably carried by the pack-animal, and consequently has no tendency to make the animal's back sore. This is always found a source of serious trouble in packing the long poles of the double- horse litter now in use. They are so long that they have to be packed crosswise on the pack-saddle, and in conse- quence invariably cause so much wabbling of the saddle that, after they have been carried for a day or two, the pack-mule gets a sore back, and is henceforth unfit for some time during the campaign. As will be seen, the present form of litter is substantially the same as the one devised by me and constructed to meet the emergencies of the service in the Modoc campaign, and the model of which is now in the Army Medical Museum. Like that model, it is intended to be constructed of strong wood braced with iron rods, with strong hinges to bear the rough usage of frontier field service, so as not to be easily broken or otherwise rendered unfit for service. Several modifications, suggested by experience and reflection, have been added, in order to cause the litter to fold up Fig. 1180.-Plan of McElderry's Single Mule-litter. proposed style of litter is specially adapted for use in broken, rough, and mountainous country ; along narrow and winding defiles, abounding in sudden and abrupt turns and angles ; and in places and under circumstances generally where no other kind of litter could be employed. A wounded man can be transported on this litter, with entire safety, on the back of any steady pack-mule or horse taken indiscriminately out of the pack-train; the animal not requiring any special training before he will pack it, otherwise than he has already received in the 141 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. more compactly and to add to the comfort of the patient. The upper part of the heavy canvas which forms the bed is intended to be made of double thickness, to be left open above. Into the pocket thus formed hay or prairie- grass is to be stuffed, and the upper edges of the canvas tied together with cords sewed on for the purpose. This forms the pillow. A canvas awning has been sketched on the plan, intended to be stretched from head to foot-board of the litter over the raised iron support, and tied in place by the cords attached to its edges. An aparejo, furnished with a good broad breast-strap and crupper, is first lashed to the animal's back with its girth in the usual way, and the litter, being then placed upon it, is firmly fixed in position by means of an extra-broad California horse-hair girth, as shown in the figure. It has been suggested to me that this litter might be constructed of iron, to render it lighter and more compact for transportation. It is possible that this might be done, and I intended to sub- mit drawings for a model of this form of litter to be con- structed of iron. Upon reflection, however, I am of the opinion that this could be much better done after due consultation and deliberation with some competent prac- tical mechanic authorized to construct the litter of such material. It is believed that by the aid of the drawings herewith submitted, and the model already in the Army Medical Museum, and any required information that I should be able to furnish him, that a competent mechanic w'ould have no difficulty in constructing two models, one of wood, braced with iron rods, and one entirely of iron. If the style of litter here submitted should receive the approbation of the Surgeon-General, and the construc- tion of a number be authorized for use in the army, I would respectfully suggest that two such model litters be made for inspection and comparison, when the one con- sidered most suitable for the service may be selected as a model and guide for the construction of others." While finishing this paper, Dr. McElderry writes : " If I have occasion ever again to use the form of litter re- ferred to, I should endeavor to have it made lighter, as I think it is too heavy, unnecessarily so I mean." This litter weighs fifty-four pounds; the aparejo and ap- purtenances weigh fifty-one pounds. A form of saddle with litters has been invented by which, on a single animal, two patients are borne on lit- ters suspended one on each side of the ani- mal. Such litters were used in the Crimean war, and gave much satisfaction. Travail.-The travail is a form of litter used by the North American In- dians, the front end supported by a pony (or other animal), the Speaking of the Crimean war, General Delafield says in his report: " The requisites for an ambulance should be such as to adapt it to the battle-field, among the dead, wounded, and dying ; in ploughed fields, on hill-tops, mountain slopes, in siege batteries and trenches, and a variety of places inaccessible to wheel carriages, of which woods, thick brush, and rocky ground are frequently the localities most obstinately defended, and where most sol- Fig. 1183.-Dakota Indian Litter. (From a drawing by Dr. J. W. Will- iams, U. S. A.) diers are left for the care of the surgeons. These diffi- culties were felt in a great degree by all the armies allied against Russia in the siege of Sebastopol, and the Conse- quence was that the English, French, and Sardinian armies adopted finally, in part or altogether, pack-mules, carrying litters or chairs. The careful and sure-footed mule can wind its way over any road or trail, among the dead, dying, and wounded, on any battle-field, as well as in the trench and siege battery. It required but suitable arrangements to support the wounded from the mule's or horse's back to attain the desired object, and this the allied armies finally accomplished and put in practice. The merit of the plan renders it worthy our considera- tion, particularly so in our Rocky Mountain and other distant expeditions." Further on he remarks: ... "I witnessed the transport of one hundred and ninety-six Fig. 1182.-Horse Litter proposed by Dr. Cleary, 11. S. A. rear end dragging on the ground. In crossing a stream the rear end is carried by a man. This form of litter can be readily extemporized, and has been used on expeditions against the Indians by army surgeons with very great satisfaction. Given saplings, hides, or skins, canvas, blankets, or osiers, and a very satisfactory travois may be constructed. The engrav- ings 1182 and 1183 will sufficiently illustrate their use. Cacolets.-Cacolets are merely a form of horse-litters, made in the form of chairs, and suspended one on each side of a horse or mule. The patients travel therein, sit- ting up, or only partially reclining. In some foreign countries, in some wars, they have been a favorite mode of transportation for the wounded, down to, and includ- ing, the recent war iu Egypt. Fig. 1184.-British Crimean Cacolet. (After Weir.) sick and wounded French soldiers, with their arms, ac- coutrements, and knapsacks, on the route from the Tchernaya to Kamiesch Bay, on these litters and chairs. Fifty-two of them were on twenty-six mules in the hori- zontal litters, and one hundred and forty-four seated in chairs on seventy-two other mules. A driver was pro- vided for every two mules or four wounded men. The 142 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. appearances, with such an examination as I gave the whole equipment, were so favorable as to recommend it for trial in our service. To make the system better un- derstood, I annex two additional figures (Figs. 1181 and 1184), showing the animal, the equipment, and position of the soldier, for which compilation and drawing I am indebted to Professor Weir." See Figs. 1181 and 1184. Tn the United States army cacolets have met with but little favor, and in this rather disfavor horse-litters have shared. The quartermaster's department particularly dis- approved. To them the problem presented was rather that of moving the wounded with the greatest economy, and they looked on money expended in the purchase of cacolets (and of horse-litters to a less degree) as wasted. And, indeed, it did appear that the cacolets furnished the army were but little used, and I know of no case in the war of the rebellion where they were fairly tested in the field. Some medical officers shared these views of the quartermaster's department. When it happened that the medical director was desirous of testing this mode of transport, the trained animals were not forthcoming ; and trained animals were necessary. The medical director of the second army corps of the Army of the Potomac reported, after the battle of Fair Oaks: "The horse-litters which permitted the recum- bent position served admirably for transporting the most painfully wounded " from the field hospital to the rail- road cars, a mile or more, and further reports that all the wounded who did not go on foot from the field to the field hospital were carried on hand-litters. In the winter of 1861 the general commanding the Army of the Potomac detailed a board, of which the author was the junior member, to report on the merits of a model of horse- or mule-litter presented. In coming to their conclusion, the board was obliged to make a careful study of several patterns of litters and cacolets before them. They recognized that the greatest objections against them were their unsuitability for travelling in ravines and a wooded country, and the need of animals trained to their use. The board, however, were of the opinion that in an open country, and for certain classes of wounded, no bet- ter mode of transportation was known, and were clearly of the opinion that their merits should be tested by trial in the field. This was also the opinion of Surgeon-Gen- eral Hammond. It did seem, however, after trial, that neither cacolets nor horse-litters were suited to the genius of the United States military surgeons. Not only horses and mules have been used for these purposes, but almost every other beast of burden. Camels are in most general use in Egypt.* Wheeled Ambulances.-A proportion of wheeled ambu- lances, drawn by horses or mules, is to be desired, and should accompany the troops to the field, if they are per- mitted or able to approach the front. Indeed, in com- parison with them, the English Commission failed to con- sider cacolets or horse-litters as worthy of consideration as part of their transport system for the wounded. Considerable ingenuity has been displayed in devising a model of ambulance that should be suitable for all pur- poses to which these vehicles must be applied. After many experiments and due consideration, the authorities of most foreign civilized armies have decided that two different kinds of ambulance are required for field ser- vice, the one light for quick movements, the other heavy and strong. To this same conclusion came the Medical Board of the United States Army before referred to. In their before-quoted report, made in 1860, in their "decisions and recommendations," appears the follow- ing: "2. That both two-and four-wheeled ambulances are necessary for the hospital service. "3. That a two-wheeled ambulance is the best for the conveyance of dangerously sick or dangerously wounded men." In the models of ambulances selected by this board, hand-litters were carried, serving as beds, and movable. Boxes, too, were arranged to carry supplies regarded as the most indispensable. The two-wheeled ambulance, very light, was to be drawn by one horse ; the litters, or beds, in one layer on Two. the bottom, each 22 inches wide. The ambu- wheeled lance being 4 feet 4| inches wide in the clear, ambulance. jleij tWo litters, i.e., two persons recumbent, while one was seated by the driver. The four-wheeled ambulance was very heavy, and needed two horses at least, and often four, to draw it. Four- The litters were arranged in two stories. Each wheeled litter was 22 inches wide, and the ambulance ambulance, being 4 feet wide in the clear, could hold two litters in each layer, or carry four persons recumbent. At the beginning of the war of secession both of these ambulances were supplied to the army in abundance, and therein many wounded were carried. But they soon showed faults. The light ones were too light. They proved, by their jolting, uncomfortable and injurious to the wounded, and many of them went to pieces. They specially disproved the before-quoted decision of the board, that they were best for the dangerously wounded. The heavy ambulances gave the best satisfaction to their occupants ; but they proved cumbersome, and too heavy when the roads were muddy or not excellent. A light or four-wheeled ambulance was accordingly soon designed, and brought into such good shape (the so- called Rucker & Wheeling ambulance) that it was gen- erally issued and used in the armies, and was selected as the regulation ambulance. No better one was invented during the war. The experience of the war, however, satisfied the proper authorities that this model of ambulance could Present be improved on, and in March, 1875, the War ambulance Department of the United States organized a of United board "to decide upon the pattern and pre- states army.pare specifications for the ambulance for army use." This board had before them a variety of models; various specifications of bodies and running-gears of am- bulance wagons approved by commissions of the Eng- lish, French, and German governments ; and the follow- ing works : "A Treatise on Military Carriages and other Manufactures of the Royal Carriage Department, Great Britain ; " an illustrated book, by Gurlt, of Berlin, on Transportation of the Wounded ; on Ambulance Wagons, by Professor Longmore, of the British Military Medical School ; by Professor Fischer, of Breslau ; by Professor Leon Lefort, of Paris ; an elaborate report on the subject by a British Commission under the Presidency of Inspec- tor-General R. Lawson ; also photographs of ambulance wagons used in Sweden and Norway ; an Atlas on Con- veyances for the Wounded, by Dr. Van Dommelen, of Holland; an ambulance presented by the Russian gov- ernment ; a number of models of United States ambu- lances ; miscellaneous plans and drawings of ambulance wagons from the Surgeon-General's office, and multitu- dinous letters from various writers. The board devoted to consideration of the subject various sittings from April, 1875, to the end of February, 1878. At an early meeting the board decided that they would not adopt a light two-wheeled ambulance, or a cumbrous four-wheeled ambulance designed to carry a large number of wounded in a recumbent position ; but that they would recommend only a two-horse or mule four-wheeled ambulance, weighing, if possible, less than one thousand pounds. They decided to adopt many feat- ures of the Rucker ambulance, and to recommend an ambulance to carry two wounded recumbent and two be- * Dr. Otis has erred in foot-note 4, page 3, of his Report on the Trans- port of Sick and Wounded on Pack Animals. The fact is that the credit of the attempt to acclimate camels in Texas is due to the late General H. C. Wayne, then captain in the quartermaster's department, and son of Judge Wayne of the United States Supreme Court. This offi- cer succeeded in interesting in the subject the Hon. Jefferson Davis, Secretary of War, and by him was ordered to Egypt to buy camels. Major Wayne went to Egypt in company with the present Admiral Por- ter. and procured the camels, which were landed at Indianola, Tex., whence they came to Camp Verde, the place selected for acclimation and breeding. The author of this paper was assigned to duty at the camel camp, and made sundry experiments as to the endurance and speed of the camels. The conclusion was then adopted that for the transport of wounded the gait of the camel was too rough. 143 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. side the driver, or else eight men in a sitting posture ; to contain but one tier of litters, and to traverse or turn on its own ground. The parts to be interchangeable, and so constructed as to be taken apart and folded compactly for shipping. Such of the specifications as may be necessary to give a clear idea of the ambulance will be here given. They provide for a body 11 feet 1| inch long (includ- ing 11| inches projection for toe-board, and 1 inch finish outside of tail-gate) and a rear step ; for a driver's box in front under his seat, di- vided by a partition, and furnished with a water keg, whose end must project with cock outside; for wooden bows to support top and curtains the whole ness in packing and shipping. These are a series of im- portant advantages which it is believed have been attained and secured, with a strict regard to economy and dura- bility of construction." The result is here figured. Speciflca- t i o n s of the United States army regulation ambulance. Fig. 1188.-Side View. In many respects this ambulance is the best model yet invented, and well fitted for a majority of the uses for which ambulances are intended. Although not perfect, its superiority is such that it does not seem worth while to waste space here in the description of any other model. Fig. 1185.-New Army Ambulance, approved by the Secretary of War, 1881. length ; the curtains and cover to be of cotton duck ; the distance from floor to ridge-pole to be 4 feet 6 inches ; the interior to be upholstered with russet leather stuffed with curled hair ; to have platform spring of No. 3 steel; the two front side-springs to be 43 inches long, with a front cross-spring 46 inches long ; the two hind side- springs to be 50 inches long, with a hind cross-spring 46 inches long, and all these springs to have seven plates ; to have a strong brake worked by the driver's foot; to have a stretcher-rest in the bottom, consisting of three rollers in a roller-bar sustained by springs ; the diameter of hind wheels without tire to be 4 feet 2 inches ; of front wheels, 3 feet 6 inches ; the iron-work to be w'ell painted black ; the wood-work, dark olive-green ; the letters U. S., six inches long, in bright yellow, and a red Geneva cross on a white ground, painted on certain panels. The board Fig. 1189.-Cross Section, A-B. Fig. 1190.-Cross Section, C-D. The medical officer must bear in mind that in quantity and quality he will be often unable to procure what he prefers, as well in transportation as in other supplies. In such case he is obliged to use what he can, and so it happens that the or- dinary vehicles of the neighborhood will often prove a precious resource. Ordinary vehicles s u bstitutes for ambu- lances. concludes its report by saying, "that the plan proposed embraces some important improvements, and has sur- mounted some great obstacles: To make the vehicle turn readily and safely in narrow roads, and at the same time to lower the height of the floor from the ground, and af- ford the maximum of floor space ; to restrict the weight, yet insuring sufficient strength ; to arrange for the com- fortable carriage of men in either the sitting or recumbent posture ; and finally, the method for securing compact- Fig. 1186.-Back View. Fig. 1187.-Front View. Fig. 1191.-Longitudinal Section through Centre. Well is this impressed on the memory of all those who witnessed the procession of motley vehicles which left Washington on the night of September 4, 1862, for the 144 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. battle-field. The second battle of Manassas was fought August 29 and 30, 1862, and on September 4th many wounded were still lying on the field. Heterogeneous enough was the train which proceeded to their relief- hacks, omnibuses, wagons, and carriages of all descrip- tions were permitted to pass through the Confederate lines, accompanied by army wagons loaded with cooked provisions and other supplies. Six or seven hundred were picked up by this train and brought to the Wash- ington hospitals, where they arrived early September 7th, not until a week after the close of the battle. It scarcely needs to be said that the ambulance system of the United States army had not yet received the sanction of law. This delayed care of the wounded went far to influence the passage of the ambulance corps law above quoted. It elicited from Surgeon-General Hammond to the Secre- tary of War the following letter, dated Washington, Sep- tember 7, 1862 : " Sir, I have the honor to ask your at- tention to the frightful state of disorder existing in the arrangements for removing the wounded from the field of battle. The scarcity of ambulances, the want of or- ganization, the drunkenness and incompetency of the drivers, the total absence of ambulance attendants, are now working their legitimate results, results which I feel I have no right to keep from the knowledge of the de- partment. The whole system should be under the charge of the Medical Department; an ambulance corps should be organized and set in instant operation. I have already laid before you a plan for such an organization, which, I think, covers the whole ground, but which, I am sorry to find, does not meet with the approval of the general-in- chief. I am not wedded to it. I only ask that some sys- tem may be adopted by which the removal of the sick from the field of battle may be speedily accomplished, and the suffering to which they are now subjected be, in future, as far as possible avoided. Up to this date six hundred wounded still remain on the battle-field in con- sequence of an insufficiency of ambulances and a want of a proper system for regulating their removal in the Army of Virginia. Many have died of starvation, many more will die in consequence of exhaustion, and all have endured torments which might have been avoided. I ask, sir, that you will give me your aid in this matter ; that you will interpose to prevent a recurrence of such consequences as have followed the recent battle, conse- quences which will inevitably ensue on the next impor- tant engagement, if something is not done to obviate them." This forcible appeal was not at once successful, as General Halleck continued to oppose the ambulance corps as a separate organization; but from this time many influences, before silent or idle, began to work and the desired legislation was finally secured.* Greene, in his report of the winter campaign in Bul- garia in 1878, says : " The only vehicles which kept up with the troops were a few hospital ambulances, in which the wounded of each affair were carried to the nearest village and left there until they could be collected by the sanitary department and transported in country carts to the large hospitals at Sophia and other places." It is worthy of comment here that in a work like Greene's, professing to give an account of the Russian army and this campaign, scarcely a word is said of the care of the wounded. Concerning them enough is con- sidered to have been said when their number is stated. The English Commission estimates the number of w'ounded for whom transportation from the bat- tle-field must be provided as eight per cent. A part of these must be carried, of course, on lit- ters. The United States Army Medical Board, in their re- port of 1860, before referred to, say : "1. That ambulance transportation ought to be fur- nished for forty men per thousand; twenty lying ex- tended and twenty sitting." The ambulance corps law, as quoted above, allows six ambulances per thousand men. As the capacity given above of the regulation ambulance is for eight men at the utmost, the ambulance accommodation provided is for forty-eight men, sitting, per thousand. Save in the heat of battle, when ambulances are most urgently needed, this amount of accommodation will suffice : and as may be seen from the foregoing, the exact amount needed during a battle must be indeterminate beforehand. It has heretofore appeared that the ambulance should carry a water-keg, and stretchers as beds. Be- sides these, most ambulances are intended to carry one or more articles, the most indispensa- ble for the comfort of the sick and wounded. In some armies the ambulance wagons are tended by a small light wagon carrying nothing but medical supplies. In Belgium a light wagon is furnished the fighting column to carry such things ; so also in the Prussian ser- vice, where, in addition, each Feld-lazareth has two such wagons. In the Evans' ambulance, the driver's seat is a box con- taining water, dressings, and a few drugs, and the Bel- gian ambulance model of 1872 contains a medicine-chest. In the United States army the Surgeon-General (Ham- mond) ordered as follows: "Medical directors of corps and division surgeons are required to have the following articles carried in the box of each ambulance, under the driver's* seat: Beef, extract of, in two-pound tins, 6 pounds; buckets, leather, 1 ; kettles, camp, 1 ; lantern and candle, 1 ; spoons, table, 6; tumblers, tin, 6; hard bread, 10 pounds. ... In addition to the above, each ambulance is to be furnished with two litters, and one keg filled with water." After the battle the field will be more or less strewn with the dying and dead, and the utmost efforts of the surgeons and the ambulance corps must now be exerted for the immediate removal of the wounded. For this task daylight will not suffice; the hours of darkness must be devoted to the same task, which must be continuously performed, even though with the disadvantage of the dim light of the moon, the stars, and lanterns, which hardly enable the surgeon to distinguish the dead from those in whom a little life still lingers. Quite recently it has been proposed to use the electric light to illuminate the battle-field, and experi- ments have been made to this end, with results as follows : The diffused electric light, equal to two thousand or two thousand eight hundred candle-power, was found to light up a field of one and a half to two miles radius suf- ficiently to allow intelligent work at the extreme limit. The concentrated electric light, of the same power, gave a sufficiently bright light at fifty yards' distance to enable the operator to perform minor operations, to ban- dage, etc. With railroads and balloons, electric apparatus may be classed as modern improvements, which may be looked for as accompanying modern armies. Where this light is attainable, the surgeon will do well to bear in mind the advantages he may derive from it, unequalled as it is for brilliancy. Number of a m b u - lances r e - quired. Contents and furni- ture of am- bulance. Remov a 1 of wounded at night. * The Medical Department of the United States army, the whole United States army, and military surgery and science throughout the world owes a great debt to Dr. Wm. A. Hammond, Surgeon-General (retired), and this is an appropriate place to testify thereto. Appointed Surgeon-General in April, 1862, Dr. Hammond found the army medical staff of unexceptionable material. Its system, however, though successful in times of peace, unchanged scarcely sufficed for the increased duties to an army immensely enlarged for a great war. Dr. Hammond inaugurated the changes which helped the Medical Depart- ment successfully to perform its work during the war of the rebellion. To partly enumerate, the liberal system of medical and hospital sup- plies to troops now issued ; the abundance of books, journals, scientific appliances and apparatus, and instruments now granted to medical officers of the United States army ; the system of ridge-ventilated pavil- ion hospitals prevailing in the United States army subsequent to 1862 ; the Army Medical Museum in Washington ; and the Medical and Sur- gical History of the War, are all due in the first place to Surgeon-General Hammond, though nobly seconded by the men whom, with a rare knowl- edge of his fellows, he selected to aid him in carrying out his plans, as well as his and their successors. As to the writer's competency as a witness, he was on duty in the most confidential relation as senior assistant to General Hammond in his office, and as acting Surgeon-General of the army during the absences of General Hammond, from soon after General Hammond's appointment in 1862, until he was unjustly driven from his office in the winter of 1863-4, the victim of enmities due solely to his unswerving and faithful discharge of duty. E 1 e ctric light. 145 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Disposition of the Dead.-The human bodies in which life remains having been picked up and sent to the hos- pitals, the ground, after a battle, will still be more or less strewn with dead bodies, both of men and animals. Not only is such disposition of these bodies demanded as may be in the interest of public health, but from the earliest times the sentiment of mankind has required that certain honorable rites and ceremonies be bestowed upon the human dead. Both of these reasons absolutely for- bid that the bodies of soldiers who have perished in battle be permitted to undergo decomposition neglected on the battle-field. The disposition of these bodies will very frequently be under the direct supervision of the military surgeon. Most frequently the dead on the battle-field are buried in the ground near the spot where they have fallen. After slight engagements, whenever, in short, the dead are few in number, it is customary to bury each body singly in a grave. This grave should be between four and six feet deep, according to the nature of the soil, and this depth is necessary to re- tain the odors of decomposition. But want of time often renders this work so hurried that the bodies receive scarcely a covering of earth. The large number of killed after a severe battle makes separate sepulture impossible, and it is then customary to bury large numbers together in a single long trench. Such trench should be from six to ten feet deep and long, according to the number to be buried. The bodies may be arranged in more than one layer. Each layer should be covered with quicklime, if the lime is attain- able. Powdered charcoal may be used instead of quick- lime if easier to procure. In most instances, during a campaign, neither will be attainable, and a covering of earth alone must suffice. The carcasses of animals are habitually disposed of by burial in long trenches, or large deep pits, covered with lime, powdered charcoal, or earth. Where fuel is plenty, the dead bodies of both men and animals should be consumed by fire. Cremation is quite as honorable a mode of disposing of the dead as relegating them to the company of worms and to slow rot, and is far more to the public welfare. But this is not the place to fully discuss the advantages of cremation, which, besides, is now undergoing the judgment of the great public. Seroice of Evacuation.-This term will be here used to signify the transportation of the wounded and sick from the field and division hospitals to the permanent hospitals. Permanent hospitals in the United States army are called " general hospitals their necessity is undoubted, but their history and description do not belong to this article, as they will be treated of elsewhere. The transfer of patients to these hospitals is necessary • First, to empty the division hospitals, that they may follow the army light, and be pre- pared to receive the wounded from subsequent battles. Second, to relieve the fighting, moving army from the embarrassment attendant on their care of the helpless wounded. Third, to remove foci of disease from the operating force. Fourth, to move the sick and wounded to where they may enjoy greater care and comfort ; the general hos- pitals, supposably, being established where conveniences and supplies of all kinds are abundant. Akin to this last are the advantages, of a sentimental nature perhaps, accruing to the patient from his return to the vicinity of, or to, his home, and from the sight of those to whom he is attached by natural ties. These advantages are real; for, Horace to the contrary notwithstanding, " Ccelum et animos mutant qui trans- currunt mare." These reasons all make it necessary that these transfers should be-not spasmodic and occasional-but constant and systematic; for this purpose lit- ters and cacolets may sometimes be used, as in the in- stances heretofore quoted as occurring in Mexico, as in the Crimean cases quoted by General Delafield, and in numerous cases in Indian hostilities. Ambulances may be also thus used, and in the war of 1861-65 the author saw many ambulance loads of sick and wounded brought to the general hospitals in Wash- ington and elsewhere. Concerning this mode of move- ment nothing more need be said than has been hereto- fore said, save that for evacuation on a large scale the supply of ambulances and litters will be ordinarily in- sufficient. They are provided in only sufficient number to transport the wounded from the field, and the sick from the regiment to the division hospital. Mobility of armies is a prime consideration in modern campaigns, and in latter years this mobility has been in- creased by the free use of railroads and steamers. Armies now build their own lines of railroad as they move, and establish their own lines of steamships. The very same means that carry to the front the able- bodied warrior must carry him Io the rear when maimed and crippled, and so a system of transport of sick by rail and boat has been established, which, while perhaps not absolutely perfect, yet in many things leaves not much to be desired. Transport of Sick and Wounded by Water.-Where campaigns are conducted on the seaboard or navigable rivers, the best mode of transporting the sick and wounded is by boat; being both the most economical and the easiest for the patients. In localities where canals exist, they are available. At the tight of Ball's Bluff and other localities in the United States, they have served to transport the wounded, and in Egypt the Brit- ish army used them to a considerable extent. Small, open boats have thus been used, hay being spread in the bottoms, and awnings of some kind stretched over the tops. The covered canal-boats lend themselves to this use with but little extra preparation. Their ordinary berths, arranged in tiers along the sides, carry many occupants in a limited space. They are gen- erally provided with cooking facilities, and when in motion, the movement, to the passengers, is al- most imperceptible. But though in some countries ca- nals may provide the principal means of transportation, in most countries they will be seldom used, because they do not exist. Steamers are used for the carriage of sick and wounded on navigable rivers ; sailing vessels and steamships on lakes and the ocean. The steamer has a great advantage over the sail-vessel as to speed, and it alone is habitually selected for such trans- port. Neither screw nor side-wheel steamer possesses undeni- able superiority, the one over the other. The machinery of the side-wheeler monopolizes some desirable space, but the vibration and jar is less disagreeable than that of the screw-propeller. On army transports generally, accommodations for the current sick are provided in the shape of berths and small rooms in some convenient site. The illy lighted and ven- tilated parts are to be avoided. The sick-bay of one of our naval vessels is in some respects a model. But an- other matter is the conversion of a whole steamer into a hospital and a home for the sick, to be occupied some- times for many days. It would naturally be expected that England, the na- tion of sailors, would be among the first to prepare float- ing hospitals and sick transports. But very little seems to have been recorded in the way of systematic prepara- tion previous to the Crimean campaign in 1854. From the Crimea to the Bosphorus, a well-appointed fleet of hospital ships carried the British sick and wounded of the campaign. The Orient, Poictiers, St. Hilda, Clifton, William Jackson, and a few others, carried in twenty-two months 114,668 patients. Of all the administration of the English army in the Crimea, that of these transports seems to have provoked the least criticism, and it is a significant fact that Lord Human dead buried in ground. Dead ani- mals buried. Trans- port on canals. Cremation. Trans- por t on ocean and river. Reas on s for transfer of patients from field hospital. Crimean transporta- tion by sea. Modes of transfer. 146 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. Panmure, in his instructions to the English Sanitary Commission, dated February 19, 1855, does not direct their attention specifically to these transports, but directs them to inspect " the modes "whereby the sick and wounded are conveyed to the transports/' In 1858, two hospital steamers, the Mauritius and Mel- bourne, were fitted out for the benefit of the British forces in China. The Mauritius was a three-decker, the lower troop- deck, divided into three compartments, being fitted for the sick and wounded. The berths ranged fore and aft. seven feet. A surgery was provided fifteen by ten feet, with all the requisites for a dispensary. The berths were six feet three inches long by two feet six inches wide, and fitted with movable galvanized metal bottoms. Good bedding and table furniture were pro- vided, and good diet. Besides the wards for the sick, each steamer contained ablution rooms, room for washing and dirty clothes, dry- ing-room, butcher's house and baker's house, pack-room, store-room, and issuing-room. These ships were fitted up as if intended for exclusive use as hospital transports. Fig. 1192.-Victor Emanuel. Plan of upper deck as fitted. In the fore compartment 320 cubic feet of air-space was allowed each person ; in the after compartment, 223 cubic feet. The compartments were warmed by the engine-room, and by swinging and cabin stoves, and ventilated by hatchways, ports, tubes, Dank's ventilators, and two tubes connected with the galley fires. Steam condensers provided one thousand gallons of fresh water daily. Eight privies contained each two seats, and urinals were also provided. The Melbourne was arranged for 126 patients, its gen- eral provisions, as far as practicable, being the same as those of the Mauritius, save that instead of water-closets between decks four Fyffe's inodor- ous closets were placed on each side. Between decks the Mauritius measured eight feet; the Melbourne, One more illustration from England s fleet. In 1873 the wooden, screw, steam, line-of-battle-ship Victor Em- anuel, of 5,157 tons burden, with maximum of 2,414 horse-power, was converted into a hospital ship and trans- port, for service on the Cape Coast, Africa. The work of transformation of the ship was commenced September 15th, and the ship left Portsmouth November 30th, having required for the alteration about six weeks, and an ex- penditure of about $200,000. It provided accommodations for 142 sick and wounded, with 333.58 cubic feet of air-space per man. In addition, the convalescent deck could accommodate 60 convales- cents in cots, or 80 in hammocks. Fifty-five men was the estimate for the hospital service Steam trans port Mauritius. Ste a m transpor t Victor Emanuel. Steam tranap o r t Melbourne. 147 Field Surgeons. Field Surgeons, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. proper of this sick transport; of these sixteen were non- commissioned officers, assigned as follows : one in charge, two compounders, one steward, two assistant ward- masters, one clerk, two chief orderlies, one in charge of pack stores, one chief laundryman, and five supernu- meraries. Thirty-nine were privates, assigned as follows: one storeman, two assistant stewards, one barber, one carpen- ter and medical storeman, one tailor, six laundrymen, four- teen orderlies for deck, three orderlies for convalescents, four orderlies to sick officers, and six supernumeraries. At Cape Coast additional aid was required and fur- During the war between the United States and Mexico, 1846-48, although the sick and wounded of the army were, many of them, sent from Vera Cruz to New Or- leans, no special boats were fitted out for hospi- tal service only. Not so in the war between the North and the South, 1861-65. Early in the war, on our Western rivers, the sick were transported on ordinary river craft. In the winter of 1861-62, Brinton, from the Army of the Tennessee, reported that the want of a number of hospital steamers properly fitted Sea and river trans- port service of United States. Transport service o f the United States army on inland waters. Fig. 1193.-Victor Emanuel. Plan of main deck. nished, and this list does not include men employed for general purposes, such as two bakers, one chief cook, and seven assistants, etc. Figs. 1192, 1193, 1194, and 1195, will give a very good idea of the internal arrangements of a ship fitted up for the transport of the sick. In the struggle maintained by San Domingo against Spain, the Spaniards employed two ships, well fitted up, the Cataluna and St. Quentin, as hospital trans- ports. A detailed description of these ships is not at hand ; but from several sources it appears that they were well fitted up, well managed, and did good service. up and well officered was painfully apparent ; and in March, 1862, he reported that he had procured such steamers. These were the germ of the noble fleet of hos- pital boats bearing sick and wounded on the rivers of the Mississippi basin. The Western river steamers required much less altera- tion than the sea-goers to fit them for hospital service. Their cabins and state-rooms, well ventilated and lighted, lent themselves easily to such purpose, and the number of small rooms into which originally divided, if not of suitable size, were easily enlarged by the removal of a flimsy partition. Better ventilation, when needed, was secured by fans Spanish transports on sea. 148 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. extending the length of the wards, and worked by ma- chinery. No complete record has been published of the numbers carried by these hospital boats during the war, but I find records of more than one hundred thousand thus carried. The steamer reported as carrying the greatest numbers was the D. A. January, which in the forty months from April, 1862, to August, 1865, made eighty-one trips and carried 23,738 patients. The trips averaged in length between four and live days. The longest lasted fourteen days, but during each trip the feet long by 45 feet wide. Her carrying capacity was for 500 patients, but on one occasion she carried 817. In addition to sick wards, and rooms for officers and attendants, these boats possessed commissary and other store- and issuing-rooms; carpenters' and blacksmiths' shops; kitchen, and special diet kitchens, with pantry and dumb-waiters communicating with wards; linen- room, dispensary, and operating-room ; bath- and wash- rooms, and water-closets. Faucets conveniently placed supplied drinking water from a refrigerating apparatus, and sometimes an independent tire-engine gave protec- tion against tire. Numbers carried. Steamer D. A. Janu- ary. Fig. 1194,-Victor Emanuel. Plan of hold as fitted. Scale, one-twelfth inch to a foot. boat passed many towns and landing-places where it could stop and renew its supplies. The January was 230 feet long, with an extreme width of 65 feet. It has carried as many as 554 patients, al- though its ordinary capacity was considered about 400. The main sick ward was on the cabin deck, from which the partitions were removed ; the middle deck had ac- commodations for 60 patients ; the lower deck for 100. The fan in the main ward was worked by steam, and made about ninety revolutions per minute. The hospital steamer City of Memphis was 330 feet long by 70 wide, and could carry com- fortably 750 wounded. The Empress was 266 Medical officers, hospital stewards, ward-masters, and male and female nurses generally were in numbers ac- cording with army regulations, but varying in proportion to the number and seriousness of the cases carried. Ha- bitually nurses were relieved every six hours. The surgeon-in-chief on the boat was in absolute con- trol, and responsible for the entire administration. He served as quartermaster, and subsistence offi- cer ; made the purchases, and hired captain, pilots, and crew. Figs. 1196, 1197, 1198 and 1199 give a good idea of the arrangements on one of these boats. In May, 1862, the medical director of the Army of the Surgeon- in-chief. Other riv- er hospital steamers. 149 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Potomac asked for a sufficient number of hospital steam- ers to carry five thousand men, and from this period the movement of wounded by boat was a recog- nized and general mode of movement in that army, and the officer in charge, a surgeon, was called the medical director of transportation. The names of thirty well-fitted hospital steamers are knowm to the writer as having been used at different times, during this war, in the East and West. While the steamer service was so arranged as system- atically to reduce the number of sick with the army be- low the number of beds for their accommodation, yet, just before a threatened battle the service increased so her 4, 1865, during which time she made twenty-eight trips along the Gulf of Mexico and Atlantic coasts, carry- ing 3,655 patients. The longest trip, from New Orleans to New York, lasted nine days. Stopping-places were not so convenient and easy of access as along the rivers; still the steamer was never very far from a port to which she could resort in distress. Figs. 1200, 1201, and 1202 represent the arrangements of this-steamer. The above description of one of our own steamers may seem meagre, but in answer to my request for additional details I am informed from the Surgeon-General's office, under date of September 22, 1885, tliat "all the material Transport service on Atlantic coast. Fig. 1195.-Victor Emanuel. Plan of hold as fitted. Scale, one-twelfth inch to a foot. as to empty as many as possible of the beds in the hospi- tals with the army. Thus the medical director of the Army of the Potomac reported that 7,000 sick and wounded were sent by steamer from the army to the base hospitals between July 2 and 15, 1862; and 14,159 between August 3 and 15, 1862, of which last number 5,629 went on the 15th. These move- ments preceded anticipated battles. The best ocean transport in the United States service was the J. K. Barnes. This was a side-wheel steamer of 1,400 tons, 228 feet in length, 35 feet 2 inches in width, with 22 feet 9 inches depth of hold. The gun-deck was fitted up for the principal ward, and the whole capacity of the steamer was for 477 patients. She was used but ten months, from January 1 to Novem- on file in the office was used" in the "Medical and Surgi- cal History of the War," p. 971, third surgical volume. This material, and some additional from another source, is here embodied. The right of the medical department to absolute con- trol of its hospital transports, uninterfered with by local commanders, was not fully recognized until early in 1865, when the Secretary of War issued an order that "hospital transports and hospital boats, after being properly assigned as such, wfill be exclusively under the control of the medical depart- ment, and will not be diverted from their special pur- poses by orders of local or department commanders, or of officers of other staff departments." In preparing a ship for the transportation of sick and wounded, the best ventilated and lighted parts should be Control of medical de- part me nt absolute. United States ocean hospital transport J. K. Barnes. 150 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. chosen for wards. The beds must not be too crowded, although various considerations will render it necessary to curtail the air space for each patient, below that ordinarily allowed in a well-regulated hos- pital. Six feet three inches by two feet six inches is a good length and breadth for beds. As patients will be crowded, special attention must be given to ventilation, cleanliness, and dis- infection. As the necessity ot thorough policing has been in- sisted on in ordinary troop trans- ports, so must it be specially em- phasized on sick transports ; and on a ship which has been for some time thus used continual watchful- ness must be directed against the first appearance of infectious or epidemic diseases. The spread of these, when once present on shipboard, will be with diffi- culty controlled. The disinfection and disposal of the excreta demands the surgeon's continual attention. Besides the wards and sleeping-berths, proper space should be provided for convalescents, a lounging-room, geon on board, in commenting on the faults of this ship, remarks that the water-closets were in excess of the re- quirements, and that it would unquestionably have been preferable to have dispensed with the block of three water- closets on either side at the bows, so as to have removed Fitting up of hospital transports. Fig. 1196.-Upper Deck or Texas of United States Hospital Steamer D. A. January. .4, A, projections of lower deck; U. Ji, roof; C, C, cabin roof above skylights ; D, D, smoke-stacks ; E, water-closets ; A', wash-house; G, G, wheels; II, II, II, water-tanks ; I, captain's room; J, social hall; K, Texas dining-room ; L. L, L, rooms for steamboat officers ; M, private rooms; N, dummy or provision rail- way, extending from lower deck to hurricane deck. all obstacles to the free current of air from stem to stern through the bow- and stern-ports. Water-closets are abundant when equal in number to eight per cent, of the passengers. Laundrying soiled clothes must be provided for, with laundry-room and laundry-men, or preferably machinery. For the supply of fresh water, in addition to water-tanks and casks, a condenser must be sup- plied, and an ice-machine must be insisted on ; $1,500 to $2,000 will buy a machine that will make ice sufficient for all the passengers the ship can carry, even in tropical re- gions. Ventilation must be effected by port-holes and hatchways, by wind- sails and tubes extending through- out the ship, some of the tubes carrying air heated at the ship's fires. Various ventila- tors have been patented ; but it is doubtful whether any of them are more efficacious than the means above in- dicated. The general basis for estimating for supplies must be Fig. 1197.-Cabin Deck of United States Hospital Steamer D. A. January. A, A, projections of lower deck; B, office; C, C, private rooms ; D, front stairs : E, E, Texas stairs; F, F, steamboat chimneys ; G, G, stoves; 77, 77, middle ward stairs; 7, nurses' dining-room : J, kitchen ; A", A', bath-rooms, hot and cold ; L, L, steamboat's wheels ; if, M, water-closets: A, private room ; O, drug store ; P, sur- gery ; y, linen-room; B, space occupied by the mirror; 8, S, cold-water pipes. with tables, chairs, or benches, and books and games, where they may sit and chat and smoke. A few berths should be provided for sick officers, and ample accommodations not neglected for the medical officers and other personnel of the hospital. Attention must be paid to the cook's galleys, not only that they are ample for the increased num- ber of passengers and suitably pro- vided with utensils, but that they are presided over by expert cooks. Poultry coops are necessary ap- pendages to the larder, and store- rooms must be appropriated to stores, and a bakery and butcher's room provided. The dispensary and surgery-room and other offices should be well fur- nished and as large as practicable. Bath-tubs and lavatories must not be omitted, nor in- odorous close stools, with a sufficiency of privies and urinals. Of these latter not too many. Thus the before- described Victor Emanuel, in addition to the water-closets Fig. 1198.-Middle Deck of United States Hospital Steamer D. A. January. A, A, lower deck; Ji, Ji, Ji, hatchways; C, boilers; D, D, E, E, middle deck; F, F, space for sick; G, G, nurses' quarters ; B, Jf, cold water ; I, side or middle deck ; J, stairs to lower deck ; J, stairs to upper deck ; K, K, water-closets; L, nurses' stairs from cabin deck; Jf, M, nurses' stairs to lower deck. the supply table heretofore given (wide p. 108), and the number of attendants will equal that of the same-sized general hospital. This number, of course, does not in- clude men required for other purposes than the direct care of the sick. Lanterns are a necessity well worth the recollection of the sur- geon, not only on this but on other duties ; and it has once happened, within the writer's knowledge, that surgical operations partly com- pleted were suspended temporarily for want of lanterns. Dumb-waiters and lifts in various parts of the ships arc great con- veniences. In cases where ships can lie alongside the wharf, the patients can be carried aboard through the gangways. But in many instances loading and unloading must be from Fig. 1199.-Boiler Deck of United States Hospital Steamer D. A. January. A, foot of stairs; B, B, space for wood and coal; C, boilers; D, stores; E, pastry room ; F, kitchen ; G. carpenter shop; P blacksmith's shop ; Z. engines; J, donkey engine; E. K, wheels; L, washstands; JZ, J/, water- closets ; N, N, main deck; O, stoves; P, P, cold water. on the upper deck, had on the hospital deck four for sick officers and eighteen for sick soldiers. The senior sur- 151 Field Surgeons. Field Surgeons. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. small boats or lighters. Here block and tackle will be necessary, as in many other cases, in moving from one deck to another. Warming must be effected by stoves, or by heated air from the ship's fires, conducted through tubes, making a species of furnace. Artificial heating is resorted to as thoughtful surgeon nearly everything needful that has not been mentioned by name. Hospital steamers should be supplied with hospital flags, or flags containing the Geneva cross, as before de- scribed. Transport of Sick and Wounded by Rail.-The use of Plan of the Fittings of the United States Hospital Transport General J. K. Barnes, 1865. Brevet Major Thomas McMillen, Assistant Surgeon, U.S.A., Commanding. SPAR DECK. GUN DECK. ORLOP DECK. Fig. 1200.-Spar-deck of United States Hospital Transport J. K. Barnes. Fig. 1201.-Gun-deck of United States Hospital Transport J. K. Barnes. Fig. 1202.-Orlop-deck of United States Hospital Transport J. K. Barnes. sparingly as possible, in consequence of the danger of that frightful calamity, fire at sea. It would be useless to attempt to enumerate every ar- ticle required on a hospital transport, and it is believed that what has thus far been said will suggest to the railroads for the movement of the sick and wounded is of recent date. Immediately after the battle of Solferino, in the cam paign in Italy, a large number of wounded Austrians were taken by rail to Verona, and a Austrian service. 152 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Field Surgeons. few to other hospitals. Ordinary cars conveyed them, the wounded frequently lying on the floor without other bed than blankets. After Sedan regularly organized railroad trains carried the German wounded to all parts of Germany. The Prussian government appointed a commission in 1867 which studied the best plan of carrying the wounded by rail. Covered freight cars and fourth-class passenger cars were found to be most readily adapted to this purpose, and the commission decided to provide in their plans for the suspension in the cars of the litters on which the patients were carried to the cars. Caoutchouc rings were the means of suspension. The railroad transportation of wounded in Prussia was placed under direction of a commission composed of officers of the line of the army, officers of the medical corps, ad- ministrative agents, and railroad officials. The French wounded also were transported in large numbers by rail after the battle of Sedan, the most of them in ordinary cars without special fitting. In 1870, however, railroad trains were specially fitted up for the carriage of the wounded. The first description of a car specially prepared in France for the transportation of the wounded, I find in 1859. It was prepared to carry the sick to Chalons Hos- pital from the extensive camp of fifteen thousand men in the vicinity. An ordinary baggage car was provided with transverse movable benches. More worthy of no- tice, how'ever, is the fact that litters were specially pre- pared to bring the sick from camp to the cars ; the same litter being received into the car and resting on the floor thereof, and thence being carried to the hospital, the oc- cupant not being changed during the whole transit. The description of this car by Jules Perier, medecin-en-chef, appears in the " Recueil de Memoires de Medecine Mili- taire," 1859. In Austria, cars were fitted up, but not very perfectly, after Solferino and Magenta. The " Order of Malta," by agreement with the government, now furnishes a certain number of railroad trains fully equipped for the trans- portation of the wounded. In England no wars on the island have rendered neces- sary the fitting up of trains for the carriage of wounded on the numerous roads there existing. But in its war in Egypt, in 1882, the British sick and wounded were not allowed to accumulate beyond four hundred in Cairo, but were systematically moved to a large extent by rail to Alexandria. The principal medical officer of the forces in Egypt re- ported that at "the recommendation of the sanitary of- ficer the railway carriages were also specially fitted up." " The carriages intended for diarrhcea and dysentery cases had apertures made to serve as latrines, and were all littered with a layer of hay to break the concussion. * ' A medical officer and a staff of non-commissioned of- ficers, and men with a supply of medical comforts, such as beef-tea, milk, plain tea, brandy, etc., ready for im- mediate use, accompanied each batch of invalids." No preparation of railroad hospital cars for the trans- portation of patients is described other than the foregoing. During the war of secession in the United States, in 1861-65, the railroad transportation of wounded and sick received considerable attention. On the Confederate side large numbers were so moved, but no cars were elaborately pre- pared for this purpose. In the North, larger numbers were transported, and their movement systematized. In the armies in the Western States this was done in 1863. In the fall of that year a hospital train was put on between Bridgeport and Nashville. Two ordinary passenger cars fitted up with bunks, two such cars unaltered, and a box car for a cooking car con- stituted the first train. In September there were added two first-class passenger cars, fitted inside with berths suspended from elastic rings. This train was able to carry sixty patients recumbent and sixty sitting up. It was under charge of a medical officer, with a detail of nurses and cooks. One medical officer states that he supervised the trans- portation of 20,472 patients, and lost but one en route. In the East, after the battle of Chancellorsville, 9,000 sick and wounded were moved by rail from the Army of the Potomac in three days ; they were moved on freight cars, whose floors were covered with hay, grass, or leaves, on which were generally spread the blankets of the pa- tients. The number of wounded at Gettysburg has previously been referred to by way of illustration. To this battle- field railroads were handy, and the transportation of pa- tients to the base hospitals began July 7th. By July 22d 15,425 wounded had been moved. July 9th the largest number on any one day are reported as having been moved-one train carried 1,012, and another 1,061 wounded. They were carried mostly on box cars, whose floors were covered with hay. Military surgeons did not rest long contented with these simple cars, with floors for beds. In Europe the plan had been tried of suspending the beds from the tops of the cars by various devices, so as to let them swing. The roofs of the cars proved unable to sus- tain the weights, and the instability of the swinging beds caused such a feeling of painful insecurity in the occupant that the plan was abandoned, and the commission to whom it was referred for examination re- ported against it, and recommended the continued use of the car floor, well covered, for beds. In the United States various ameliorating plans were proposed. All the hospital cars were by preference mounted on trucks with elliptical steel and India-rubber springs, which rendered them far easier to the patients. But it was also desirable to in- crease the carrying capacity as well as the patients' com- fort. Both ends were sought to be obtained by arrang- ing the berths in several tiers, and by adopting new devices for suspending or sustaining the berths. We may consider the hospital cars, then, under three headings. 1. The ordinary railroad car without special fitting. 2. The car whose beds are shifting and movable. 3. The car whose beds are fixtures. 1. The ordinary passenger car is used sometimes by lay- ing boards from seat to seat, or over the backs ; and in some cases the scats have been violently removed, and the patients laid on the floor. But open cars and box cars, or freight cars, are most fre- quently used. In the first place, they are gener- ally at hand. They have brought men, material, and sup- plies to the front, and may at once be utilized on their re- turn. If uncovered, a canvas cover may be readily spread over them as a roof, and the floor being well strewn with a thick layer of grass, hay, straw, leaves, or twigs, and small branches of trees ; on these, with or without blank- ets, the patients are laid. In actual experience the writer has found these cars very comfortable to the sick. His experience is confined, however, to routes requiring but a few hours to travel. 2. Regarding cars fitted with movable beds. Some of these cars have been equipped with beds in tiers, which fitted in grooves, sliding in and out of place so that the bed could be carried to the patient out- side the car, receive him, and with him, be borne into the car and replaced. Many cars were fitted with upright stanchions at suit - able distances, to which the beds were attached by suit- able devices. The question of elastic suspenders is of some importance. In the United States and Europe they were tried, and the verdict concerning them has varied between unqualified approval and disapproval. It was believed that by means of caoutchouc rings, two at each end of the bed supporting it, the vibration and jolting of the cars might undergo resolution into a gentle motion of the bed and patient, free from shock. After careful consideration the writer is of the opinion that this resolution does not take place in actual experi- ence. The writer has carefully examined cars thus fitted, German service. French service. Berths suspended from the roof of the cars. Cars on springs. English service. Cars with- out special p r ep a ra- tions. Cars with movable beds. United States of America service. Elastic rings. 153 Field Surgeons. Fig. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and in 1863 travelled on a train of such cars laden with sick and wounded between Washington and Philadelphia. The movement of the beds was carefully scrutinized while the train was in motion, and the patients were questioned, and the opinion formed was unfavorable. If the caoutchouc rings were sufficiently thin to ad- mit of the full benefit of their elasticity to the patients, they failed to render the bed sufficiently stable ; indeed, the feeling of instability resulting from the movements of undue stretching of the rings was excessively annoying. Besides, rings so thin were so weak as to endanger the security of the bed. On the other hand, if the rings were very thick and strong, they differed not from any firm inelastic attach- ment. It is worthy of emphatic expression here, that the com- The superiority and simplicity of this plan of suspen- sion over any other plan of suspension by elastic rings is so undoubted that it does not seem worth while to de- scribe any other. 3. Cars with fixed berths have been arranged in many ways. The extemporary preparation by stanchions, cleets, and boards is the easiest. However, such plan of extemporary fitting must be adopted as may be determined by the material available, and the skill and ingenuity of the mechanics present. As long as fighting is not a frequent amusement of na- tions, so long will the necessity for the use of railroad hospital cars be rare, and in this state of uncertainty it is doubtful whether any government will beforehand pre- pare and keep properly fitted hospital cars. Should a government, however, decide so to do, there can be no Cars with fixed beds. fort of the well or sick traveller in a railroad car depends much more on the smoothness of the track and the rate of speed than on any characteristic whatever of the car or the bed. If the road-bed is smooth, and the rate of travel slow, scarcely any discomfort is felt by the traveller from either the vibration, the jolting, or the swaying of the car. Anyone who has travelled much, recumbent, in a Pullman car, can testify that in rapid travel the chief discomfort is not from the lesser vibrations-such vibra- tions as might be most probably prevented by elastic suspension-but from the major movements of the car, tossing actually from place to place the occupant of the bed. This tossing about can only be remedied by pad- ding with pillows, and then not completely. If, then, the travel is slow and on a smooth track, any arrangement of berths is easily endurable ; if the train moves rapidly over a rough road, no system will entirely obviate jarring and rough movements. Abundant pad- Fig. 1203.-Side Elevation of United States Army Hospital Railroad Car. doubt that the plan of the car selected should be that which promises the most comfort to the sick traveller, such as the plan of the Pullman or Wagner sleeper. These cars have a lower tier of cushioned seats, which can be made into beds in their own space. Above these is an upper tier of beds, secured by hinges to the outer wall of the car, at a sufficient height above the lower tier. The inside border of this bed, secured by appropriate movable fastening to the roof when not in use, can be lowered when needed, so that the bed rests horizontally, supported by rods or chains extending from the edge of the bed toward the upper part of the car. The seats, or lower tier of beds, are boxes ; and so are the spaces enclosed by the upper berths when not in use. In these, and suitable closets arranged elsewhere in the car, are contained bedding and linen. It remains to mention one other arrangement of cars which has commended itself to some. Spiral springs Fig. 12^4.-Ground Plan ot United States Army Hospital Railroad Car. ding with pillows about the person of the traveller is the best remedy, and partially succeeds. The great advantage attainable in cars thus prepared is, that the litters on which the patients are brought to the cars may be suspended in them, and at the end of the journey unhung and removed, the patient remaining un- disturbed through all. The simplest and best mode for arranging cars for this mode of transportation is by the erection of strong stan- chions on each side of the car, at a distance from each other, longitudinally to the car, corresponding to the length of the bed or litter to be suspended ; and transversely to the car, at a distance from each other and from the sides of the car, relative to the width of the bed or litter, and so as to leave an aisle or passage sufficiently wide to permit the manipulation of the bed. On pins or hooks on these stanchions the caoutchouc rings may be hung. have been secured to the car floor, on which have been secured either the bed or a platform on which beds are placed. This plan does not commend itself to the judg- ment of the writer. The movement derived from the spring cannot cure the swaying and rocking resulting from the rapid movement of the car. All the move- ments combined do not resolve themselves to a state approaching rest, and besides, economy of space is want- ing. It must be repeated, then, that for impromptu transpor- tation of sick and wounded, ordinary cars are the best ; the patients being laid on the floor, which should be thickly covered with hay or similar material to serve as padding, and prevent tossing about. If cars are specially prepared, the Pullman or some eco- nomical modification thereof is the best. Railroad cars have been specially fitted up in various ways not here de- 154 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Field Surgeons. Fig. scribed. Their description is omitted because they have been tried and found wanting. Hospital Train.-A railroad train fitted up to carry the sick and wounded of a modern army is practically a hos- pital ; its only differences therefrom arise from the fact that it is tenanted for such a limited time, and travels. It should comprise, besides the engine and tender com- mon to all trains, a cooking car, a car of provisions, a dispensing car with medicines and hospital stores, a baggage car, a car for the surgeon and his assistants, a car for fuel, where the route is long and through an unsettled country where can be found no depot for supplies, and the cars for the sick and wounded. The number of these cars in each train where wounded and cars are both in abundance must be de- cided by the condition of the railroad, i.e., whether level and well laid. Twenty cars for wounded has been found a con- venient number, and about as many as can ordinarily be man- aged in a train. Ten is the number given in the "Medical and Surgical History of the War " as a proper number for one train, but more can be used to advantage. The cooking car should be fitted with a suitable range, Fitting of cooking utensils, dishes, knives, forks, spoons, cars. and other table furniture in quantity sufficient for the maximum number of persons the train can carry. Food, stimulants, hospital stores, instruments, and dressings must be carried in the amount needed, which amount must be determined by the number of patients, and the length of the route. An office, desk, and book-cases must be provided for the surgeon, and in each car a supply of water, seats for attendants, closets, and water-closets, shelves, and in winter, stoves for heating purposes. Ventilation must be enforced. In the United States, cars are constructed with this end in view, and generally the rapid motion of the car will effect it. It must be re- membered that in a hospital car the amount of air space per man is very small. Different classes of patients must be carried in different cars. This classification is important. Such a train will ordinarily need a surgeon in charge, and four assistant surgeons; and at least one skilled nurse is required for every hospital car. A greater number of both may be needed, depend- ing on the condition of the sick, the severity of the wounds, and the length of the route-that is, whether long enough to require more than one relief. Figs.1203,1204,1205, and 1206 will give a very good idea of a hos- pital railroad car, and of the handiest mode of using elastic rings. Trains of hospital cars should be desig- nated by some mark to indicate their character. They should carry the hospital flag, and have painted on them the Geneva cross, as before described. Conclusion.-In concluding this article concerning the duties of the military surgeon in the field and campaign, and the care and removal of the wounded after a battle, the author calls attention to the habitual silence of military surgeons in their reports concerning the topics here treated. In the writings of military surgeons full information can be found regarding the surgical aid to be given to the wounded, but little, or nothing, concerning the extra professional care. In this paper are embodied the results of the author's researches, and still more of his own experience during more than thirty years' service as an army surgeon. The facts and opinions here found can be found col lected nowhere else, and many of them heretofore unre- corded, and it is believed their record may be of use to not only the military surgeon, but especially to the large number of surgeons in civil life liable, at the outbreak of war, inexperienced, to be called on to meet the hazards and perform the duties peculiar to the military surgeon. Joseph R. Smith. What a hospital train should consist of. FIDERIS, a mineral spring of Switzerland, affording the weakest of alkaline waters. It was described three hundred years ago by Conrad Gessner, who claimed for it considerable medicinal value. Its water is recom- mended chiefly for children and in cases of moderate ame- mia, especially where it is the result of dyspepsia. An establishment has been erected, and is patronized espe- cially by the Swiss. J. M. F. FIG {Ficus, U. S. Ph., Br. Ph.; Figue, Codex Med.), the composite fruit of Ficus Carica Linn. ; Order, Arto- carpea, dried. This little tree, a native of Syria and Asia Minor, has been cultivated both there and in other warm countries of the Old World, from the remotest antiquity. Its fruit is an article of food or luxury all over the world. In Fig. 1205.-Rear Elevation of Hospital Railroad Car. medicine, however, it has almost no value, and conse- quently can be only briefly noticed here. It is a stout shrub or small tree, with a smooth reddish or gray bark, an abundant milky, caoutchouc - containing latex, and alternate, variously pal mately - lobed, dark - green, stipulate leaves. The inflorescence is lateral, con- sisting of solitary, fleshy, pear-shaped, hollow recep- tacles, upon whose inner surfaces the small, numer- ous, and rather depauperate, unisexual flowers grow. A small aperture at the apex of the receptacle admits air, and the insects which assist in the diffusion of the pol- len. The staminate flowers, which are nearest the opening, have a diminutive perianth of a few segments and two or three stamens ; the pistillate ones, which are the most numerous, consist of a very mi- nute and delicate perianth, and a single one-celled ovary ripening into a one-seeded drupe. These drupes are the " seeds" of the fig. The fig itself is the thick and fleshy receptacle with its numerous contained true fruits. The fig-tree has been introduced into the New World, and is now cultivated in nearly every tropical and warm tem- perate region. Where accessible, the fruit is eaten fresh as a dessert, but in colder climates and for medical pur- poses the dried figs of Southern Europe and Asia Minor are employed. Besides the varieties distinguished by the names of the places from which they are exported, as Smyrna, Turkey, Greek, Marseilles, etc., figs are im- ported in two forms, known as "pulled''and natural. The former are rolled and kneaded until their structure is broken up and they have become soft and pliable ; the Personnel of train. Fig. 1207.-Ficus Carica, Leaves and Fruit. Fig. 1206.-The Free or Inside Method of Suspending Litters by Rubber Rings. 155 Fig. Fingers. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. solidly packed, layered, flattened figs are of this sort: the others are simply dried in the natural condition. These are oblong, rounded, and longitudinally wrinkled. Figs do not require description. Their composition is simple and of no physiological interest; glucose, two-thirds, mu- cilage, fatty, and odorous matters, and vegetable tissue. They are only employed ofticinally in the Confection of Senna (Confectio Senna, U. S. Ph.), of which they com- prise twelve per cent. They are a well-known laxative food. Allied Plants.-The genus is a large one, compris- ing a number of species with active physiological prop- erties, several others of the greatest value as producers of Caoutchouc, q. v. Allied Drugs.-All sweet and mucilaginous fruits. W. P. Bolles. filaria cases have some elephantiasis disease ; and that in filaria countries about ten percent, of the general popula- tion have filaria. In the London Medical Times a nd Gazette of February 17, 1883, he asserts that some of the phe- nomena observed in filaria patients may be explained in this wise: The parent worm being located in some lymph- channel of a patient, instead of throwing off the filariae alive and with a diameter of inch, aborts and throws off eggs before the embryo is fully developed ; but the eggs have a much greater diameter than the filariae, and they plug lymph-vessels through which the latter would pass. The current being arrested, the vessel becomes distended behind the point of occlusion, and the result is lymph scrotum, chyluria, etc. Certain mosquitoes in drawing blood take with it into their stomachs some of the filaria;, where the latter un- dergo changes and are deposited with the mosquito's eggs and faeces in water, where they may make further progress and finally be drunk by a human being and in this second host attain full development. Of many varieties of mosquitoes examined only one was proved to be an acceptable host, and perhaps the re- striction of this variety of mosquito to certain localities may explain the limitation of the origin of the disease in- cident to this parasite to certain hot countries, such as China, Brazil, etc., where, as above mentioned, so large a proportion of the population is said to have filariae, although they may show no symptoms. There is no cure known for the dis- ease ; prophylaxis demands filtering or boiling drinking-water. The length of life of this worm is unknown. Manson, in "The Filaria Sanguinis Hominis," speaks of one case in reference to which he says: " This worm had lived in the patient's lymphatics for at least thirty-two years." lie does not say why the pa tient might not have been re-infected and have had a series of worms during this time. A case observed by the writer in the New York Hospital shows a lengthy duration of symptoms (say ten years) after the commencement, and after the patient had left his home in the West Indies, where he must have acquired the parent worm. P. L. D , male, aged thirty-seven, born in the West Indies, entered hos- pital February 8, 1882. In 1864, while on a voyage to Copenhagen, he passed a plug of mucus from the urethra ; this was followed by white urine," which continued for some time. He then re- mained free from symptoms for seven years. He returned to the West Indies. In 1871 he passed an- other plug of mucus, followed again by milky urine for three months. In 1874 he came to New York and had phlebitis of right leg and thigh. In 1875, while under Dr. Ilobert Abbe's care, it is reported that the patient's urine coagulated after standing twenty to thirty minutes, becom- ing liquid again after twelve to twenty-four hours. Clots occasionally passed containing filariae. The blood was not examined at this time. For five years afterward this pa tient's symptoms were less annoying; but he had occa- sional severe attacks ; six weeks before entering the hos- pital he had a series of furuncles ; his urine cleared somewhat after sleep, but at other times it was milky. In this case, as in other reported cases, filariae were found in blood taken at night, but not in that taken by day. The experiment of changing his habits (i.e., letting him sleep by day and watch at night, which has elsewhere been successfully tried) was not essayed with him. The filariae found were not numerous ; sometimes sev- eral slides would be examined under the microscope be- fore finding one filaria. FIG WORT {Scrofulaire, Codex Med.). Several Euro- pean species of Scrophularia have formerly been in use as "tonics, resolvents, sudorifics, and vermifuges," but are at present only used, and that not commonly, in coun- try domestic practice. Two are still officinal in France: Scrophularia nodosa Linn. (Herbe aux icrouelles), the com- mon Figwort, a coarse, bitter, disagreeable herb, with small, dull, globular flowers, and opposite lanceolate or heart-shaped, serrated leaves. It is a native of Europe, but grows freely as a weed in damp waste places. Its Latin and French names both indicate its supposed value in scrofula. The second, S. aquatica Linn. (Ilerbe aux hemorroides), has, in general, similar qualities. It is used as a poultice or external application in haemorrhoids, etc. The principles scrophularin, a bitter crystalline substance, scrophularosmin, an odorous stearoptene (?), and scrophu- laracrin, have been separated from the above. Allied Plants.-See Foxglove. IF. P. Bolles. FILARIA SANGUINIS H0MIN1S is the name given by Dr. T. R. Lewis to the microscopic embryo of a nematode worm. The mature worm is called by Cobbold Filaria Bancrofti. The embryos are found in the blood of many human beings in some of the hot countries. The male of the mature worm is at present unknown ; the female has the body capil- lary, smooth, and uniform ; the head has a simple circu- lar mouth, no papillae, neck narrow ; the reproductive outlet is close to the head ; the anus is just above the tip of the tail. The largest ones found have been about inches long by -fa inch in diameter. The worm emits the filaria) from two loops at the centre of the body ; these embryos as found in the blood are fa by sfao inch, the eggs are nunr to 7^77 inch. The embryo filaria as found in the blood is en- closed in a sac too long for it, so that a kind of lash is formed at the rear end of the filaria as it moves in different directions, or even at both ends (see Fig. 1209). In 1872 Dr. T. R. Lewis found filaria) in the blood, in chylous urine, and in milky discharges from the eyes of patients ; there is no evidence that they advance beyond this microscopic stage in man without an intermediate host. They may be found in the blood of most patients suffering from chyhiria, in some cases of haematuria, lymphatic abscess, some forms of hydrocele, varicocele, and orchitis, elephantiasis of the leg and scrotum, helmin- thoma elastica, and craw-craw, and in many cases where the patient is not perceptibly diseased. Dr. Patrick Manson says that fifty-eight per cent, of Fig. 1209.-Embryo of Filaria Sanguinis, largely magnified. (See Archives of Medicine, 1882.) Fig. 1208.-a. Female Filaria Ban- crofti, about half natural size : b, head and neck; c, tail : d, free embryo; e, egg containing em- bryo : f, egg with cleavage of yolk, magnified. (After Cobbold.) 156 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fig. Fingers. In May some glands below Poupart's ligament on the right side became enlarged, and in the hope that the parent worm might be lodged there, they were dissected out. Some fine filaments were drawn out, but were lost before a thorough examination could be made, and were not proved to be the worm. After the operation his symptoms improved, and there is no record of filaria being again found in the blood. Patient left the hospital and remained away two years. On readmission the urine was occasionally milky, and he had phthisis pulmonalis, from which he died October, 1884. A most searching post-mortem examination was made by Dr. Frank Ferguson. In the lungs there were cavi- ties, in the intestines ulcers ; the bladder was sacculated, the ureters distended, the thoracic duct and the lymphat- ics about the lumbar region were exceedingly large and tortuous ; but in spite of prolonged search no filariae were found in the blood of any part, nor could any parent worm be discovered. Several times parent filariae have been withdrawn by the cannula in tapping the tunica vaginalis testis for lymph scrotum ; but, so far as the writer knows, the only time when the parasite has been discovered in the lymph- channels was in a case of Manson's, where he amputated a lymph scrotum and found part of the worm on the cut surface, the remainder being in a lymphatic vessel. Manson thinks the male is smaller than the female, and lodged in the same place. For other filariae see Nematodes. Charles E. Hackley. ber bands must be used in such manner as the possibili- ties of the case will allow, and the ingenuity of the surgeon suggest. In very severe cases the only remedy is amputation. But it must be remembered that even a greatly deformed finger may become far more useful than an arti- ficial hand can ever be, es- pecially as a patient learns the trick of using it in some unexpected way ; and un- less it be the seat of pain, that we must weigh the dangers of an operation against mere unsightliness more seriously in the hand than in the foot, as in this last it materially interferes with locomotion. Operations for the relief of such contractions occasion- ally afford marked benefit, but from the tendency to re- contraction they are, as a rule, only partially successful. Incision of the cicatrix, either linear or V-shaped, if it be small and recent, may be tried. This must extend through the entire width and depth of the cicatricial tissue. By suitable extension-apparatus the fingers must be retained in position till the cut heals, which should be Fig. 1212.-Deformity following Burn, the little finger being dislocated backward. (Erichsen.) FINGERS, CONTRACTIONS OF. Contractions of the fingers arise from vicious cicatrices, affections of the muscular or nervous systems, diseases of the joints, and, finally, there is a peculiar form of disease affecting the fibrous tissues, especially the palmar aponeurosis, known commonly as " Dupuytren's finger-contraction." These disorders will be considered in the order named. Occa- sionally they are congenital, as in Fig. 1210. I. Contractions from Vicious Cicatrices.-Such cicatrices result most fre- quently from burns and scalds, occasionally from deep abscesses or wounds, especially gunshot wounds and machinery accidents, more rarely from tumors, gangrene, etc. The well- known tendency of the cica- trices of burns and scalds to contract, even for a longtime after complete healing, often produces finger distortion, varying in degree from very slight deformity to almost unimaginable distortions. Fig- ures 1211 to 1214 well illustrate this fact. Fig. 1211 illus- trates a moderate contraction permanently flexing the fin- gers and partially obliterating the hollow of the palm. Figs. 1212, 1213, and 1214 show far more marked degrees of de- formity. In the first the little fin- ger is dislocated on the dorsum of the hand, and in all the fingers are webbed and mat- ted together by dense cicatricial tissue. Treatment.- This iseither that of prevention or of cure. Unfortunately, the first is always difficult, and often unavailing. Free and repeated skin-grafting may hasten the healing and modify to some extent the cica- trix, while bandages, splints, and elastic traction by rub- Fig. 1213.-Deformity of Right Hand from Burn. (Erichsen.) aided, if possible, by sutures so applied as to make the transverse wound longitudinal. Excision is available in old and firm cicatrices (espe- cially in the form of narrow bridles) if not too large in extent. The entire scar, and a little more, both in width and depth, must be removed, care being taken that under- lying vessels, nerves, etc., are not injured. Skin-grafts are often useful. Plastic operations may be occasionally resorted to, and with repeated operations and great ingenuity may yield in some cases very satisfactory results, as shown by Post ("Trans. Amer. Med. Assoc.," 1879). The entire cicatrix must be. removed, and even a little more, and its place supplied by healthy flaps of skin from the adjacent surface or other parts of the body. The skin must be liberated by incisions at all neces- sary points, and even parts of the bones must sometimes be exsected. The usual rules governing such operations must be carefully followed, and the after-treatment, both surgical and me- chanical, must be judiciously and patiently carried out. II. CONTKACTIONg FROM AFFECTIONS OF THE MUS- CLES.-These may arise from inflammation or over-use of the muscles, or inflammation of the synovial sheaths, from syphilis, from wounds which divide the tendons of one or more muscles, when the muscular opponents may produce contraction. Fig. 1215, from Erichsen (ii., p. 328) is an excellent illustration of the contraction of the flexors and pronators following the use of heavy shears. Rheumatism is an occasional cause. The treatment must be, as a rule, in accordance with Fig. 1210.-Congenital Contraction of Thumb. (Gross.) Fig. 1214.-Deformity of Left Hand from Burn. (Erichsen.) Fig. 1211.-Vicious Cicatrix from Burn. (Gross.) 157 Fingers. Fingers. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the general principles applicable to each case. In over- use the occupation must be changed ; in wounds the divided tendons should each be carefully sutured with carbolized or chromic catgut, and suitable relaxing splints be applied. In the later treatment, frictions, douches, by their passive resistance to stretching, have flexed the last two phalanges. The heads of the metacarpal bones make palmar " knuckles." In these ulnar cases, before the deformity has gone so far, even the mode of " making a fist " is pathognomonic.- The last two phalanges are first flexed, and then the flexed fingers, by the further action of the flexors, are rolled into the palm. A pencil or coin placed in the palm cannot be seized ; nor can the ends of the fingers be opposed to the tip of the thumb, the func- tion of the interossei (to flex the first phalanges) being lost. Occasionally similar results may follow septic wounds. Some years ago I saw a lady who, while she had a slight abrasion on a finger, washed the handkerchief used by her consumptive daughter to receive her sputa. Her hand and arm became inflamed and swollen, purpura haemorrhagica with severe constitutional symptoms fol- lowed, and her life was almost despaired of. She, how- ever, recovered, with subsequent wasting of the entire arm, including the shoulder, moderate contraction of the fingers, and semi-paralysis of all the muscles of the affected arm and hand. Ten years have passed with a moderate improvement following the use of the means above indicated, and constant use of the arm in house- hold occupations. In all cases in which a nerve has been divided, the ends should be immediately sutured with catgut and the wound closed antiseptically. In a case I so treated, five years ago, the ulnar artery and nerve and some of the flexor Fig. 1215.-Contraction of Flexors and Pronators of Hand from Use of Shears. (Erichsen.) massage, gymnastics, and electricity, all may afford re- lief, singly or together. III. Contractions from Affections of the Nerv- ous System.-These may originate in the nerve-centres or the peripheral nerves. In cases of paralysis from cerebral softening, hatmor- rltage, etc., one of the not uncommon later results is atrophy and contracture of the muscles of the fingers. In the earlier stages, long-continued frictions, massage, and Faradization may do much to modify the progress of the deformity, but in the later stages very little. Noth- ing, of course, will restore voluntary motion in old cases, but we can sometimes relieve the deformity. Thus, some years ago, a lady from Erie, Pa., consulted me as to her right arm, which had been paralyzed many years before. When the wrist was flexed the fingers could be straightened, but the moment the wrist was straightened the fingers were violently doubled up into the palm, and under the least excite- ment-such as entering a street car-the entire arm flew out from her body in various direc- tions, and was a most serious annoyance. I di- vided all the flexor tendons just above the wrist, antiseptically, and placed the hand and forearm on a straight splint for two weeks. The flexion of the fingers was almost entirely relieved, and better than all, the involuntary spasms of the arm entirely ceased. In the cases arising from the peripheral nerves the cause is usually traumatic. Figs. 1216 and 1217, from Fig. 1217.-Paralysis of all the Muscles following Dislocation of the Head of the Humerus. The ext. comm. dig. and ext. long. poll, have recovered voluntary movement, but the thenar, hypothenar, and inter- osseous muscles and flex. long. poll, are still atrophied and paralyzed. Nearly complete recovery followed. (Duchenne.) tendons were completely severed in a child three years of age. The nervous function, as well as could be ascer- tained in so young a child, was re-established as to sensa- tion in three days, and as to motion in a week, and not the slightest atrophy or deformity has followed. Even in cases of long standing, repeated recent experi- ence is decidedly in favor of operative interference. Cut down at the seat of the injury, expose the two ends of the divided nerve, resect their bulbous extremities and unite the two ends by catgut, flexing the parts if need be to approximate the separated ends, and the lost function of the nerve in time will generally be restored. The after- treatment is especially important. Faradization, or, if the muscles do not respond to this, galvanism, must be em- ployed for weeks, and even months, to restore the atro- phied muscles, with the douche, massage, and manual gymnastics. Even so bad a case as shown in Fig. 1217 was greatly benefited by these means. But both doctor and patient must have the utmost perseverance. When the paralysis does not yield to all these means after a sufficient trial, some form of prothetic apparatus is the only remedy. IV. Contractions from Diseases of the Joints. -These arise from the various forms of arthritis, from rheumatism, or from the long-continued use of bandages and splints. In the latter the muscles also participate, to some extent, from non-use. The amount of contraction varies considerably. To remedy these the ordinary means must be used to Flo. 1216.-Paralysis of Ulnar Muscles following Wound of Ulnar Nerve at A. The flexors and common extensor not being paralyzed. (Du- chenne.) Duchenne (" Phys, des Mouvements ") illustrate this. The first shows the effect of a lacerated wound of the ulnar nerve (at A), and the second from pressure on the axil- lary nerves the result of a dislocation of the head of the humerus. Injuries to the ulnar nerves are especially easy of recognition by the "griffin hand." Observe here the prominence of the tendons, and the pronounced atrophy of the interossei and the group of thenar and hypo-thenar muscles. Their paralysis has allowed their opponents to act unopposed. The extensors have even subluxated the first phalanges in extension, while the two flexor muscles, 158 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fingers. Fingers. were obtained in an examination of 700 elderly inmates of workhouses, of whom 444 were women. I have collected to the present time notes of 253 cases in all (including Noble Smith's), and these give the fol- lowing clinical facts : The age of onset is recorded accurately only in 90 cases ; of these 47 occurred after forty years of age, 18 between thirty and forty, and 25 before thirty years of age. Of these last 4 (probably 5) were congenital, and several were children. The sex is noted in 227 cases ; of these 187 were men, and only 40 women. Many surgeons have even denied its existence in women. Yet Dupuytren mentions a case, Menjaud (1861) mentions 3, and Eulenberg (1863), Made- lung (1875), and Carter (1881), each 1. I have seen my- self 4, and operated upon 1. The occupation is noted in 123 cases, exclusive of Noble Smith's cases. Of these 49 were manual and 74 non-man- ual. In only 12 cases in women is it named, of which 8 were manual. The majority of Noble Smith's cases being in workhouses, would probably have followed manual occupations. Both of the hands are usually affected, but in a good many cases only one hand is involved. The preference is on the whole for the right hand. Of 184 cases the right hand only was attacked 58 times, the left 23, and both hands 103 times ; the right hand thus being involved 161 times to 126 for the left. In 26 cases only is it noted which hand suffered first. In 15 of these the left hand preceded the right. The fingers are very unequally involved, the three ul- nar, and especially the ring and little fingers, bearing the brunt of the attack. In 214 cases the fingers attacked are noted. The thumb was involved 11 times, the forefinger 24, the middle 73, the ring 199, the little 165 times. The ring and little fingers were contracted together 125 times. The first two phalanges are usually contracted sep- arately or together ; the last is very rarely attacked. Heredity is a marked feature. Be- sides such general statements as to its being seen in brothers " several times," and excluding Noble Smith's cases, in which this feature is not considered, I find it as a family com- plaint in 50 out of 198 cases. In 5 cases it occurred in two persons of the same generation, affecting 10 per- sons ; in 11 cases it existed in two generations, affecting 29 per- sons ; in 3 cases in three generations, affecting 9 per- sons ; in 1 case it involved one person each in four gen- erations. The existence or non-exis- tence of gout or rheu- matism is stated specifi- cally in 95 cases (ex- cluding Noble Smith's cases). In 64 there was a gouty history, per- sonal or family, in 31 it was excluded. The character of the palmar cord deserves careful study. It arises usually at the level of the web of the thumb or a little higher, be- comes more pronounced as we approach the fin- gers, where it terminates in two ways : 1. Near the base of the first phalanx it divides into two cords inserted into the base and sides of this phalanx, but occasionally pro- longed to the second. Sometimes only one of these lat- eral cords is developed. 2. Sometimes it is prolonged as a combat the original cause. When tlie disease has sub- sided, or the splint is removed-which should always be done at the earliest practicable moment-active and pas- sive movements, together with the means above-men- tioned, must all be used, and persistently used, until the ankylosis is removed and the function of the joint is re- established. Sometimes the ankylosis must be overcome by forcible breaking up of the adhesions under ether, re- peated if need be at suitable intervals. Excision may even be resorted to. V. Dupuytren's Finger-contraction.-This de- formity is dependent chiefly upon chronic disease and contraction of the palmar aponeurosis. Within the last few years it has had a long-unwonted prominence in sur- gical literature. The clinical history of such a case is very peculiar, and in brief is as follows (I quote from a somewhat elabor- ate paper of my own in the Philadelphia Medical Times, March 11, 1882). A man usually of forty years of age qr over, generally without any assignable cause, will ob- serve that his little or ring Anger is slightly stiff. On making the attempt, he finds that complete extension is hindered in some unknown way. If a man of quick ob- servation, he may perhaps notice in the palm two or three little, bean-like, smooth, and slightly tender nodules in the axis of the affected finger, and that the skin is a little depressed in a crescentic pit at one or two places, usually about the level of the lowest or middle transverse palmar line. Gradually, extending over several years, from four or five up to fifteen or twenty, but without any pain, the trouble increases. The little, hard nodules coalesce into what at last becomes a well-marked cord, extending to the finger (though the cord often forms without any such antecedent nodules) ; the skin becomes still further re- tracted, forming two or three very deep crescentic folds with the convexity upward, sharply lifted by the cord, to which it is intimately adherent at its palmar edge, with deep hollows on each side of it (Fig. 1228). The finger, which at first only had its extension limited, has slowly but surely flexed, until now the first two phalanges are each, it may be, bent at a right angle, so that the finger- tip nearly touches the palm. Worse still, the immediate neighbors on one or on both sides have begun to flex, and are but little behind the first. Meantime, too, the other hand, at a varying interval of years, has probably suffered from the same deformity, so that at last one, or more likely both hands, are in part or wholly useless for most of the occupations of life. Nay, more, if he live to an advanced age, he may not only find the hand useless, but the finger-tips or finger-nails, by further flexion, may bore into the palm, producing painful ulcers, which, as in the case of a patient now under my care at eighty-five, may render life a burden. The patient, meantime, finding the disability becoming a serious annoyance, has sought medical advice, and has used liniments, ointments, bandages, baths, electricity, massage, and, these all failing, he has gone to the sur- geon, only to be told that an operation can be done by cutting the tendons of the flexor muscles, to which the trouble is due, but that, while such an operation will re- lieve the flexion, it will only substitute for it completely and permanently extended fingers. His last case, then, would be worse than the first, for, whereas permanently flexed fingers are to some degree useful, permanently ex- tended fingers are only in the way, and subserve no pur- pose in life. From the time when Dupuytren first announced the real pathological anatomy of the disorder, in 1831, isolated cases had been published by various surgeons, but no at- tempt had been made to group the facts elicited by a sys- tematic collection of the recorded cases, and a comparison and analysis of the data they would afford, until the pub- lication of my paper above mentioned. Since then the most important numerical addition is that by Mr. Noble Smith {British Medical Journal, Feb- ruary 7, 1885), in which he records 55 cases of contrac- tion of the fingers, and 15 of fascial induration, thicken- ing, and contraction, the fingers not being bent. These last were, curiously enough, all in women. All of the 70 Fl». 1218.-Dissection of Contraction of Middle and Ring Fingers, from a speci- men in St. Bartholomew's Hospital Mu- seum. a, Contracted band of palmar fascia, just below which goes a band to the base of the first phalanx ; b. flexor tendons far beneath the palmar cord and near the bone : c, fibrous sheath of flexor tendons binding them to the bones; d, digital prolongations of pal- mar cord to base of second phalanx. (Adams.) 159 Fingers. Fingers. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. median cord, adherent to the skin midway down the first phalanx, and then, after separating from the skin, splits into two lateral bands attached to the sides and base of the second phalanx. Sometimes the two forms coexist. As the cord forms the subcutaneous fat disappears, especially along the ridge formed by it, and the cord and the skin coalesce. At the same time the skin is drawn distinctly wrist-ward by the adherent and shortening band, thus producing the crescentic folds already de- scribed. Pathological Anatomy.-Not a few of our current text- books, and many most excellent surgeons, misstate and misunderstand the true character of the disease. Nor out, if the surgeon places his finger in the patient's palm, and the patient flexes the contracted finger, the cord is relaxed instead of being tightened, as it should be were it the tendon. Again, the flexor tendons being inserted into the sec- ond and third phalanges, these two, rather than the first, should be flexed were the tendons at fault. At most, flexion of the first phalanx should only follow that of the last two. The contrary is the fact. In not a few cases the first phalanx is the only one flexed, in many others its flexion precedes that of the second, and in very few cases is the third flexed at all. Moreover, if the median cord above described existed alone, it would be pardon- able to suppose it to be the tendon; but when it splits into .two lateral cords, going to the base of the first phalanx, the mistake of supposing it to be the tendon is unpardon- able, in view of the anatomical facts that no such bifurca- tion of either tendon takes place at the level of the knuckle, nor is either tendon attached in any way to the base of this phalanx. Not seldom, also, the abnormal cord appears entirely out of the line of any tendon what- ever. But there have been now recorded more than a dozen dissections of such hands, and the proof is absolute that the tendons are entirely free from disease. It is the fibrous tissues that suffer, and especially the palmar fascia. The most recent dissection, I believe, is that by Menard and Variot (Chevrot, These de Paris, 1881), in which the microscopic examination also is reported. Richet (Prog. Med., 1877) also has reported a case, with the only other microscopic examination, which confirms this. The palmar fascia was tripled in thickness ; with slight thickening of the epidermis and derma ; disappear- ance of the fatty tissue ; a dense fibrous tissue resembling cicatricial tissue interposed between the skin and the aponeurosis, binding them together, or, rather, confound- ing them in a single layer, so intimate that the scalpel only could separate them ; and, finally, a thickening of the sudoriparous glands. The cartilages of the joints, where they were in contact, were normal, but were eroded and yellowish at the posterior part of the heads of the metacarpal bones. This union of skin and fascia one can easily appreciate by palpation in any well-marked case. And in the gross dissection it accounts for the varying views of different authors, one dissecting more away with the skin and finding marked lesions on its under surface, another leaving it all with the fascia and restricting the disease wholly to the latter. In dissecting a normal hand one is struck with the many fine but strong fibres running in and through the layer of fibro-fatty tissue between the skin and the fascia, uniting fascia, fibro-fatty tissue, and skin together, quite as marked while passing from the palm to the phalanges as in the palm itself. These are especially marked on the ulnar half of the hand, and particularly in the line of the ring finger. Many of the longitudinal fibres pass from the fascia in the palm to the skin of the fingers, especially on the first phalanx. These fibres do not show well after dissection, but can only be appreciated as they are cut one by one by the scalpel. Besides these cutaneous fibres there are many fine fibres going to the sheaths of the flexor tendons, and to the sides of the base of the second phalanges, where they are lost in the fibro-fatty tissue. The division of the fascia into its easily recognized four digital slips, each of which bifurcates and is inserted into the sides of the base of the first phalanx, uniting there with the interosseous and extensor tendons, readily ex- plains the palmar cord which divides at the base of the contracted finger into two lateral cords, going to the base of the first phalanx and flexing it. Sometimes only one arm of the bifurcation is thickened. The fibres inserted into the skin of the first phalanx, and those running to the base of the second, explain the median cord of the first phalanx with its lateral bifurcation to the base of the second. This is best illustrated by Fig. 1218. We can now understand how either the first or the sec- ond phalanges may be separated or successively involved, and how we may have as a result of the thickening and Fig. 1219.-Dissection of Contracted Little Finger in King's College Mu- seum. a, Contracted band of palmar fascia ; b, flexor tendon lying much deeper. (Druitt.) will anyone who has ever seen a case wonder at the mis- take. The palmar cord is so round and stout and strong (see Figs. 1227, 1228, and 1224, though none of these show the cord as well as I should like) that at the first glance nothing is more natural than to believe it to be a contracted flexor tendon, and that its division, therefore, would probably result in a permanently extended finger (see Figs. 1225 and 1224 for the disproof). But when we look into the facts more carefully we find ample proof that the flexor tendons are not and cannot be involved. The cords are most elevated at the level of the knuckle-joints. But it is just here that the flexor tendons are bound down firmly, both by their sheaths and by the arches of the palmar fascia ; and if by the finger and thumb, one on each side of the cord, we grasp the skin in the interval between the elevated cord and the underlying tendon, we can in some cases distinctly differentiate cord and tendon, and feel the latter move when the patient flexes his finger. Besides this, when the flexors are really con- Fig. 1220.-Another View of the Same Dissection, showing still better the palmar cord going to the second phalanx. (Druitt.) traded, as in the secondary contractures of hemiplegia, etc., the tendons are marked in the palm, but no eleva- tion occurs at the knuckles (see Fig. 1217). These flexed fingers from contracted tendons also behave very differ- ently in response to passive motion. If the wrist be flexed to relax the flexor muscles the fingers can be ex- tended, only to flex again strongly when the wrist is placed in extension ; whereas, in Dupuytren's contraction the palmar fascia, not being affected by any change in the position of the wrist, the fingers remain contracted in all postures of the hand. As Noble Smith has pointed 160 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fingers* Fingers. shortening of the normal bundles of fibres in the fascia, and of those going to the skin, stout cords developed much resembling tendons to the eye and touch. These details of the anatomy of the palmar and digital cords are essential to the correct treatment, as we shall see directly. Two other details must be mentioned. An inch below the division of the palmar fascia into its four digital slips, at the web of the fingers and, in fact, forming the basis of this web, is a stout bundle of transverse fibres called the "fibres of Gerdy." These, strange to say, are hardly mentioned in many descriptions of the palmar aponeuro- sis. Some of the fibres go all the way, some part way, across the hand, while many arch over from finger to fin- ger at the web. If normally placed low down, flexion of one finger necessitates flexion of its neighbors. These arching fibres pass partly to the slips going to the base Of the first phalanx, but many of them go to the fibres pass- ing down the middle of the first phalanx to sling the base of the second. Very rarely is any connection described between the thumb and the palmar fascia. This digit, in fact, is usu- ally expressly excluded from its attachments. But this is incorrect. Two not stout but constant bands exist. One is a slender bundle of longitudinal fibres (equivalent to a fifth digital slip) from the upper part of the fascia. The other runs in the web of the thumb, and consists of the proper transverse fibres of the fascia. These two unite into a single cord to some extent, and then split, as in the fingers,*at the base of the first phalanx, and are inserted on each side of the tendon of the long flexor. The exist- ence and contraction of this band is quite sufficient to ex- plain the contraction of the thumb in the eleven recorded cases. Fortunately, in Goyraud's case the thumb was thus contracted, and these bands are described from the actual dissection. Whether these bands of thickened fibrous tissue, as be- lieved by Sanson, are merely hypertrophy of the normal pre-existing fibres, or whether, as Goyraud maintained, they are fibres wholly of new formation, cannot, I think, be decided, and is in fact a matter of indifference. Etiology.-Two different views have prevailed: 1. That its cause is local. 2. That its cause is constitutional. Nearly all of the earlier writers, and many later ones, follow Dupuytren in believing its cause to lie in the slight but continuous ' ' labor insults " incident to such occupations as that of the coachman, sailor, engraver, sportsman, soldier, gardener, etc. But many cases occur in which neither the clinical his- tory nor the occupation can be reconciled with the theory of such labor traumatisms and the resulting chronic in- flammation ; for instance, gentlemen of no manual occu- pation or amusement, men whose occupation involved the right hand wholly-as cloth-cutters (Abbe), and yet the contraction began in the left-and women exempt from manual labor. Moreover, in far more than one- half of all the cases (103 out of 184) both hands are af- fected. Some of these facts early led to the search for a consti- tutional cause. Guerin, in 1843, first mentions gout and rheumatism as probable causes, and a number of later writers are quite decided in this view. Many others regard the exciting cause as mechanical injury followed by inflammation, but recognize in the background constitutional predisposing conditions, among which the gouty diathesis is prominent. Recently Dr. Abbe, of New York, has put forward the theory that it has a spinal reflex origin, as follows : a slight injury, a spinal impression from this injury, a re- flex influence to the site of the injury producing hyper- a;mia, nutritive disturbances, and new growth in the fascial bands, and occasional arthropathies resembling rheumatism ; from the tense contractions a series of sec- ondary reflex symptoms, including corresponding troubles in the opposite hand. Noble Smith (1885) thinks possibly that local nervous irritation causes contraction of the pal- maris longus, and the two together cause the fascial con- traction. I have had no opportunity to examine for this alleged contraction of the palmaris longus. The analysis of my 253 cases, made as far as possible without bias, shows that in a goodly number of cases the clinical history is clearly one of traumatism, the disease beginning immediately after a distinctly remembered in- jury, or from the positive influence of occupation. As to the existence or non-existence of gout or rheu- matism, I find it recorded in 95 cases, exclusive of Noble Smith's. In 64 there was a distinct personal or family history of gout or rheumatism, in 31 it is expressly ex- cluded. Noble Smith discredits gout, yet (excluding the 15 cases not affecting the fingers) of the 11 women 6 had more or less rheumatism, none of them gout, and of 44 men 3 had distinct gout, and all but 19 had had gout or rheumatism. Chevrot also records a remarkable case arising during an acute attack of rheumatism, in hospital, and followed from day to day to rapid and well-estab- lished contraction. I have at present a case under my own observation in which the disease has followed acute rheumatism at an interval of a few weeks. In my paper, already alluded to, I have expressed the opinion that " its cause lies deeper than any local influ- ence, and that a constitutional vice like gout or rheu- matism, if sought for, will nearly always be found." This conclusion I based upon some personal cases there re- lated, and upon the following considerations, for the full discussion of which I must refer the reader to that paper; 1, The statistical results; 2, the marked heredity of the disease; 3, the age of onset, late in the period of active labor or after it; 4, its occurring in women, and yet its rarity in that sex, who are, as a rule, exempt both from labor and from gout; 5, its occurrence in men who are exempt from manual labor ; 6, its frequency in the ring and little fingers, which fingers are less employed than the others in manual labor ; 7, its invasion of the left hand so frequently, and often before the involvement of the right-yet the left hand is less laborious than the right; 8, its invasion so frequently of both hands, which points to a general cause; 9, its occasional appearance as a congenital disease ; 10, the absence of any signs of a local inflammation; 11, its analogy to contractions of the plantar and antebrachial aponeuroses. Abbe's theory of a nervous origin seems to me only probable in so far as gout and rheumatism are possibly nervous in their remoter origin. Even as he has formu- lated the chain of pathological events, the disease, where bilateral, should attack first the injured hand; but in his first two cases of cloth-cutters who used the shears with the right hand, the disease began in the left hand, and of the eight other cases, in three there was distinctly a rheu- matic history, and in two of these finger-contraction ex- isted in other members of the family. This marked heredity seems inexplicable on any theory of its origin in nervous reflex action following traumatism. Treatment.-Medical treatment proper is out of the question. Mechanical treatment by extension may pos- sibly avail in the rare cases in which it is seen in children. Thus Stetter cites two successful cases in children aged ten and twelve, but this is of no value in adults. There are two methods practicable: 1, By open wound; 2, by subcutaneous operation. 1. Open Wound. Of this there are three different methods, those of Dupuytren, Goyraud, and Busch. (1) Dupuytren's Method. The finger being firmly held in extension, the skin and palmar cord were divided transversely at the base of the ring finger by an incision an inch long, which liberated the finger. For the little finger, an incision was made opposite the first phalangeal articulation, another opposite the knuckle-joint of this finger, and finding complete extension not yet possible, he made a final incision in the middle of the first phalanx, when this finger also could be extended. The wounds were dressed with dry lint, and placed on a posterior splint in extension. Considerable pain, swelling, and suppuration followed, but the ultimate result was suc- cessful. Extension was kept up day and night for a month after healing, and afterward only at night. (2) Goyraud's Method. A longitudinal incision is made through the skin to the fascia. If necessary, as Bichet proposed, this may be modified by two short transverse 161 Fingers. Fingers. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. incisions at each end, thus giving two lateral rectangular flaps. The skin on each side is then separated from the fascia, exposing the bands clearly. In doing this many of the finer fibres to the skin will be divided. The palmar cords are then thoroughly divided transversely, and at as many points as may be necessary to allow of complete extension of the finger involved. These divided cords may then be either partly or wholly excised. Each finger will require a separate incision, and the incisions must be carried down on to the fin- ger whenever necessary. Two great advantages exist in this method : one can see the abnormal bands clearly, and know when they are entirely divided ; and the longitudinal incision does not gape when the finger is extended, as is the case when a transverse incision is made. (3) Busch's Method. A triangular flap of skin, with as much subcutaneous tissue as possible, is dissected over the palmar cord, the base of the flap being where finger and palm join, and its apex at the wrist end of the cord. The exposed band of fascia, equally well seen in this opera- tion as in the last, is then divided by slight cuts of the knife, together with every tense fibre that by stretching the finger is perceived as a hinderance to complete extension. The triangu- lar flap, of course, retracts strongly, leaving a Y-shaped wound to heal by granulation, which requires three to four weeks, assisted, if need be, by skin-grafting. The edges of the gaping ■wound may be united by sutures to facilitate healing, but no tension must be produced in the effort to bring them together. No attempt is made to extend the fingers until after the granu- lations have appeared. 2. Subcutaneous Operation.-In 1822, ten years before Dupuytren, Sir Astley Cooper first recog- nized the nature of this affection, and proposed the subcutaneous operation. But as Dupuy- tren's name is of right associated with it, be- cause he first compelled a hearing in respect of its true nature, so William Adams is the one who has really intro- duced the subcu- taneous opera- tion, an operation now well recog- nized in text- books. Were the ten- don involved, a single subcutane- ous section wo u 1 <1 be sufficient for the release of each fin- ger, but as the aponeurosis consists of numerous fibres more or less aggregated in bundles, several, and in some cases many, subcuta- neous cuts are necessary. Espe- cially in this method must the various anatomical details as to the palmar fascia be remembered (pp. 161-2), for every one of these bundles of fibres, not only in the palm, but in the finger, must be cut. I have never had to make over eight cuts, but Adams has made eighteen, and Abbe as many as twenty-five. The method is as follows : The knife may be a sharp-pointed, stout-backed, straight-edged teno- tome (Fig. 1221), or any other similar instrument. The blade should be short, so that when cutting the fascia the shank will occupy the skin-wound, and not enlarge it. The operation should be done antiseptically. The knife is introduced one-fourth to one- half inch from the fascial band, at its carpal end, and carried flat- wise between the skin and the band. This requires care, but is perfectly practicable. The knife is then turned with its cutt ing edge downward, and, the Anger being held in extension to make the band tense, it is divided as in ten- otomy, by a sawing motion, from the skin toward the bones. Care must be taken not to dip into the palm here, lest the palmar arch be wounded. The next puncture should divide the same palmar cord at or near the junc- tion of the finger and palm. Next the lateral cords to the base of the first phal- anx should each be di- vided in the same way, care being taken not to wound the digital arteries and nerves. Other inci- sions may be required in front of the first phalanx, or at its sides, or at the base of the second phalanx, and occa- sionally others in the palm. Constant attempts to extend the finger will reveal the need for each of these incisions. Very often two incisions of the fascial bands may be made through only one puncture in the skin. Each finger must be sepa- rately treated. As each operation is finished the incision should be closed by plaster after the few drops of blood have been pressed out. The released fingers are then immedi- ately extended, care being taken that the skin is not torn, or but very slightly so - an accident which may easily occur, and which it is desirable to avoid as far as pos- sible-and a dor- sal or pal m a r splint (Fig. 1222) is applied. This immediate exten- sion widens the gaps made by the knife. After-treatment: The first dressing, if all goes well, should be left un- disturbed for three or four days ; but not un- commonly the pain of the complete extension -a posi- tion to which the hand may have been a stranger for many years-is such as to require a redressing and a little relaxation on the second day. After twenty-four Fig. 1223. Fig. 1221. -Adams' Knife for S u bcuta- neous sec- t i o n of Cords of Palmar Fascia. Fig. 1222.-A, Palmar splint; B, bandage. (Adams.) Fig. 1224. 162 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FI liters. Fingers. hours the punctures will all be healed. On the third or fourth day, and thereafter, the splint should be removed chair-lifting, dumb-bells, etc. The hot douche, inunction, and passive move- ments are all very important. How good the result may be in such a case is shown by Figs. 1223, 1224, and 1225, from one of my patients operated on five years ago. He is an iron merchant, then aged sixty, of very musical taste, and for fifteen to twenty years had had his finger contracted. Infifteen days he was able to use his fin- gers well, and even to play the piano, write letters, etc. How complete flexion and ex- tension are, the photograp hs show. Mr. Reeves (British Medical Jour- nal, March 7, 1885) has recent- ly also reported a case in which a pianist re- covered com- plete use of her hand in three weeks after ex- cision of the bands by open wound (Govraud's meth- od).- Figs. 1226,1227, and 1228 are from another case of my own, with almost as satisfac- tory results. Adams only encourages ac- tive muscular movement after the third week, and Busch does not even begin extension until the granula- tions have formed. Both of these, I think, are serious errors of detail, and the better course is that indicated above. In case immedi- ate and complete exten- sion cannot be obtained -a result not seldom seen in severe cases, and especially in contraction of the second phalanges -we must follow a lit- tle different after-treat- ment. The fingers are then to be extended as far as possible and re- tained in place by a rack and pinion splint, as shown in Fig. 1229. This is my own modi- fication of Adams' splint as suggested by experi- ence. The tin prolon- gation A hooks around the web of the thumb and pre- vents lateral dis- placement. To avoid pressure, the dorsal plate D is scolloped over the knuckle and its front edge slightly turned up, screws B and b are tilted up, and the con- cave plate C, as well as the termi- Fig. 1227. Figs. 1223,1224. and 1225.-Case of S. D. S . Fig. 1223 shows the ring- finger, contracted for nearly twenty years, as it was January 29, 1881. The palmar cord and puckered skin show fairly in this and in the ex- tended hand. Figs. 1224 and 1225 are from photographs taken Novem- ber 1, 1881, to show how complete are both the extension and flexion. He is equally well now (April, 1886). Subcutaneous operation. In fifteen days could play piano, sign checks, etc. The photographer's supports show at the wrist in Fig. 1223. Fig. 1225. night and morning. The hand should then be bathed for a considerable time in very hot water, followed by gentle frictions and passive motion. The whole hand is com- monly considerably swollen and in- flamed. In several of my cases at- tacks of a gouty character have fol- lowed the operation. Active motion must be begun soon after, but the general swelling and pain will not permit much of these dur- ing the first week. By this time I generally take off the splint for an hour or two every day, lengthening this time daily till the splint is only worn at night, which must be done. as a rule, for several weeks. Occasionally I have had it worn off and on for some months. As soon as the splint is off I encourage ac- t i v e manual gymnastics by a series of light wooden cylin- ders of gradu- ally lessening diameter, the largest being two to two and a half inches thick, by the use of the fork at table, then of the knife (if the right hand), the scissors, the pen, Figs. 1226,1227, and 1228,-Fig. 1226 is the right hand of Rev. Dr. (College President), Dec. 21,1879. The fore and middle fingers should be completely extended. Fig. 1227, left hand. The forefinger should be completely extended, and the middle finger less flexed. Fig. 1228, left hand, Jan. 14, 1880, three weeks after subcuta- neous operation. The crescentic folds and puckerings of the skin show well. The apparent suture in the line of the ring-finger is due to stretching of the skin. Two of the punctures show on the first ring phalanx, and these joints are enlarged. Good, but not complete, flexion of this hand was secured. The right ring-fin- ger was completely cured; the little finger only half extension. Recontraction took place in the right hand after three years, and was relieved by a second similar operation. Severe lumbago followed two days after the first operation. Fig. 1228. Fig. 1226. 163 Fingers. Fleabane. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES nal joint is saddle-shaped at the end. The second and third phalanges do not require separate joints. The fin- ger is fixed to the splint by leather loops or glove-fingers. It is not advisable to put on too much pressure at first lest ulceration follow. By the rack and pinion the finger may be gradually, and generally completely, extended. Each finger requires a sep- arate splint to be attached to the dorsal plate D. The same course of after-treat- ment by gymnastics, douche, etc., must be begun as soon as possible, and carried out as before. The treatment in these cases is generally somewhat longer than in the sim- pler cases, but is not a whit less satisfactory. The case shown in Figs. 1223, 1224, and 1225 was so treated with the good results indi- cated. Appreciation of Different Methods. -As for Busch's method, I have had no experience with it, and not- withstanding the good results reported by German authors it seems to me to possess no advantages over Goyraud's or the subcutaneous methods. To one or the other of these I should always revert. Dupuytren's is no longer to be considered. The subcutaneous method has yielded such excellent results, as I have shown, that, as a general rule, I should prefer to adopt it. Especially in the milder cases and those in which the skin is only moderately adherent to the underlying bands it is certainly the best. Modern antiseptic methods have so robbed open wounds of their dangers and discomforts that I should favor the operation of Goyraud by skin flap and excision of the band, or at least its thorough division, together with di- vision of all outlying fibres in those cases in which the skin and band are fused as one, and in which the attachments of the'fibres run deeply into the palm. It has one great advantage, that one can see clearly exactly what is to be cut. In operations by open wounds Esmarch's bandage should be employed, since it enables us to see far more clearly the abnormal bands. In all operations, except possibly the simplest, the use of an anaesthetic is advisable. Even if the pain of the incisions were entirely bearable the proximity of vessels and nerves and the force requi- site to straighten the fingers would be quite sufficient to justify its use. Recontraction.-This may occasionally occur, even when the first operation has been thoroughly done. It is most apt to happen when the after-treatment has been neglected, especially the long use of the splint at night. When it does occur, a second operation will be necessary, and especially in subcutaneous operations can be as well done as the primary one. I have had but one case (Figs. 1226, 1227, 1228) in which it has recurred- A second op- eration lately has remedied the difficulty entirely. Made- lung reports one interesting case, in which he operated successfully by Busch's method on the ring-finger, in which after three years the disease attacked the little fin- ger. Were it of reflex nervous origin, should not the re- lief of a successful operation have prevented such a sub- sequent extension of the disease to another Anger ? W. W. Keen. sized conical evergreen, with a slender trunk, spreading branches, and large, erect, purplish-blue cones. It has the habit and characters of the hrs in general; scattered (not clustered) flat leaves, flat jind rounded (not tuber- culated) cone-scales, and rather few and scattered small catkins as compared with the true pines, with which in most other morphological respects the firs agree. From most of the other common firs and spruces (Hemlock, Black, Norway, etc.) its large, erect cones, and rather per- sistent-pointed bracts, as well as the blister-like oil reser- voirs in the bark, serve to distinguish it. It is a native of the Northern United States and British America, occur- ring abundantly interspersed among the other trees of the forests. Most of the turpentine is collected in the vicinity of Montreal and Quebec. The turpentine is collected from the " blisters " in the bark above mentioned ; these are of a flattened lenticular, oval, or oblong shape, from one to two millimetres be- neath the surface, and have a capacity of from several grams downward. The collectors puncture each of these reservoirs separately, and collect the few drops which they contain in small bottles, or in pots made for the pur- pose. These are frequently made of tin, or some metal, and have a tube or beak, sharpened at the extremity, by means of which the puncturing of the bark and the col- lection of the secreted liquid are done at the same time ; the collection is slow and laborious, as the trees and branches have to be climbed for the purpose, and the viscid liquid patiently teased out of its little cells. About half a pound is said to be the average yield of a tree, and half a gallon the reward of a good day's work. The work of gathering it is done in the summer, and mostly in the regions which look to Montreal and Quebec as their markets. It has been in use since the middle of the last century. " Fir Balsam " is a beautifully clear, pale-yellow liquid, of about the thickness and color of pure honey ; there is a tinge of green in its color, and also a slight fluorescence. Upon exposure to air it becomes thicker, and finally solidi- fies into a soft, brittle, transparent resin, but never dis- plays any crystalline formations. Its odor is mildly and pleasantly terebinthinous, its taste bitterish and slightly acrid. It is perfectly soluble in chloroform, benzol, and ether, and but partially so in alcohol; specific gravity, 0.998. Composition.-From one-fourth to one-sixth, accord- ing to age and thickness, of its weight is a terpene, re- sembling common oil of turpentine in odor and taste, and like it, capable of being separated by fractional distilla- tion into several liquids of different densities, but differ- ing from it in its behavior with polarized light, and in other respects. The remaining four-fifths, or so, consist of two amorphous resins, one of which is, and the other is not, soluble in boiling absolute alcohol (Fliickiger). It is not in any properly-restricted sense a balsam. Uses.-Fir Balsam is scarcely used in medicine. It has the same properties as Common Frankincense (Tere- binthina, U. 8. Ph.) and various other turpentines. It is, however, in universal employment in microscopical technology, both to cement the lenses together and as a medium for the permanent preservation of transparent objects. For the latter purpose it is often prepared by evaporating off the oils, and then dissolving the resins in chloroform, which makes a more rapidly drying solution. Allied Plants.-Abies Fraseri Pursh, a smaller- fruited fir, growing in the Alleghanies, bears similar blisters, and is said to be the source of some of the bal- sam in the market. Strasburg Turpentine, from Abies pectinata D. C., of Europe, is an exactly analogous but nearly obsolete product. For further comparison, see Turpentine. W. P. Bolles. Fig. 1229.-Keen's Modification of Adams' Splint for Mechanical Extension of the Fingers. FITERO, OLD AND NEW, on the borders of Castile, Navarre, and Aragon, Spain, are in high repute for their mineral springs, especially with the inhabitants of north- ern Spain. The waters are of 117.5° F. in temperature, and contain lime as the chief ingredient. They are em- ployed for the most part in rheumatic and paralytic affec- tions. The season for visitors is from June 1st to Octo- FIR, "BALSAM" OF (Terebinthina Canadensis, U. S. Ph., Br. Ph.; Baume du Canada, Codex Med.; Canada Turpentine, Canada Balsam, etc.). The Balsam Fir, Abies balsamea Mill (Pinus balsamea Linn.), is a middling- 164 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fingers. Fleabane. ber 1st. The cold sulphur springs of Cerdella are situated within about a mile of Fitero. J. M. F. marked by frequent and very distinct rings and remains of leaf-scales, and below is covered with the circular scars of the roots. It is pale or reddish-brown externally, white and spongy within. Its texture is very light, being traversed by large air-spaces separated by only a single row of cells. A cross-section shows these as large holes, and the walls as a lace-like reticulation, varied with oc- casional woody bundles (see Fig. 1230). The oil-cells are like those of the general parenchyma, but larger, and are generally situated in the angles formed by the confluence of three or four of the partitions, as shown in the section. The principal constituent is the oil, of which it con- tains one or two per cent., a yellow or brownish, very FLAG, BLUE {Iris, U. S. Ph.). Iris versicolor, Linn.; Order, Iridacea, the common Blue Flag of American swamps and brooksides, is a perennial endogenous herb, arising from a horizontal or ascending fleshy rootstock, with an upright leafy stem, leaves sword-shaped, equi- tant, parallel-nerved. The flowers have the general features of the genus (see Orris), but are less showy than the Flower de Luce, on account of the inconspicu- ousness of the inner circle of petals. They are generally blue or lilac, and quite pretty. The dried rhizome, which is the part used in medicine, is "horizontal, con- sisting of joints, two to four inches (5 to 10 centimetres) long, cylindrical in the lower half, flattish near the upper extremity, and terminated by a circular scar, an- nulated from the leaf-sheaths, gray-brown ; rootlets long, simple, crowded near the broad end ; odor slight; taste acrid, nauseous " (U. S. Ph.). This drug was in use by the aborigines, and has been employed to a very moderate extent by physicians for many years. The uncertainty and harshness of its ac- tion has, however, preventedits ever becoming a favorite. An acrid resin, fixed oil, tannin, gum, starch, etc., are given as its constituents. Its action is that of an irregu- lar, nauseating cathartic, with some influence, as thought by some, upon the liver and kidneys. It is an ingredient in " anti-bilious" and similar nostrums, and is more em- ployed by " eclectics " and other irregular practitioners than by regular physicians. Dose of the powder from one-half to one and a half grams. An extract {Ex- tractum Iridis, U. S. Ph.) and a fluid extract {Extractum Iridis Fluidum, U. S. Ph.), are officinal. A precipitated extract, " Irisin " or " Iridin," is in rather common use. Allied Plants, etc.-See Orris. Allied Drugs.-Podophyllum, leptandrin, etc. W. P. Bolles. Fig. 1231.-Transverse Section of the Same. (Baillon.) fragrant, liquid of specific gravity 0.9. It also contains a soft resinous substance, with a bitter aromatic taste, the glucoside Acorin. Calamus is a pleasant tonic, aromatic, applicable to all the purposes for which such remedies are used. Dose, from two to four grams; of the oil, from ten to fifteen drops. Allied Plants.-No other species of Acorus have any special value. Allied Drugs.-See Ginger, Cardamon, etc. W. P. Bolles. FLAG, SWEET (Calamus, U. S. Ph.; Rhizoma Ca- lami, Ph. G.; Awre vrai, Codex Med.). The rhizome of Acorus Calamus Linn.; Order, Aracece. An endogenous perennial with a thick, fleshy, long and branched hori- zontal rootstock, and very long and narrow (one-half to one metre) linear equitant leaves. The flowering scape is also long and flattened, like one of the leaves, and bears at its apex a straight, solid, fleshy, cylindrical spadix from five to ten centimetres long. Flowers perfect, small, crowded. A long, leaf-like bract or "spathe" (Bentley and Trimen) arises at the junction of the spa- dix and scape, and proceeding in a straight line, looks like a continuation of the scape, while the really terminal spadix is diverted to an angle with the axis, and appears to be lateral. Sweet Flag is in- digenous in parts of Asia, as Asia Minor, India, etc., and in some parts of Europe and North America, but has been so ex- tensively spread and naturalized by hu- man intervention that it is found in nearly the whole north temperate zone. It grows either in the water or in swampy and shady places, and is very variable in size. All parts of the plant are slightly aro- matic, the leaves least so, but for medici- nal use only the rhizome is employed; it should be gath- ered in the autumn or spring, washed, cleaned, and dried. In Germany it is generally peeled or scraped before dry- ing ; but while the appearance is improved by this pro- cess, the strength and quality are deteriorated. Although it grows in great abundance in the swamps of the United States, a large portion of what we use is imported from Europe or Southern Russia. Calamus comes in pieces of from ten to thirty or more centimetres in length, by one or two in thickness (4-12 inches x 4 inch) ; it is shrivelled and slightly flattened, FLEABANE, OIL OF {Oleum Erigerontis, U. S. Ph.). The essential oil, obtained by distillation from Erigeron Cana dense Linn.; Order, Composita (Asteroidea), (Horse- weed ; Butter-weed); a coarse, rank annual, with an up- right wand-like stem from fifty to one hundred centi- metres high; long and narrow, sessile, mostly entire leaves, and very numerous minute panicled heads of greenish- white flowers. Flowers few in a head, rays inconspicu- ous, pappus simple, achenia flattened. Involucre of a single row of narrow scales. This Erigeron is a native of America, but it has extended, as a common weed, to many other countries. The herb has an aromatic, bitter, and slightly acrid taste, and contains, besides the oil, a bitter extractive and some tannic and gallic acids. The oil is a pale-yellow or brownish liquid, of a pecul- iar aromatic, rather pleasant odor, and a pungent, warm taste. It consists, principally, of a hydrocarbon of the CioHic series, specific gravity about 0.850. As Erigeron is an American plant, it is natural that its introduction to use should also belong to this country. In company with several other species of the genus, it has been employed for a half century or more. At the last re- vision of the Pharmacopoeia, the present oil took the place of three species of Erigeron, which were heretofore of- ficinal-E. Philadelphicum and E. heterophyllum, and the above. The properties of all are similar : astringent, slightly tonic, mildly diuretic. The oil of E. Canadense has some reputation in internal haemorrhages. Dose, from ten to twenty-five drops. Allied Plants.-The Erigerons are closely related to the Asters and Golden-rods-one of the latter, Solidago odora, yields an oil of similar properties to the above. For the Order, see Chamomile. Allied Drugs.-The essential oils in general, espe- cially those of the Composita. See further, Turpentine. W. P. Bolles. Fig. 1230.-Rhi- zoina of Acorus Calamus, show- ing Cicatrices of Adventitious Roots. (B a i 1- lon.) 165 Flinsberg. Florida. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FLINSBERG, located in Prussian Silesia, two and one- half miles from the station Griefenberg, is noted for its alkaline iron springs. These are named the Stahlquelle, the Oberbrunn, the Pavillonquelle, the Spring by the Royal Inn, and the Niederbrunn. The analysis of the last, which is the richest in permanent constituents, indicates that each pint contains : bier lias suggested that the custom of tight-lacing may be a cause ; he thinks that the liver offers less resistance than the spleen to pressure from above, hence the larger num- ber of right-sided displacements. There is no change in the structure of the organ. The peculiar bean-shaped form can be ordinarily made out; the tumor can fre- quently be pushed some distance to the right or left, but is generally more easily moved upward and down- ward (Niemeyer). The displacement may take place in any direction, but is most frequently downward; it may recur at intervals. Carcinoma and other diseases may cause the displacement. It has been suggested by Dr. Eugene Martel that the movements of the foetus in utero cause the displacement of the kidney : in the fourth or fifth month of pregnancy the fundus uteri ap- proaches the lower border of the kidneys, and from the fact that the uterus most frequently inclines to the right side, the right kidney is the most pressed upon; at this time the lower extremities of the foetus begin to move, and as the left occipito-cotyloid position is most com- mon, Dr. Martel thinks that the right kidney may be displaced by blows from the knees and feet of the child. He found that in several cases of movable kidney the foetal movements of recent pregnancies occurring in these patientshad been very marked (New York Medical Record, January, 1886). The diagnosis of this affection is not usually a diffi- cult one to make ; the floating kidney may, however, be confounded with a distended gall-bladder, an ova- rian tumor, a collection of faeces, or a movable spleen (Flint). The tumor can generally be found between the false ribs and the umbilicus, although it may descend into the iliac fossa. If the patient is not too fat the shape of the kidney can be made out by palpation, the abdominal walls being relaxed. The tumor gen- erally moves upward and downward with the move- ments of respiration. Frequently the organ can be re- stored to its normal position ; to accomplish this the patient must lie on the back. When the patient is bend- ing forward a depression may be noticed over the usual situation of the kidney, which may disappear after the supposed kidney is replaced. On percussing over the normal situation of the kidney a tympanitic resonance, from the intestine, may be obtained instead of the usual dull sound. When the organ has become adherent in an abnormal situation the diagnosis is much more difficult. Beyond the presence of the characteristic tumor there are seldom any symptoms of this condition ; sometimes there may be paroxysmal attacks of pain, which are due to a stretching or twisting of the ureter. The only com- plications which are likely to be induced are slight in- flammations of the peritoneum, due to the pressure of the kidney on the peritoneal covering of some other organ, and hydronephrosis, due to the obstruction to the flow of urine. The fact that such a tumor exists may produce an unfavorable moral effect on a nervous patient, and would be likely to cause hypochondriasis in such an individual. There are said to be vague, indefinable feel- ings when the floating organ is pressed upon, as in at- tempts to restore it to its natural position. The urine in such cases is said occasionally to contain mucus or blood, or both. Several cases of mistaken diagnosis in this con- dition have been reported. In the London Medical Times and Gazette, 1878, the case is reported of a tumor which was supposed to be a floating kidney, but which was found to be the right ovary ; the pedicle was one foot in length. The same journal (for 1858) contains a description of a case in which both the kidneys were affected: both or- gans were considerably lower than normal, and both were movable ; the case was described by Dr. Hare. Floating Liver.-Cases of " floating " or "wander- ing " (as it is sometimes called) liver are not so common as cases of floating kidneys. As in the case of floating kidney, the causes are obscure; pressure from above and a relaxed abdominal wall seem to favor the production of the condition ; cases occur, however, without the presence of the above causes. The condition is observed most fre- quently in women who have borne children. In nine cases reported by Thierfelder no cause could be assigned Grains. Ferrous carbonate 284 Manganese carbonate 007 Sodium carbonate ,. 568 Calcium carbonate 1.198 Magnesium carbonate 1.006 Total solid constituents 3.063 Cubic inches. Free carbonic acid gas 38.646 The water is used both for drinking and for bathing. It is drunk plain, or with cow's milk, or with goat's milk. J. M. F. FLINT SPRINGS. Location and Post-office, Three Riv- ers, St. Joseph County, Mich. Access.-By Kalamazoo Division of the Lake Shore & Michigan Southern Railway, and Air Line Division of the Michigan Central Railroad. Analysis.-None. Waters unclassified. G. B. F. FLOATING TUMORS OF THE ABDOMEN. Tumors occurring in the abdominal cavity, which are so loosely attached as to be movable to a marked extent, are known as "floating" or "movable" tumors of the abdomen. The movement or displacement may occur spontaneously as a result of changing the position of the body, or it may be effected by external manipulation. Such a floating tumor may consist of an entire organ, as the liver or spleen, or it may be a new growth attached to an organ, as an ovarian cyst; it may be an unduly distended organ, as the colon or some other portion of the intestine ; the omentum, or new growths of the omentum, not infre- quently form such tumors. Dr. Watson ("Practice of Physic") says that tumors which are readily movable are generally intestinal, omental, or ovarian. The causes of displacement by which an organ, as the kidney, becomes floating are obscure ; in some instances it is a congenital condition ; it may be produced by a fall or other injury, or it may be the result of disease ; prob- ably the most common predisposing cause is the relaxa- tion of the abdominal walls due to repeated pregnancies. Occasionally tumors are found freely movable in the ab- domen, which have no attachments and are of idiopathic origin. Organs which have been displaced, and new growths which have for a time been movable,,forming floating tumors, may become adherent in an abnormal lo- cation ; serious inconvenience is more likely to be mani- fested after such adhesion, and is due to pressure on sur- rounding parts. When organs are "floating," serious symptoms are generally due to a twisting or stretching of the vessels, nerves, or ducts, which are involved in the pedicle of the tumor. Floating Kidney.-This is, perhaps, the most com- mon instance of a displaced organ forming a movable ab- dominal tumor ; it is not of very infrequent occurrence, many instances having been reported. The organ is usu- ally surrounded by areolar tissue, and the renal vessels and ureter are elongated and covered by a mesentery formed by a reduplication of the peritoneal coat. The right kidney is most frequently displaced. Of ninety-one cases collected by Ebstein, sixty-five were of the right kidney (Quain's "Dictionary of Medicine"); in thirty-five cases examined by Dr. Hare, about seventy-four per cent, involved the right kidney, while in about twenty-three per cent, both organs were involved. This affection sel- dom occurs in men ; in thirty-five cases thirty occurred in women (London Lancet, 1869). This affection generally occurs without a known cause, although the relaxation of the abdominal walls due to pregnancies, as stated above, seems to be a predisposing factor; this predisposition would account for the fact that women who have borne many children are the most frequent subjects. Cruveil- 166 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Flinsberg. Florida. other than the fact that the patients were all women who had borne children. Disease has caused the displace- ment. The diagnosis of a floating liver must depend mainly upon the presence of a large body resembling the liver in size and shape in an abnormal situation ; a tympanitic resonance may be obtained by percussion over the right hypochondrium instead of the usual liver dulness ; the percussion note over the suspected liver should be dull. The diagnosis may be confirmed by the ability to restore the supposed floating organ to its proper place (Flint's "Clinical Medicine"). In a case occurring in a married woman, thirty-five years old, there had been pains in the right side of the abdomen for eleven years ; a tumor the size and shape of the liver was found in the right iliac fossa; the liver was not in its proper place. It was afterward found that the cause of the displacement was an echinococcus cyst of the suspensory ligament (Maack, Ann. Med. Chirurg.). In a case reported by Cantani, the liver, after delivery, was found between the umbilicus and the symphysis pubis ; it was normal in size, was freely movable, and could be restored to its proper situa- tion. It had been mistaken at one time for a uterine tumor. The condition lasted eleven years, and occasioned no trouble except that the knowledge of the tumor had an unfavorable effect mentally {Medical Times and Gazelle, 1870). In the same journal tor 1876 is recorded a case of a woman who had borne twelve children, and in whom the liver was found one inch above the symphysis pu- bis ; the organ would move two or three inches on chang- ing the position of the body. In a similar case the sus- pensory ligament was felt to be on the stretch ; there was no pain {Lancet, 1881). Floating Spleen.-Cases of floating or movable spleen are very rare, or, at least, very few have been reported. Dr. Flint says that the position of the spleen may be changed by various affections of the chest and of the ab- dominal viscera ; he has met with one case in which, after confinement, the spleen was found to have been displaced into the pelvis ; it could be easily restored to its normal position by the hand. The diagnosis of this affection must be based on the absence of the organ from its normal position, and on recognizing its peculiar shape in the floating tumor, which may be done if the abdominal walls are not too thick. (It should be remembered that the displacement of the left kidney is comparatively rare.) Three cases of displacement of the spleen have been re- ported by Rokitansky; in one it occurred in a married woman, twenty years old, the organ being adherent to the right ilium ; in another it occurred in a micro-cephalic female, the spleen being in the left iliac region; in the other the spleen was also adherent to the pelvis. (In these cases the displaced organ had probably been movable be- fore the adhesions formed.) The adhesions may cause atrophy of the organ involved {British and Foreign Medico-Chirurgical lieview, 1860). Several cases of "floating" tumors of the abdomen which are not floating organs have been reported. In the Medical Times and Gazette for 1854 is cited the case of such a tumor occurring in a young, unmarried woman twenty-eight years old ; it was about the size of a man's fist; it was hard, and had existed for seven years in the left hypochondrium ; it was freely movable ; there was no pain; the patient was chlorotic. The same journal re- ports a probably fibrous growth which was freely mov- able ; also a fatty tumor of the omentum, which formed a floating tumor. A post-mortem examination in the case of a man who died at the age of eighty-five revealed the presence of a fibroma which was loose in the peritoneal cavity ; it was of cartilaginous consistence, and weighed one hundred and twenty grains. There had been considerable pain in the abdomen, which may, however, have been due to an elongated intestine {British Medical Journal, 1881). Floating tumors due to collections of gases (wind- tumors), to masses of faeces, and feigned tumors, or tumors due to muscular contractions, will be diagnosed from the histories ; the treatment must be the treatment of the cause. Treatment.-The only treatment which can be em- ployed in cases in which an organ is "floating " is replac- ing it and holding it in position by means of some elastic bandage; even when the organ cannot be replaced, the patient will be benefited by wearing a supporting band of some kind, especially if the abdominal walls be much relaxed. The attacks of pain must be relieved by the use of opiates. William H. Murray. FLORIDA. The winter temperature of Florida, and more particularly of the southern half of the peninsula portion of the State, is milder than that of any other region lying within the territory of the United States. The equability of its winter temperature is greater than that of any district of the United States lying east of the Rocky Mountains. The number of clear and fair days occurring throughout the course of the winter months is greater in Florida than in any other State of the Union lying upon the Atlantic seaboard. For these reasons the reputation of Florida as a winter health-resort for in- valids, and especially for sufferers from pulmonary dis- eases, is very high, and until recent years was unrivalled by that of any other district of the North American con- tinent. Within the past fifteen or twenty years, however, the attention of the medical profession has been directed to the great importance of the factor of dryness in estimat- ing the value of any climate to be selected for the allevia- tion of pulmonary consumption ; and other regions lying within the United States territory have been observed to possess this important factor in a very superior degree to that which was possible in the case of a peninsula lying between the warm waters of the Gulf Stream on the one hand, and of the Gulf of Mexico on the other, and throughout its whole extent presenting no point of sur- face rising to an altitude of more than a very few hun- dred feet above sea-level. Furthermore, in the matter of equability of temperature, Florida (at least all the main- land portion of the State) is surpassed by Southern Cali- fornia ; and when we come to consider the subject of cloudlessness of sky during the winter months, we find that this exists in a higher degree at places situated in Colorado upon the eastern slope of the Rocky Moun- tains, in Arizona, and in New Mexico. Nevertheless, despite these facts, and despite the strong rival claims of the Rocky Mountain plateau resorts, of those lying upon the Pacific coast, and of many excellent inland sanatoria of the Eastern States, it cannot be ques- tioned that Florida still retains, and justly retains, at least a good share of its former reputation as the winter resort par excellence of the United States. The disease above all others for the arrest, alleviation, or cure of which recourse is had to the expedient of a climate-cure, to an air-cure (or " Luftcur," as the Germans aptly term it), is unquestionably pulmonary phthisis. The relative power of the Florida climate in averting this disease, or in arresting its progress, when compared with the similar power possessed by the climates of such other health- resorts as have been just above alluded to, it is, perhaps, difficult at the present moment to decide with reasonable accuracy; but that the climate of Florida does possess this power in a good degree experience seems to have proved. Residence, or temporary sojourn, in Florida has also been found beneficial to persons suffering from a variety of other complaints, some of which will be mentioned further on in this article. Descriptions of some of the leading health-resort stations of Florida will be found elsewhere in the pages of this Handbook ; the writer's object in this present article is merely to give a brief gen- eral account of the climate of the middle and southern portion of the State, taken as a whole, together with a few remarks concerning the various classes of disease which may be expected to be alleviated or cured by residence in different regions lying within this territory. That part of Florida which lies immediately contigu- ous to the States of Georgia and Alabama (constituting a strip of territory having a length, from east to west, of about three hundred and twenty miles, and a breadth, 167 Florida. Florida. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from north to south, of about fifty miles) contains but few places which up to the present time have been util- ized as health-resorts, with the exception of such as lie within its extreme eastern portion, as, for example, Fer- nandina upon the Atlantic coast, Jacksonville and Mag- nolia on the lower St. John's, and Lake City and Suwa- nee Springs in the interior, some seventy-five miles back from the Atlantic and Gulf coasts. The two latter sta- tions possess climates similar to that of Thomasville, Ga.; the three first mentioned are types respectively of the Atlantic coast stations and of the low-lying river stations of the St. John's. The parallel of 30° N. lat. divides this whole district from the peninsula portion of Florida, and it is to this latter that our attention will be chiefly directed in the present article. Full charts representing the climatic conditions prevailing throughout the course of the year at Jacksonville, at Cedar Keys, at Punta Rasa, and at Key West, may be found under these respective headings in the Handbook ; and, inasmuch as the winter season is the time of the year during which Florida is chiefly (and almost exclusively) visited by invalids, the data to be presented in this article shall be such only as serve to represent the winter climate of the State. Jack- sonville alone, of all stations lying north of lat. 30°, will be admitted among the number of those from which these data are presented. The average winter temperature (December, January, and February) of Jacksonville is 56.58° F.; that of Cedar Keys is 60.4 F.; at Punta Rasa, on the Gulf coast (lat. 26° 36' N.), the mean temperature of these three months is 65.16° F.; while at Key West, situated upon an island bearing the same name, and lying some forty-five miles southwest of Cape Sable, the southern extremity of the Florida peninsula, the mean winter temperature is no less than 70.88° F. The relative humidity figures for each of these four points during the winter season are as follows: Jacksonville, .73; Cedar Keys, .791 ; Punta Rasa, .761 ; Key West, .783. During the month of March the average temperatures of the four stations are as follows: Jacksonville, 62.70° F.; Cedar Keys, 63.90° F.; Punta Rasa, 68.30° F.; Key West, 73.60° F. The relative humidity figures for each of the four places are decidedly lower in March than dur- ing any of the three winter months. Thus in March, Jacksonville has a relative humidity of .654; Cedar Keys has a relative humidity of .715 ; while the figures for Punta Rasa and for Key West respectively are .721 and .705. The absolute humidity figures for each of the four stations (calculated from Professor Guyot's table, pub- lished by the Smithsonian Institution) are given in the following short table, the left-hand column of which gives (approximately) the absolute humidity during the three winter months, while its right-hand column presents (also approximately) the absolute humidity figures of each sta- tion for the month of March. December. January. February. March. Jacksonville 15.0 10.7 16 4 17 4 Punta Rasa 13.5 12.7 12 9 13 4 Cedar Keys 12.1 12.1 12.2 13.5 Key West 8.1 8.9 8.9 9.4 Table B.-Mean Daily Range of Temperature. For purposes of comparison, figures of like character are subjoined in the table next following : Table C.-Mean Daily Range of Temperature. December. January. February. March. Colorado Springs.. 29.95 31.15 28.17 27.01 San Antonio 20 6 20 3 21 1 21 5 St. Paul 16.0 19 5 20 0 19 0 Augusta <Ga.) 19.6 17.3 19.4 21.3 Boston 16.5 18 3 18.5 16 5 New York 13.1 13 6 14 2 14 6 Charleston 14.6 14 6 14.5 15.0 New Orleans 13 8 13 9 14 5 15 0 San Diego 15.5 17.3 15 3 13.8 San Francisco 11.1 8.6 11.4 10.8 As serving in some measure to illustrate the cloudless- ness and the comparative cloudlessness of the Florida winter sky, the following table is here inserted. The figures opposite the name of each station shows the aver- age number of "fair" and "clear" days taken together occurring at that place during the three winter months : Table D.-" Clear" and "Fair" Days of Winter Sea- son. Jacksonville 64.1 Cedar Keys 71.6 Punta Rasa 72.6 Key West 76.8 Yuma (Arizona) 84.0 Denver 80 1 Santa Fe (N. M.) 76.7 Colorado Springs (1884) 60.0 San Diego 67.2 Visalia (Cal.) 66.8 San Francisco 64.2 Charleston 62.7 New Orleans 58.0 New York 56.7 Boston 54.8 San Antonio (Tex.) 53.2 Brownsville (Tex.) 50.0 Note.-For explanation of the terms " fair " and " clear," see article " Climate," in vol. ii. of Handbook. All data hitherto presented in the course of this article are either quoted from, or deduced from, meteorological charts furnished to the writer by the United States Signal Service, with the exception only of the figures for Colo- rado Springs, given in Tables C and D. Of these two, the first is derived from the pamphlet entitled " The Health-Resorts of Colorado Springs and Manitou," and the second is taken from the chart on page 238 of volume ii. of the Handbook, a chart kindly filled out for the writer by Professor Loud, of Colorado Springs. To assist the reader in forming a correct opinion re- specting the average winter temperature of the Florida peninsula, and respecting the still milder winter climate of the islands lying off the southern extremity of the pen- insula, the following additional data are herewith pre- sented. The source from which they are taken is No. 277 of the " Smithsonian Contributions to Knowledge," containing the very full temperature tables prepared by Mr. Charles A. Schott, Assistant U. S. Coast Survey. One of these Smithsonian tables presents data for the average temperature of each month, each season, and for the year, at no less than forty-five stations lying within the Florida territory. Of these, twenty-seven sets of fig- ures are from places lying south of lat. 30° N. The two warmest were Key West, and Fort Jefferson in the Dry Tortugas Islands (lat. 24° 38' N.; long. 82° 52' W.). The mean winter temperature of the former (derived from twenty-six years and six months of observation) is given as 70.44° F.; that of the latter (derived from eight years and one month of observation) is given as 71.11° F. The warmest winter station on the mainland of the Flor- ida peninsula, according to Mr. Schott's tables, was Fort Dallas, situated on the Atlantic coast of Dade County (lat. 25° 48' N.; long. 80° 13' W.), where six years and eleven months of observation showed a mean winter tem- Table A.-Absolute Humidity. Winter average. March average. Jacksonville 3.797 4.160 Cedar Kevs 4 708 4 701 Punta Kasa 5.342 5.579 Key West. 6.461 6.402 The prevailing wind at all four stations during the winter season is that which blows from the northeast. During the month of March the prevailing wind at Punta Rasa is still the northeast; at Key West it is the east wind ; while at Cedar Keys and Jacksonville it is the southwest wind. That one of the three winter months giving the highest figures for monthly range of tempera- ture is, at all four stations, the month of December. The average extreme range of temperature during this month at each station is as follows : Jacksonville, 62°; Cedar Keys, 56° ; Punta Rasa, 48|° ; Key West, 44°. The fol- lowing table exhibits the mean daily range of tempera- ture at each station during each of the four mouths, De- cember to March ; 168 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Florida. Florida. perature of 67.21° F. By calculation we find the average of the mean winter temperatures of those of the twenty- seven stations which lie upon the mainland (viz., of the twenty-five stations situated between lat. 30° N. and Cape Sable) to be 59.77° F. Nearly all of these twenty-five stations lie between lat. 29° and lat. 30°, and the average of the mean winter tem- peratures of those thus situated, eighteen in number, is 58.21° F. The average of the mean winter temperatures of the seven mainland stations lying south of lat. 29° F. is 63.78° F.; the coldest of the seven, Fort Mead, in Polk County, having a mean winter temperature (derived from three years and seven months of observation) of 60.59° F. Two others of the coldest three out of the seven are Fort Burke, at the head of Tampa Bay, and Fort Deynaud, about thirty miles E. N. E. of Punta Rasa. The mean ■winter temperature of Fort Burke (derived from obser- vations extending over twenty-seven years and eleven months) is 61.99 F.; the mean winter temperature of Fort Deynaud (derived from two years and five months of observation) is 63.07° F. Respecting the eighteen stations situated between 29° and 30° N. lat., we find that three, and only three of them, have a mean winter temperature as high as, or higher than 59° F., to wit, New Smyrna, on the Atlantic coast of Volusia County ; Ocala, in Marion County ; and Micanopy, in the southern part of Alachua County. The period of observation in the case of the two last- mentioned places was very short, being about a year and a half for each station. In the case of New Smyrna the period of observation was three years. Mr. Schott's fig- ures for the mean winter temperature of each of these three places are as follows: New Smyrna, 63.13° F. ; Ocala, 60.69° F.; Micanopy, 59° F. Four, and four only, of the eighteen stations between lat. 29° and lat. 30° have a mean winter temperature below 57° F. These four are Fort Heiloman, in the southwest corner of Put- nam County ; Gainesville, in Alachua County; Gordon, about eighteen miles north of Gainesville; and Fairview, near Palatka. Two of these places, Gainesville and Fair- view, have a height above sea-level assigned to each re- spectively of 184 feet and 152 feet. The mean winter temperature at Fort Heiloman (observations of two years and seven months) is 54.90° F. ; that at Gainesville (ob- servations of four years and nine months) is 56.75° F. ; that at Gordon (observations of one year and three months) is 56.83° F.; and that at Fairview (observations of one year and six months) is 56.97° F. Unfortunately the length of the period of observation at many of the stations is very short; thus, out of the whole number of those quoted above, the duration of this period was less than three years at thirteen, and it ex- ceeded five years at only seven of the twenty-seven. Despite the general mildness of its winters, a character- istic of the Florida climate which is well shown in the foregoing figures, and -which is so marked a feature as to lead Blodgett, in his celebrated work on the ' ' Climatolgy of the United States," to allude to the lower part of the Florida peninsula as possessing a higher winter tempera- ture " than is experienced anywhere else in the same lati- tude-higher than that of the tropical islands off the coast of China, and higher by a small difference than the Arabian Gulf and Hindostan" (op. cit., p. 213) ; nevertheless the figures we have given manifest a decided difference in this respect between the northern stations of the strictly peninsula portion of the State and those lying near to its southern extremity; and a considerable degree of that va- riability of temperature so generally characteristic of the United States is still to be detected in this its most equa- ble region east of the Rocky Mountains. The "cold waves," which are little short of a veritable scourge to some portions of this cis-Rocky division of our country, and which visit with very considerable severity all the States lying to the eastward of that great mountain range, make themselves felt (although of course in far milder degree) even in the Florida peninsula ; and frost is a thing not absolutely unknown to any district in the mainland portion of the State. Thus, even at Fort Dallas, which has been already alluded to as perhaps the warm- est station of Florida outside of those lying upon the islands off its southern tip, we find a temperature of 30° F. recorded as having occurred in the month of January, 1857 ; and temperatures of 31° F. in January, and 32° F. in December, are recorded for Fort Myers, near Punta Rasa, as having occurred in the year 1852 (see " Smith- sonian Contributions to Knowledge," No. 277, p. 209). In further illustration of this subject the following table is here inserted. The figures of the table are taken from columns D and F of the writer's Signal Service charts for the four places in question. Note.-The left-hand column under each month corresponds to column D of the larger charts ; the middle and right-hand columns correspond with the left-hand and right-hand subdivisions of column F in those charts. For explanation of the full meaning of the figures in these columns, see article "Climate," in vol. ii. of Handbook, p. 190. Table E.-Average Minimum and Absolute Minimum Temperatures. Period of Observation. November. December. January. February. March. Jacksonville.... Oct. 1, 1871, to Dec. 31, 1883. 55.3 43.0 30.0 49.4 41.0 19.0 48.3 45.0 24.0 52.1 42.0 ' 32.0 56.2 47.0 31.0 Cedar Keys Nov. 7, 1879, to Dec. 31, 1883. 57.8 45.0 33.0 53.5 42.0 22.0 52.6 48.0 32.0 56.6 43.0 35.0 58.5 49.0 40.0 Punta Rasa Sept. 1, 1871. to June'15, 1883. 64.1 51.5 37.0 58.4 56.0 34.0 58.5 53.0 33.0 60.3 52.0 43.0 62.7 55.0 38.0 Key West Nov. 1, 1870, to Dec. 31, 1883. 71.7 67.5 52.0 67.2 68.0 44.0 66.2 67.5 48.0 68.2 , 65.0 55.0 69.5 68.9 53.0 We have seen from the figures which have now been quoted that the so-called * ' frost-line " exists nowhere on the mainland of Florida, except, perhaps, close to the very southernmost extremity of the peninsula. The following quotation from the "Report of the State Commissioner of Immigration " (published at Tallahassee in 1882) will tend to throw additional light upon this subject of exception- ally low temperatures in Florida : " In the northern tier of counties," says the commissioner, Mr. A. A. Robin- son, " frost is frequent and often severe, and occurs with less frequency and severity as we go south, until the lower portion of Dade and Monroe Counties is reached. . . . During a residence of fourteen winters on the south side of the Manatee River the writer cannot recall a winter when a light frost did not occur there, though some winters not severe enough to affect tender tropical plants ; nor, indeed, of a character, ordinarily, to injure vegetation seriously, but sufficiently to make its effects discernible upon tender tropical growth. It is true, and very properly to be noted here, that at irregular intervals of eight, ten, or more years Florida has been subjected to the influence of cold waves destructive to tropical vege- tation over much the greater part of her territory. In 1835 the orange-trees were killed over the larger portion of the State. Several times since that period the orange- trees in the northern counties have been either killed to the ground or badly damaged. In 1868 there was ice as far south as the Manatee River. . . . These currents of Arctic air seem to come in belts, and the coldest weather in the southern counties has not been always simultane- ous with the severest cold in sections of the northern counties. On December 31, 1880, when the last 'cold snap' of this character occurred, the mercury fell in Tallahassee, for a few hours only, however, to 14° F., and was very injurious to the orange-trees in that sec- tion. The thermometer at Manatee was but little, if any, below the average of the coldest winter weather there. The writer on Florida in Appleton's ' Handbook of Winter Resorts' tells us that "as a general thing no frost occurs throughout the year below lat. 28° N." As is doubtless well known to most readers of this article, a " cold wave " of exceptional severity has visited Florida during the present winter season (1885-86). A correspondent of the New York Evening Post, writing to 169 Florida. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that journal from De Land, in Volusia County, on Jan- uary 30, 1886, alludes to the occurrence of a snow-storm at Orlando, in Orange County, and to the fall of one- fourth of an inch of snow at Manatee, on the Gulf coast (lat. 27° 25' N.), as very unusual phenomena accompany- ing this exceptionally severe visitation of cold weather. As an illustration of the contrasts, in point of tempera- ture, which may be experienced in middle Florida dur- ing such an exceptionally variable winter season as the present, we quote from the same letter a statement to the effect that Sunday, January 23d, was "the last of a series of hot, sultry days, during which the mercury usually reached 80° in the shade," while a thunder- storm, occurring on the afternoon of that day, devel- oped into a chilly northeast rain-storm of twenty-four hours' duration. The remainder of the week (Jan- uary 24th to 30th) was characterized by almost uninter- ruptedly cloudy weather, and it was so cool, the writer says, that open fires were required in-doors, and winter cloaks and brisk walking were necessary out-of-doors. As a type of the changes of temperature which may oc- cur on the Atlantic coast of Florida, another writer (Dr. G. Halsted Boyland, of Baltimore, in New York Medical Record, April 26, 1884) instances the following experience at St. Augustine (lat. 29° 53' N.): " St. Augustine, Sun- day, December 16th, ice; Tuesday, December 18th, thermometer 75° in shade ; Wednesday, December 19th, thermometer 80° ; January 6th, thermometer 24° above zero, pump frozen." This was in the winter of 1883-84. The latter part of this item by Dr. Boyland serves to illustrate the occurrence of a low winter temperature, rather than a rapid fall from a high to a low tempera- ture, the two dates, December 19th and January 6th, be- ing too far apart to serve this purpose ; the first part of the record illustrates both a low temperature and a rapid rise from a low to a high temperature. The reader must bear in mind that, in what has just been said concerning the occurrence of cold weather in Florida, we have been discussing and illustrating rather exceptional phenom- ena, and the figures in the left-hand subdivisions of the columns of Table E, as well as those quoted to show the average winter temperatures, should be enough to reassure him in respect to the general mildness of the Florida winter. In point of fact, Florida approaches more nearly to the possession of a truly tropical winter climate than does any other portion of the United States; but the greater part of the peninsula proper necessarily shares to some extent the liability to considerable depressions of tem- perature in winter which characterizes the North American continent east of the Rocky Mountains ; and to the fanci- ful student of maps its very shape may not inaptly sug- gest a great finger, pointing the seeker after a perfect type of the tropical climate to regions lying yet farther south. Dr. C. J. Wilson, of Philadelphia, in a paper read before the American Climatological Association, May 28,1885, di- vides the Florida peninsula into " four distinct strips of territory, which differ from each other in their climate in essential particulars. ... 1, The Atlantic seaboard ; 2, the St. John's River; 3, the elevated pine-lands forming the watershed of the State ; and 4, the Gulf coast." The Indian River country, extending along the coast of Orange and Brevard Counties (lat. 27° N. to 28° 45' N.) is, of course, included in the Atlantic seaboard ; but, as he tells us, this region "is as yet inconvenient of access and lack- ing in suitable accommodations for invalids." The two chief Atlantic stations of St. Augustine and Fernandina " have a climate essentially maritime," and are exposed to ' ' the northeast storms which occasionally prevail here as elsewhere on the Atlantic coast." The clinfate of the St. John's River he describes as " essentially a subtropi- cal lake climate, in many districts a marsh climate." He strongly recommends the establishment of well-managed sanatoria along the Gulf coast, especially on Point Pi- nellas, a sandy peninsula about twenty-five miles long, separating Tampa Bay from the Gulf of Mexico. The middle region of Florida, or what he alludes to as the ele- vated pine-lands of the watershed, he speaks well of as being, both on account of its soil, its moderate elevation, and its situation at a considerable distance from the At- lantic coast, well suited for the residence of invalids. " This divide," he tells us, "extends from the Okefinokee Swamp, in Georgia, southward and somewhat to the east, with an average altitude of about two hundred feet, and occasional ridges reaching an elevation of three hundred feet. Between this main ridge and the Gulf there is a second line of elevation known as the Sand Hills, which attains a height of about one hundred and twenty feet. . . . The climate of these pine-lands is, in many re- spects, not unlike that of Aiken or Thomasville, but much milder and more even. The soil is sandy and deep, with good natural drainage facilities." (See paper from which these quotations have been made in New York Medical Record of December 19, 1885.) This higher central district of the peninsula seems to include portions at least of several counties, to wit, those of Alachua, Marion, Sumter, Orange, Polk, Hillsbor- ough, and Hernando. Thus pine-lands (i.e., lands con- sisting of a more or less purely sandy soil) are alluded to by the State Geologist, Mr. Robinson (op. cit.) as existing in Alachua, Marion, Orange, Polk, Hillsborough, and Hernando counties ; while in respect to elevation above sea-level, he tells us that ' ' the highest altitude of Alachua County is nearly two hundred feet above sea-level; " that "the general elevation of Sumter County is said to be about two hundred feet above tide-water;" that "the greatest elevation of Polk County above the level of the sea is two hundred and thirty-five feetand that in Hills- borough County "about three-fourths of the northern boundary line, all of the east line, and half of the south line ... is from seventy-five to one hundred feet higher than the bay shore in the centre." Dr. George Troupe Maxwell, of Ocala, in Marion County, puts the ele- vation of that town above sea-level at one hundred and seventy-three feet (Philadelphia Medical News, December 19, 1885). In a paper by Dr. J. M. Keating, of Philadel- phia, read before the American Climatological Associa- tion (May 28, 1885), the writer says; " Most people would be surprised to learn that immediately west of Lake Apopka, a lake upon the summit of Orange County, cov- ering fifty-six square miles, the land rises in several points to the height of five hundred feet above the ocean." No other author with whose description of Florida the pres- ent writer is acquainted, has claimed so considerable an elevation for any portion of the peninsula. Three hun- dred feet above sea-level is said by the writer of the arti- cle upon Florida, in the "Encyclopaedia Britannica," to be the extreme of elevation attained in any portion of the State. The undeveloped and unsettled condition of much of the Florida peninsula, and the imperfect data as to its climate, topography, and soil, which are all that we now possess, to- gether with the conflicting claims of rival health-resorts within its territory, greatly hamper and embarrass any- one who attempts to give a carefully worded and accu- rate description of this region ; but the contributor of this necessarily imperfect article trusts that the statements and quotations which he herewith presents to readers of the Handbook, may assist them in forming a fairly cor- rect notion of the topography and climate of the penin- sula portion of the State, and in arriving at a discrimi- nating and just decision respecting its importance and value as a health-resort. The varieties of land to be found in the peninsula are pine-land, high hummock, low hummock, savanna, and swamp. "The soil is generally sandy, except in the hummocks, where it is intermixed with clay " (Encycl. Brit., art. "Florida.") The pine-land regions are those in which the sandy soil predominates, and for the resi- dence of invalids places possessing such sandy soil ap- pear to be the most healthful. This remark applies par- ticularly in the case of invalids suffering from pulmonary disease. As has already been pointed out, soil of this de- scription appears to be chiefly characteristic of the central counties of the State, of the lake plateau. Nevertheless, so varied is the surface configuration of the country, and so irregularly distributed are these different kinds of land and of soil, that, in arriving at a conclusion respecting the soil to be found at any individual town or health-re- 170 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Florida. Foetus. sort, it is not enough to know that it lies within the limits of a particular county ; and for the determination of this important matter the inquirer must be referred to such descriptions of individual Florida resorts as may be found scattered through the eight volumes of this Handbook, or as appear in the pages of special treatises upon such resorts. Information, also, respecting the equally impor- tant matters of drainage and water-supply must be sought by the reader in such special articles or treatises. The winter climate of the Florida peninsula, taken as a whole, has been found beneficial in the case of persons who have inherited or acquired a predisposition to pul- monary phthisis, and to those in the early stage of this disease. It is well suited to the case of those who are afflicted with any form of chronic inflammation of the respiratory mucous membrane, such as chronic nasal, pharyngeal, or laryngeal catarrh, bronchitis, and to some cases of asthma. The backbone of the State is the region to be chiefly recommended to all such sufferers. Its warmth and its abundant sunshine also render the cli- mate of Florida useful during the winter months to per- sons suffering from chronic rheumatism, gout, senile de- bility, or enfeeblement of the nervous system due to overwork or to worry. The establishment of additional meteorological stations, and the keeping of full and detailed records of tempera- ture, humidity, amount of sunshine, etc., together with a more precise and detailed study of the soil and surface configuration, is much to be desired, as tending more ac- curately to fix the relative position of the State, and of different portions of the State, among the great number of regions and localities which to-day claim the attention of the student of climato-therapeutics. Most careful attention to the items of local drainage, sewerage, and water-supply is demanded of those who undertake the establishment of sanatoria or hotels for in- valids in a country which has such varieties of soil and surface configuration, and too much care cannot be be- stowed toward averting the dangers to health inherent to overcrowding, in a region which is so rapidly increasing in population. Huntington Richards. cells. The two layers of cells are joined at their edges, and have a cavity between them ; the ectoderm at this stage is known as the primitive blastoderm. The essential identity of the relations is shown by the two figures 1232 and 1233, the former showing an ovum with the yolk di- Fig. 1232.- Egg of Axolotl after Segmentation ; transverse section. Kw, germinal wall or part of yolk corresponding with kw of the next figure; Bl, many-layered ectoderm (blastoderm of authors) ; s.c., seg- mentation cavity. (After Bellonci.) vided into cells, the latter with the yolk (entoderm) not divided into cells. Now, in the lower animals we find the same two layers, and likewise joined together by their edges ; in the sim- plest form they are arranged so as to constitute that larval type, now commonly known by the name of gastrula (see Gastrula, Fig. 1381, A and B), characterized by the inner layer of larger cells forming a sac within the outer. (For further details, see Gastrula.) The inner sac is the primitive digestive cavity, and its opening is the primi- tive or gastrula mouth. The figure referred to, 1381, illustrates diagrammatically how we may pass by the gradual enlargement of the entoderm to a type iu which FCETUS, DEVELOPMENT OF. This article gives a general outline of the history of the embryo up to about the end of the second month, that is, until all the princi- pal organs have been formed. The details of the devel- opment of the organs are given under the heading of each organ. See Embryology for a list of the embryological articles in the Handbook, also for a short history of em- bryology, and an account of embryological methods. The first stages in the development of the human ovum are not known, and can only be inferred from the corre- sponding stages in mammals and other animals. The first step in development is the union of the spermato- zoon and ovum, which is treated in the article Impregna- tion ; the second is the cleavage of the yolk, which is discussed under Segmentation of the Ovum ; the third is the disposition of the cells into the embryonic layers, forming the Blastoderm (see vol. i., 528) ; the fourth is the production of the primitive streak, which marks out the longitudinal axis of the embryo upon the blastoderm, and as this process is the first indication of embryonic or- ganization, we begin this article with the description of it. Part I. Development of the Vertebrate Or- ganism.-1. Formation of the Primitive Streak, and the Origin of the Vertebrate Embryo.-The essential result of segmentation is to develop two areas, or layers, sheets, of cells. One of these areas is composed of large cells, and one is composed of small cells ; the latter is called the ecto- derm, the former the entoderm. In ova which contain a great deal of yolk, the yolk is found to associate itself al- most exclusively with the large cells, which are accord- ingly charged with immense numbers of vitelline granules; the presence of the granules retards the development of the large cells, and in many large vertebrate ova the retar- dation is extreme, so that, as in birds and selacians, we find the large cells represented for a considerable period by a continuous mass charged with yolk granules, and containing many nuclei, which later appear in separate Fig. 1233.-Ovum of a Flounder, in transverse vertical section ; semi- diagrammatic. Z., zona radiata, or vitelline membrane ; kw, seg- menting zone (Keimwall) or nucleated portion of the entoderm or yolk ; Bl, ectoderm, or so-called primitive blastoderm ; s.c., segmentation cavity : s.g., subgerminal plate ; gl, oil ot globule. the entoderm is represented by a large multinucleate yolk mass, with a cap or disk of small cells or ectoderm resting upon it, E. This is essentially the disposition we find in the vertebrates with large ova ; the variations among ver- tebrates are described under Segmentation of the Ovum ; compare Figs. 1232 and 1233 above. Such a comparison renders it evident that the line of junction of the two primitive germ layers, or, as we may name it, the ectental 171 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. line, is in all cases homologous, and corresponds always with the edge of the gastrula mouth. In vertebrates, then, there is a disk of cells resting on the yolk. This disk, as already described under Blasto- derm, is the ectoderm, the cavity between it and the yolk is the so-called segmentation cavity (Figs. 1232 and 1233, s.c.), where the disk at its margin rests on the yolk is the ectental line. We proceed to give an account of the formation of the primitive streak, following what appears to the writer to be actual history as far as known. Fig. 1234, A, is a gen- eralized diagram of a meroblastic vertebrate ovum repre- senting the ectodermal disk, Bl, as seen from above, rest- ing upon the yolk ; a, a, S, n, is the ectental line. The first change noticeable in the disk is the appearance of a small groove running round its margin, between it and the yolk ; as the disk grows and expands the groove is no longer present along the front edge, a, a, of the blastoderm, but only on the sides and behind. About the same time there usually, but not in all forms, appears a distinct notch, n, which marks the posterior end of the disk. If, now, a section be made across the line X, Y, the relations will be found to be essentially as represented in the diagram (Fig. 1234, B) ; the disk rests on the yolk, Vi, which contains numerous nuclei; between the yolk and the ectoderm, Whitman. Although the concrescence is in many forms perfectly obvious and very easily observed, it has been ignored by a number of writers and misconceived by others. Let us endeavor, with the assistance of the ac- companying diagrams, Figs. 1235 and 1236, to make con- crescence clear. Fig. 1235 is similar to Fig. 1234, but represents a more advanced stage. The ectodermal disk, Bl, is much en- larged, and its anterior grooveless margin, a, a, a, is rela- tively much more increased than the posterior grooved margin, s; the centre of the notch, Fig. 1234, n, has re- mained nearly, if not quite, stationary, Fig. 1235, pr.s. ; while the margin, s, 8, of either side has been growing toward its fellow in the manner indicated by the arrows, and as they meet the two side margins grow together in the median line, making a longitudinal structure. The manner and results of the concrescence of the margins from the two sides, to form a median longitudinal struct- ure, become clearer in section, Fig. 1235, B. The margin at the side, m, still shows the same relations as in Fig. 1234, B ; in the median line, however, the margins have Fig. 1234.-Diagram of a Vertebrate Blastoderm to Illustrate the Forma- tion of the Marginal Groove. A, surface view ; Bl., blastoderm ; a, a, anterior grooveless margin ; £ (Sichel), marginal groove; n, marginal notch ; X, K, line of section. B, section along the line X, Kof A; Ec., ectoderm ; En.. entoderm ; m, ectental margin ; s.c., segmentation cav- ity ; Vi, yolk with nuclei; m, ectental margin. Fig. 1235.-Diagram of a Vertebrate Blastoderm a little more advanced than Fig. 1234. A, surface view; B, section along the line X, K; Bl., blastoderm; a, a, a, anterior margin; s, s, posterior margin (Sichel); A.o., area opaca; A.p., area pellucida ; n.r., neural ridges; N, neural or medullary groove ; pr.s., primitive streak ; bl, blastopore ; Ec., ectoderm ; in, ectental margin ; En., entodermic cells ; Vi, yolk ; mes., mesoderm; s.c., segmentation cavity. Ec, is the segmentation cavity, s.c. The groove is bounded above by a layer of cells, En, which are larger than those of the ectoderm, and have been produced by the yolk, Vi. Sometimes there are cells lying in the segmentation cavity at this stage, the formation of the mesoderm having al- ready begun. The essential point to note in this stage, as Kollmann has shown, is the division of the margin of the ectodermal disk into two parts, one, a, a, resting directly on the entodermic yolk, the other, S, directly continuous with a layer of entodermal cells, B, En, forming a little groove under the margin of the disk. The two portions of the ectental margin have entirely distinct functions; the anterior, a, a, is destined to grow over and cover the yolk by the extra embryonic portion of the ectoderm ; the posterior, 8, is destined to form the longitudinal primitive streak of the embryo by a remarkable process of con- crescence. The discovery of the true method of formation of the vertebrate embryo is chiefly due to Rauber, His, and met and intimately united, so that what were originally two grooves have completely united to form a single canal, Ent, bounded above by entodermal cells, below by the entodermal yolk, Vi. This canal is the primitive en- todermal cavity. A moment's consideration renders it evident that the canal must be open posteriorly; this opening is the blastopore, bl. There are some further de- tails to be mentioned ; where the ectental margins have united in the median line there appears a lateral out- growth, mes, which is the beginning of the mesoderm; in some cases this mesodermic tissue appears before the margins concresce; when viewed from the surface the mesoderm can be seen through the ectoderm, as was ob- served long ago ; it is this faint appearance which early writers called the primitive streak, it being the fore- shadowing of coming organization. In the middle line there appears a little furrow known as the primitive 172 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. groove, perhaps the homologue of the ciliated ventral furrow of Annelids. The Fig. 1235, A, also shows in front of the primitive streak the first trace, N, of the central nervous system, which we shall describe later. The blastoderm is seen also to be divided already into two parts, the lighter area pellucida, A.p., and the darker area opaca, A.o. ; the latter also shows the first blood islands. For further descriptions of these areas, see Area Embryonalis, ante, vol. i., p. 300. From the observations of His, Kollmann, and others, it seems that at the anterior ectental margin, a, a, a, there are produced from the yolk cells which grow in toward the embryo, and constitute part of the mesoderm, and are especially concerned in forming the first blood, which is produced always in the extra-embryonic area. This mesoderm of peripheral origin His has named parablast, a term which unfortunately has been employed differently by some subsequent writers. The ectoderm, entoderm, and axial mesoderm His groups under the collective name of archi- blast. Finally, it is to be noted that the yolk under the blastopore often forms a distinct accumulation of cells, so that the blastoporic canal usually passes through a cellu- lar mass. Sometimes the canal is obliterated by the cells growing together. See Blastopore, ante, vol. i., p. 531. Fig. 1236 is a diagram intended to illustrate the spreading of the ectoderm (blastoderm, anct.) over the the formation of the primitive streak, is excessively varia- ble in details. Thus the marginal groove, which is very distinct in selacians and in the chick, can scarcely be identified in the frog ; in bony fishes the posterior end of the primitive streak often projects as it grows, so that the blastoderm exhibits a protuberance rather than a notch ; in some cases the entodermal cavity is very small, as in the frog; in others very wide, as in birds; the primitive furrow is by no means constant. Numerous other illustrations might be given, but in spite of all Fig. 1237.-Longitudinal Section of an Embryo of Petromyzon Planeri, 136 hours old. me., Mesoderm of the primitive streak ; bl., blastopore; yk., segmented yolk ; al, entodermic cavity; s.c., segmentation cavity. variants the main facts remain, that the ectental line (gas- trula mouth) divides into two parts, one the posterior, to develop the primitive streak by concrescence, the other an- terior, to grow over the yolk, and at its margin be asso- ciated with the development of the peripheral mesoderm (His' parablast). As shown by Fig. 1236, that part of line a, a, which was originally anterior, comes by the spread of the blastoderm to lie behind the primitive streak. The mesoderm grows out from the line of con- crescence, and appears to arise rather from the entoderm than the ectoderm (Fig. 1235, B). If the manner in which the entodermal canal is formed be duly regarded, it will become evident that it neces- Fig. 1236.-Diagram illustrating the Growth of the Blastoderm. IV, neu- ral or medullary groove ; n.r., neural ridges ; Bl., blastoderm ; S, grooved margin of blastoderm; pr.s., primitive streak; bl., blastopore ; Yk., uncovered yolk. yolk, and the growth of the primitive streak. The whole ovum is represented as seen in projection ; the proportions are such as have been suggested by the ovum of a floun- der and a frog. The stage of development in Fig. 1235 is here indicated by the blastoderm Bl.", bounded by the lines, S", a", a" ; the concrescence which results in the formation of the primitive streak has developed only as far back as 1; the lateral margins, 8", which are to con- cresce later, still form part of the edge of the blasto- derm, the rest of which is marked by the anterior ecten- tal line a", a". The ectoderm grows rapidly, and is soon found to have moved its edge to a', a', while more of the grooved margins, S', have concresced so that the primitive streak and groove now extend to 2. The ex- tension continues, bringing the ectental line to 8, a, a, a, and carrying the primitive streak and blastopore, bl., back to 3. A little more, and the primitive streak will be en- tirely completed, and the blastopore, which has hereto- fore been moving, will remain at its posterior end ; and behind it there is often still a small area where the yolk is uncovered ; this area it is which is known in the frog's ovum as the anus of Rusconi, Yk. The development of vertebrate ova, especially during Fig. 1238.-Diagram Showing the Relations of a Vertebrate Ovum, with an Embryo in Cross Section, and Large Yolk. Ec., ectoderm ; N, neu- ral groove ; mes., mesoderm ; s.c., segmentation cavity ; Ent., entoder- mic cavity ; a, a, is the line where the ectoderm is growing over the yolk and corresponds to the ectental line a, a, a, of Figs. 1234, 1235, 1236. sarily arises behind the segmentation cavity, as is well seen in longitudinal sections, Fig. 1237 (compare also vol. i., Fig. 425, p. 530). In this Fig. 1237 the blasto- pore is seen to be simply the posterior opening of the di- gestive canal, al; but in mammals the posterior end of the entodermic canal is very narrow, and at first com- 173 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pletely closed, and runs, moreover, obliquely upward and backward, and consequently appears as a more or less distinct structure, known as the blastoporic canal, or sometimes as the neurenteric canal; this term, as shown in the special article upon it, is a somew'hat inexact one, and has been applied to various structures. In those cases where the ovum has much yolk, it is practically convenient for study to separate the embry- the notochord, as will be described presently. After the notochord has been formed it is found lying between the entoderm and the bottom of the medullary groove (Fig. 1241, B, Ch). The medullary plates appear in the hen's ovum after about eighteen hours' incubation, in the rabbit's on the seventh day after coitus. Once formed the medullary groove rapidly deepens (Fig. 1241, A, B), while its sides curve upward, so that the edges of the groove are brought into close approxi- mation ; the upper edges then meet and coalesce, converting thereby the open groove into a closed canal; the inner surface of the canal (Fig. 1242, 3/i7), correspond, of course, to the outer sur- face of the ectoderm. The ectodermal tube constitutes the embryonic central nervous system, and it develops into the brain, medulla, and spinal cord, and produces also the cerebral and spinal nerves. The manner of closing the medullary folds varies in different animals, but in general the clos- ure begins a short distance behind the anterior end, and proceeds from this point both forward and backward. Hence we may have, as in a chick of two days, the me- Fig. 1239.-Transverse Section through the Posterior Region of an Em- bryo Chick, with Six Pairs of Myotomes, after Waldeyer. Ec., ecto- derm ; Mes., mesoderm ; Ent., entoderm ; Md., medullary groove. onic tissues proper from the yolk, so that the entodermic cavity loses its inferior wall, to wit, the entodermic yolk. Thus, let the relations in the chick be represented in the foregoing diagram (Fig. 1238), the embryo being drawn very much too large in proportion to the yolk, for the sake of clearness. Suppose the layers to be cut through on the lines x, x', we could then evidently remove the embryonic portion, and this is what is actually done in practice. It is important to clearly understand that the yolk is part of the embryo, and that our sec- tions usually represent only a torso. 2. Formation of the Medullary Groove and Notochord.-The first organ of the embryo of which we can discern a trace is the so-called medullary groove, the commencement of the central nervous system. It arises from the ectoderm of the embryo, and appears as two thickenings, one on each side, and just in front of the primitive streak ; the thickenings increase until they meet in the median line, and form a plate of thicker ectoderm than elsewhere ; this plate is concave upon its outer surface, thus making a shallow groove, with well-marked an- terior and lateral edges, but without any distinct poste- rior boundary (Fig. 1235, N). The plate grows at its pos- terior edge, so as to extend along each side of the primitive Fig. 1241.-Transverse Sections of an Embryo Chick, with Eleven Pairs of Myotonies, after Waldeyer. A, some distance behind the last myo- tome; B, close behind the last myotome ; Ec., ectoderm ; Mes., meso- derm ; Ent., entoderm; Md, medullary groove; Ch, notochord ; W, commencement of the Wolffian duct; MS, muscular segment or myo- tomes. dullary canal in front (Fig. 1242), gradually passing over posteriorly into a shallow medullary groove ; so that in a series of sections, from a single embryo, we can trace the developmental process through all its stages. It is evident from the foregoing description that the whole of the primitive groove and the blastopore are in- cluded in the medullary groove, and if the blastopore, as appears to occur in certain species, persists after the whole Fig. 1240.-Transverse Section of a Young Mole's Embryo, after Heape. Ec., ectoderm ; Mes., mesoderm ; Ent., entoderm ; site of the noto- chord is the central line of the entoderm. groove, and shortly after the primitive streak has been completed the neural plate grows past the posterior end of the streak, and ends just behind the blastopore, which therefore opens into the caudal extremity of the neural groove. The actual appearance of the plate in an early stage is shown in Fig. 1289, a transverse section of a very young chick. The ectoderm, Ec., is thickened in the median line, Md; the mesoderm has already separated itself somewhat from the cellular entoderm, but not yet from the ectoderm in the axial line. Soon after the shallow groove is first formed it grows deeper and narrower (Fig. 1241, A). This change begins in front and progresses backward, so that in a single em- bryo we find various stages, the least advanced posteriorly, the most advanced toward the future head. As the medul- lary groove deepens, its edges become more sharply defined, and its inner lower border comes close down to the entoderm (Fig. 1240), thus forcing asunder the two halves of the mesoderm ; along the line of contact be- tween the outer and inner germ-layers the latter produces Fig. 1242.-Transverse Section of a Chick Embryo of the Second Day, after Waldeyer. Som., the somatic mesoderm, and Spl., the splanchnic mesoderm; Ec., ectoderm, Ent., entoderm; V.C., vein; IK., Wolf- fian duct; Md., medullary canal; Ao., aorta; Ch., notochord; MS., myotome. of the groove has closed over, then it will be a passage leading directly from the cavity of the nervous system to that of the future digestive tract, and is properly desig- nated as a neurenteric canal. As the neural plates are developed the primitive groove disappears, hence the me- dullary groove is always in front of it. Older writers were 174 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. not aware that the primitive groove was a distinct struct- ure, but included it with the medullary groove in their descriptions and. figures. To illustrate this error we have copied, Fig. 1243, one of Bischoff's figures of the rabbit's ovum, in which no distinction is made between the two grooves. The notochord first appears as a band of cells, quite narrow, which is distinguished from the rest of the ento- derm by the greater thickness of the epithelium. This median band of cells divides off from the entoderm and forms a separate cord, which soon acquires a rounded nucleus retires to a corner ; the cells by mutual pressure acquire angular shapes ; the cell walls are very much thickened (Fig. 1254, Ch). As the result of all these mod- ifications, the tissue acquires a remarkable resemblance to a vegetable parenchyma, and is, therefore, quite unlike any other vertebrate tissue, and consequently may be eas- ily recognized. 3. Differentiation of the Germ-layers and Origin of the Coelom.-The origin of the embryonic layers is described under Segmentation, their characteristics and morphol- ogy under Germ-layers. The ectoderm and entoderm are from the first distinct. The mesoderm arises from the line of junction of the two primitive layers; therefore, when the ectental line has formed the embryonic axis by concrescence, we find the mesoderm spreading out from the axis and from the blastopore in all directions ; at first the growing mesoderm is without demarcation from either ectoderm or entoderm, but as it expands the more periph- eral portions become separate, first from the entoderm and then from the ectoderm ; hence there are portions which are found united with the outer, but not with the inner, layer, a relation which has led some writers to maintain that the mesoderm is produced by the ectoderm. The separation of the mesoderm from the other layers progresses from the periphery toward the axis of the em- bryo. As above described, the mesoderm is separated into two masses, one on each side, by the deepening of the medullary groove. (See Figs. 1239, 1240, and 1241, A and B.) While the medullary groove is gradually changing into a canal, the mesoderm of each side splits into two plates or layers (Fig. 1241, A and B, Mes.), one nearer the ecto- derm, the other nearer the entoderm ; the space between the two laminae is the coelom or primitive embryonic body cavity. One of these layers (Fig. 1242, Som.) be- comes closely associated with the ectoderm, the two form- ing what is known as the somatopleure or body-wall; the other is similarly associated with the entoderm, and forms with it the so-called splanchnopleure. The split, it will be noticed, does not extend actually to the median line, but there remains between the mesodermic cavity (Coe., Fig. 1244) and the medulla, Md, a considerable space, which is occupied by the large myotome, MS, united with the wall of the coelom by a special bridge of tissue, by the developing Wolffian duct, W, by scattered meso- dermic cells, m, m, and certain blood-vessels to be de- scribed hereafter (of. Fig. 1244, Ao and v). The split in the mesoderm rapidly widens (Figs. 1242,1244,1246 p.p., 1247 Coe.). If we study the histology of the mesoderm during these processes, we find very significant changes. The meso- derm is at first very compact, its cells pressing against one another very closely ; but as it spreads out the cells Fig. 1243.-Blastoderm of Rabbit's Ovum, after Bischoff, showing the primitive and medullary grooves as a single straight line. form in transverse section and lies between the entoderm, which has closed over below it, and the medullary groove above it (Figs. 1241 and 1242, Ch). The develop- ment of the notochord is earlier toward the head than caudalward, so that, as with the medullary groove, we find in the embryo a more advanced stage of the chorda at the anterior end of an embryo than at the posterior end. The details of the development and structure of the notochord are described in a separate article. We need, therefore, mention here only a few general points. The statements in regard to the origin of the notochord are in many points perplexing, since certain writers have laid undue stress upon secondary modifications of the devel- opment in sundry vertebrates. It seems to me, however, that we have essentially the same processes in all verte- brates. It appears probable that the notochord arises typi- cally as a groove in the dorsal wall of the entoderm, and that this groove becomes a separate closed canal. In am- phioxus this is clearly the actual course of development, and it can be seen that by the obliteration of the lumen of the canal a solid cellular rod is produced. In the lower vertebrates the process is essentially as in amphioxus, but among the am- niota the stages are, so to speak, somewhat blurred, as if the force of heredity were here being weakened. The best opinion at present is that the notochord is a modification of an entodermic canal, running be- tween the digestive canal proper and the central nervous system. This view has recently ac- quired fresh significance from the fact that, as pointed out by Ehlers, a comparable canal is known in certain in- vertebrates. This canal may be phylogenetically related to the vertebrate notochord. In mammals the notochord is a purely embryonic or- gan. It is the primitive structural axis, but subsequently completely atrophies, and is replaced by the vertebral column. ' The cells of the notochord very soon lose their epithelial character, and form a peculiar massive tissue ; the cells proliferate and enlarge, and at the same time be- come clear and transparent; the protoplasm withdraws almost completely to the periphery of the cell, and the Fig. 1244.-Section of a Chicken Embryo of about Thirty-six Hours, after Waldeyer. Ec., Ectoderm ; Soni., mesoderm of the somatopleure ; Spl., mesoderm of splanchnopleure : Ent., entoderm ; IF, Wolffian duct; m, mesoderm cells ; Md., medullary canal; v, vein ; Coe., ccelom ; MS, myotome ; Ch, notochord ; Ao, aorta. in the peripheral part are found to move away from one another, although they still remain connected by threads of protoplasm running from cell to cell. At first the cells are quite close, the connecting threads short and fine, but as the distances increase the threads elongate and appear as the branching processes of the cells. Finally the en- tire segmentation cavity, that is, the space between the ectoderm and entoderm, becomes filled up by the meso- derm ; much of which consists of cells which have al- 175 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ready acquired the character of embryonic connective tis sue. These cells (Fig. 1245) have a large nucleus of rounded form, with a distinct nuclear reticulum of pro- toplasm and one or several granules of chromatin (nucle- oli) ; the granular body of the cell has an irregular form, and is but little bigger than the nucleus ; it sends off fine processes, which unite with the processes of adjacent cells. The whole of the mesoderm, however, does not go through this metamorphosis, but, on the contrary, a part remains closely compacted; but ultimately it is only placed nucleus ; the upper portion of the layer, i.e., to- ward the entoderinic cavity, is charged with a great number of yolk granules, to which the opaque appear- ance of this region in the fresh specimen is due. As de- scribed in the article Area the thick entoderm continually changes at its inner edge into the thin epithelium of the pellucida, and grows at its outer edge by accretions of new cells from the yolk. The preceding description of the formation of the ver- tebrate embryo is based upon our knowledge of the pro- cess in all classes except the mammalia. The exact ho- mologies of the very early stages of mammals, especially as concerns the entoderm and yolk, have not yet been worked out (see Blastoderm, vol. i., pp. 528, 530). 4. Appearance of the Myotomes.-It will be remembered that beside the portion of the mesoderm which forms the somatic and splanchnic layers, and surrounds the body cavity, there is another portion on each side nearer the axis of the embryo (MS, Figs. 1242, 1244, and 1247, and Pc, Fig. 1246). This mass gives rise to the series of struct- ures known as myotomes (protovertebrae of Remak, me- soblastic somites of Balfour). Each myotome is a sepa- rate cavity lined by a thick epithelium, and is at first rounded in shape (Fig. 1242, MS), but soon becomes more cuboidal in form (Figs. 1246, Pc, and 1247, MS). The Fig. 1245.-Mesoderm of Chick of the Third Day, from close to the Otocyst. A, Nucleus with the chromatin loops seen in optic section, being in karyokinesis. the single layer of cells immediately bounding the cce- lom, and the cells constituting the myotomes (Fig. 1244, MS), which remain thus close together. These cells, therefore, have all the characteristics of an epithelium, so that the coelom is limited by an epithelium of cuboidal cells, for which I have proposed the name mesothelium. For the remainder of the mesoderm we may adhere to the convenient term of mesenchyma, introduced by the brothers Hertwig. Hertwig's views as to the morpho- geny of the mesenchyma seem to me erroneous; I con- sider this tissue to be properly only a modified epithe- lium, with hypertrophy of the intercellular bridges. Finally, we find in the mesoderm certain cells which are quite independent and isolated, and which I have grouped together under the general name of mesamoeboids, as indic- ative of the position and character of the cells. The ectoderm has a nearly uniform character at first, the earliest change in it being the formation of the medul- lary plate. The entoderm, on the other hand, undergoes an early and very conspicuous differentiation. In the central re- Fig. 1247.-Section of a Chicken Embryo of Fifty-five to Sixty Hours, after Wahleyer. Ec., Ectoderm ; FC, vena ; Md. medullary canal: m, mesenchyma; Ch, notochord ; MS, myotome ; Ao, aorta; r, inter- mediate cell mass ; 11' Wolffian duct; Coe., coelom ; Som, somatic me- soderm; Spl., splanchnic mesoderm. myotomes begin to appear very early in the cluck and rabbit, before the medullary groove has closed over to form the canal. If the embryonic area be viewed from above, as in Fig. 1248, at a stage when the groove, rf, is about to close, there will be seen near the middle of the embryo a few pairs of small, dark, squarish bodies, sepa- rated by lighter interspaces. These bodies are the " proto vertebral " of old writers, or the myotomes, as they are properly called. The most anterior pair is the first to be developed, the second pair appearing next, the third next, and so on. The whole of the embryo in front of the first pair of myotomes enters into the composition of the fu- ture cephalic region. Myotomes continue to form at the caudal end of the series, until the whole number is completed. In this case also the devel- opment is more precocious headward than tail- ward. From some careful observations which have been made, especially on the lower vertebrates, it ap- pears that the myotomes really arise as a series of blind pouches or evaginations of the coelom, and subsequently become separated off to form closed epithelial vesicles. It is probable that, though this course of development is somewhat masked, at least in the amniota, it yet represents the true morpho- logical relations of the myotomes, which must therefore be considered as derivatives of the mesothelium (epithe- lial mesoderm), and the cavity of the myotome as an iso- lated portion of the coelom. The epithelial myotomes are apparently the commence- ment of the muscular system. Formerly they were be- lieved to be the beginnings of the vertebrae, and were accordingly named protovertebrae, a mistake which was excusable for the older writers to make, but is unpardon- able to-day, although pertinaciously adhered to by certain Fig. 1246.-Section through the Dorsal Region of a Chicken Embryo of Forty-five Hours. A, Ectoderm; c, entoderm ; Me, medullary canal; Pc, myotomes; Wd, Wolffian duct; p. p,, pleuro-peritoneal space or ccelom; So., somatopleure; v, », blood-vessels ; Sp., splanchnopleure ; op, inner edge of the area opaca ; w. w, w, entoderm of the area opaca ; ao, aorta; ch, notochord. (After Balfour and Sedgwick.) gion in and about the embryo it soon becomes very thin, almost like an endothelium, and this thin part marks out the area pellucida (see Area Germinativa). Farther away from the axial structures the entoderm is thicker (Fig. 1246), w, w, w), corresponding to the area opaca ; the cells are cylindrical, very large, and with a basally 176 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. investigators. It may be considered as settled that the myotomes have nothing whatsoever directly to do with the development of the vertebrae ; it is possible that some cells are thrown off from the myotomic walls to take part in the production of the mesenchym, and that such cells or their descendants may enter into the composition of the vertebrae, but the myotomes as such do not share in the production of the vertebrae. It is, therefore, ex- tremely desirable that the misleading term protovertebrae should' be at once and utterly discarded. The myotomes are the primitive segments of the body ; as soon as they appear the body is segmented ; as each myotome has its separate nerve, the nerves are segmentally arranged; as between every two pairs of adjacent myo- tomes a vertebral body is developed, the vertebrae are not segmental structures (as they are commonly thought to be) but fnter-segmental. The segmentation of the body is thus recognized to be primarily dependent on the myo- tomes, secondarily on other features. The myotomes soon alter their shape, so as to appear elongated in transverse section (Fig. 1251, My.), and take an oblique position as shown in the figure; their upper ends point to the median dorsal line and are close to the neural canal, N ; their lower ends in- cline downward and outward. Ex- amined carefully, they still show the internal closed cavity, which is now a mere slit between the outer and inner layers of epithelium. The outer layer contains a large number of nuclei crowded together, while the inner layer contains many fewer, and therefore appears lighter in stained sections ; in the lighter in- ner layer the differentiation into muscle fibres has already begun. Somewhat later the outer plate prob- ably also changes into muscle. Of course the two plates of epithelium are continuous at their edges, and the myotomic cavity is everywhere closed. In the course of further de- velopment the myotomes grow down into the somatopleure, up over the medullary canal, send offshoots into the limbs, and presumably produce all the skeletal muscles. They lose quite early their epithelial character, and divide into separate masses, which ultimately become the individual muscles of the adult; but much investigation is still necessary to clear up the history of the muscular system. The genesis of the muscle fibre from the epithelial cell may be thus described : Each cell of the myotome elon- gates in a direction parallel with the longitudinal axis of the embryo until it extends the whole length of the myo- tome. The nuclei in the interior of the cell multiply, and soon a single fibril of striped muscular substance, and then other fibrils, appear in the protoplasm of the cell. By the growth of the cell, the increase in the num- ber of fibrils and nuclei, and the separation of the cells from its neighbors, it is converted into a» muscle fibre, the cell membrane becoming the sarcolemma. The striped-muscle fibre is a modified epithelial cell. 5. Shaping of the Embryo. Formation of the Chorion, Amnion, Yolk-sac, and Allantois.-The ovum is a round body, in the amniota of considerable size ; the germinal area lies upon it somewhat like an inverted watch-glass, the space between it and the yolk is the entodermic cavity. The middle germ-layer is divided by the coelom into two leaves, the outer of which unites with the ectoderm to form the somatopleure, the inner with the entoderm to form the splanchnopleure; in the axial region of the embryo the mesoderm is undivided (Fig. 1247). Now the ectoderm grows over the whole ovum, and so, later, does the mesoderm also ; when the mesoderm splits the yolk is covered with the continuous lamina of the meso- derm ; next comes a space, the coelom, outside of which follows the embryonic splanchnopleure, which, so far as it does not enter into the formation of the embryonic body, receives the name of chorion ; from the chorion arises the amnion, as previously described (vol. i., pp. 133-139, and Fig. 90). This, and the remaining rela- tions with which we are now concerned, are illustrated by the following diagrams (Fig. 1249) of two longitudinal sections, A, of an amphibian ; B, of a mammalian em- bryo . Emb. represents the embryonic axial structures ; br. indicates the position of the branchial clefts ; bl. is the blastopore; All. the allantoic diverticulum of the ento- dermic cavity, Ent.; Ch. is the chorion, or extra-em- bryonic somatopleure, covering the yolk, or, as it is named in later stages, the vitelline sac, Vi. The upper figure, A, misrepresents the yolk-sac in that it is drawn hollow, whereas in the amphibia (and birds, etc.) it con- tains a mass of yolk ; the actual relations for A can be seen by referring to vol. i., Fig. 426. In mammals, owing to the reduction in the amount of yolk, the yolk- Fig. 1248.-Germinative Area of a Rabbit of Eight Days and Nine Hours, with Five Myotomes. After Kolliker. a o., Area opaca ; a.p., area pel- lucida : rf, medullary groove : A', position of the future ore-brain ; h", position of the future mid-brain ; p.z., parietal zone of embryo; stz, Kolliker's stammzone ; pr., primitive streak. sac is hollow and lined by an extension of the entodermic epithelium. The allantoic diverticulum, it will be seen, runs out into a large mass of tissue, which is part of the mesoderm, and derived from the thick post-blastoporic end of the primitive streak. In man the diverticulum always remains small, except the part next the intestine, which is ultimately converted into the bladder. In other mammals, as in reptiles and birds, the allantois grows away out into the space between the yolk-sac and the cho- rion, and forms a large vesicle appended to the hinder end of the embryo, and which varies exceedingly in its modifications in the different classes of the amniota. In man it is hardly more than the mesoderm around the allantois, which is preserved to maintain the channels of connection between the embryo and the chorion (see Umbilical Cord). We have now to consider the way in which the flat embryonic disk is shaped into the embryonic body. This may be made clear by the study of the sections of chick embryos shown in Figs. 1247, 1250, and 1251. In Fig. 177 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 1247 it will be seen that the splanchnopleure, Spl. is still spread out upon the yolk, but the somatopleure, Som. has already begun to bend downward, so that the axial por- tion of the embryo rises higher than the lateral; further out, at Ec., the somatopleure again bends upward, corre- sponding to the section of the lateral amniotic fold. In Fig. 1250 these changes have become much more marked ; the downward flexure of the somatopleure, so. is more accented, the lateral amniotic fold, amt rises up higher, and, moreover, the splanchnopleure shows a distinct downward inclination. In Fig. 1251 the bending down- ward of the splanchnopleure has progressed further, and the fold of the amnion has risen up so high that it has arched over the back of the embryo, met there its fellow of the opposite side, and united with it, so that one por- tion of the amniotic fold forms the true amnion, Am, next the embryo, the other the false amnion or serosa, 1251. The chorion, Cho., envelops completely all the other structures. If longitudinal views be examined, similar processes of folding down and under will be observed ; the process progresses faster at the cephalic than at the caudal ex- tremity, as is illustrated in Figs. 651, A and B, and 652 (vol. ii., pp. 145 and 144). In this manner the connection between the embryonic intestine and the yolk-sac is re- duced not only in the transverse but in the longitudinal direction (Fig. 1263, A and B, V), so that it becomes pos- sible to distinguish a distinct yolk-stalk and yolk-sac ; the latter is often called the vitelline sac, or umbilical vesicle. In mammalia the yolk-sac is always small. In man the yolk-stalk becomes very long and narrow, Fig. 1276, V.S. (cf. Yolk-sac). For an account of the manner in which the yolk-stalk and the allantois are gradually enclosed by the expanding amnion, see Umbilical Cord. While the embryo is being thus separated off from the yolk, its shape alters. The most conspicuous change is the enlargement of the head and neck, accompanied by a dilatation of the medullary canal to form the brain, and by the development of the heart (see below). Shortly after this stage the head makes a distinct bend downward at about its middle, and the tail end, which at first curves slightly upward, at least in man, curls over ventrally, and as the back curves also, the dorsal outline of the young embryo seen in profile becomes convex. The con- Fig. 1250.-Transverse Section of the Rump of a Duck Embryo, with Twenty-two Myotomes; from Balfour, am., Amnion; so., somato- pleure ; ca.v., cardinal vein ; ms, myotome ; sp.g., spinal ganglion ; sp.c., spinal cord; ch, notochord; ao., aorta: hy, entoderm; sp., splanchnopleure ; st, mouth of Wolffian tubule; wd, Wolffian duct. vexity subsequently increases, so that for a certain period the head and tail of the embryo are closely approximated (Figs. 1261, D, and 1276). 6. Development of the Wolffian Duct and Urogenital Fold.-The first trace of the urogenital system to appear in the embryo is a single longitudinal cord of cells, which is seen in cross sections of the rump lying between the myotome and the lateral plates of the embryo, and near the ectoderm (Fig. 1244, W, Fig. 1246, Wd). This longi- tudinal cord of cells early develops a central lumen, and moves away from the ectoderm (Fig. 1247, IF), but re- mains close to the lining epithelium of the body cavity {Coe.). The canal formed in this wise is the Wolffian duct (see also Fig. 1251, W. d). In the chick its development, according to Balfour, is apparently as follows : In an embryo with eight myotomes the first trace of it is visi- ble (Fig. 1241, B, W, and Fig. 1242, IF) as a ridge pro- jecting from the cell mass, intermediate between the coe- lom and the myotome ; the ridge is seen in the region of the seventh myotome, and rises toward the ectoderm. In the course of further development it continues to con- stitute such a ridge as far as the eleventh myotome, but from this point it grows backward by the division of its cells as a free column in the space between the ectoderm Fig. 1249.-Diagrams for the Comparison of Amphibian and Mamma- lian Embryos. Explanation in text. Ch, the homologue of the mammalian chorion. The embryo now has a distinct body, though as yet it is by no means clearly delimited from the amnion and yolk splanchnopleure. The final stage in this separation is shown in the diagram, Fig. 1252, of the entire ovum. The splanchnopleure, Spl., has bent so far over as almost to meet, in the median line below, its fellow from the op- posite side, so as to ultimately form by ventral fusion a closed canal, In, the alimentary tract. The yolk appears now as a separate appendage hanging down from the embryo, and connected with the embryonic intestine by a narrow pedicle. The somatopleure, Som., is likewise bent over and under-preparatory to closing the embry- onic body underneath by uniting with the splanchno- pleures; the body cavity of the embryo, Coe., will thus become closed on each side. The amnion, Am., still ex- tends over the embryo essentially as in the previous Fig. 178 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. and mesoderm. In an embryo of fourteen myotomes the small lumen has appeared, and thereafter gradually ex- tends through the ridge and cord. The hind end of the duct lengthens out, and finally unites with and opens into the hind end of the intestinal canal (cloaca). It is not im- probable that the ridge of cells does not really belong to the mesoderm at all, but comes originally from the ecto- of these tubules is very clear ; they arise as invaginations of the mesothelium on the dorsal wall of the coelom, nearer the median line than the Wolffian duct ; there is one invagination, so far as they appear fore and aft, for each myotome. The invagination becomes a cylindrical tube, which grows out transversely to the axis of the em- bryo until it meets the Wolffian duct, with which it unites. Fig. 1251.-Section through the Rump of an Embryo Chick of the Third Day. Ch., chorion ; Am., amnion ; Som., somatopleure ; v, v, v, blood- vessels: Coe., coelom; Spl., splanchnopleure; In., intestine ; ao., caudal branch of the aorta ; W.d., Wolfflan duct; V.car., vena cardinalis ; Ch.d., chorda dorsalis; My., myotome; Md, medullary canal. derm, as Spee has shown to be the case in the guinea-pig, and Hensen in the rabbit. Very near the Wolffian duct runs in the embryo the main afferent vessel of the rump, the cardinal vein (Fig. 1250, ca.v., Fig. 1251, V.car., and Fig. 1247, V. C.\ Very soon, as the body cavity grows wider, the region of the Wolffian duct forms a protuberance into the cavity as shown in Fig. 1247. The protuberance runs length- wise of the body, and as development advances it be- The result is a series of segmentally arranged openings on the dorsal wall of the coelom, which lead into a series of transverse tubules, which empty into the laterally sit- uated longitudinal Wolffian duct, which opens into the posterior end of the intestine. The tubules lengthen out Fig. 1252.-Diagrammatic Cross Section of an Amniote Embryo and Ovum. The embryo is shaded; the eatira-embryonic mesoderm is in- dicated by a dotted line. Som., somatopleure ; Spl., splanchnopleure; Cho,, chorion; Am., amnion ; Coe., coelom; In., intestinal cavity. Fig. 1253.-Section of the Urogenital Fold of a Chick Embryo of the Fourth Day ; after Waldeyer. W.D., Wolffian duct; M.D., Muller's duct; Coe., ccelom ; W., Wolffian body ; mes., mesentery ; Ov., primi- tive ova in the germinal epithelium, G.ep. ; Gl., glomerulus. comes more and more pronounced ; it is called the uro- genital fold from the fact that the entire excretory and genital apparatus is developed from it. The first struct- ures to appear in it after the Wolffian duct are the tubules of the Wolffian body (mesonephros) and of the head-kid- ney (pronephros), both of which exist in the amniota only during foetal life, being temporary excretory organs. In the lower vertebrates, notably in the sharks, the history and become much coiled, and may develop glomeruli similar to those of the mammalian kidney. We find in this arrangement an effective excretory apparatus. The tubules constitute the so-called Wolffian bodies. They are frequently called segmental tubules, and have been 179 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. compared, and even homologized, with the segmental or- gans of worms. The origin of the tubules is much less clear in the am- niota ; but it seems now satisfactorily established that they appear as solid cords of cells connected with the mesothelium (peritoneal epithelium), Fig. 1250, st, and run transversely in an S-shaped course to the Wolffian duct, wd. They are, however, more numerous than the segments of the region they occupy. Their connection with the peritoneal epithelium is soon severed, and their lumen, formed meanwhile, becomes considerably dilated; hence, when we examine a mammalian Wolffian body im- mediately after its first appearance, we see that it consists of a slightly protuberant mass with the straight Wolffian duct laterally placed, and nearer the median line the short transverse tubules, looking like a row of little ves- icles. The tubules, however, soon lengthen out, become much coiled, produce glomeruli, and so create in a short time the bulky Wolffian body, which takes up most of the greatly enlarged uro- genital fold. A section through the urogenital fold of a more advanced embryo of one of the amniota, shows that the fold is oc- cupied chiefly by the Wolffian tu- bules, W., and duct, W.D., Fig. 1253, but on the median side there is a distinct thickening of the mesothelium, G.ep., to constitute the germinal epithelium, which gives rise to the sexual products ; under- neath this thickened layer the cells of the mesen- chyma are more crowded than elsewhere in the fold. The genital area is further marked off by its inde- pendently bulg- ing out in the median line. This trace of a separa- tion of the fold in- to distinct parts, a laterally situ- ated excretory and a medially situated gen- ital part, is probably an inherited remnant of the condition in the lower vertebrata, in which we find two entirely distinct folds on each side (Fig. 1254), the inner, small- er but more protuberant of the folds, Gen., is the genital, and it occupies the same relative posi- tion as in the amniota to the larger but less protuberant Wolf- fian fold, W. This was presum- ably the primitive condition in vertebrates, the partial fusion of the two folds in the amniota be- ing therefore a secondary modi- fication. There remain a few points con- cerning the history of the Wolf- fian body to be especially men- tioned. It consists of two parts, one nearer the head, which extends over only a few segments and remains rudimentary in reptiles and birds, and has not yet been satisfactorily identified in mammalian embryos. It has been suggested that this anterior portion (head-kidney, pronephros) had its separate duct, which is preserved to us as the long-known Mullerian duct of vertebrate em- bryos, out of which the female genital ducts are devel- oped. The second and larger part is the Wolffian body proper, and has its Wolffian duct, which becomes the spermiduct of the male. In the course of further development, the Wolffian body undergoes almost complete atrophy, only remnants of it being found in the adult of either sex. In consequence the genital fold becomes (in man after about the third month) the chief representative of the original urogenital fold, and out of it are developed the sexual glands and genital ducts ; the permanent kidney is an entirely new and independently formed organ. (See sections 12 and 13 of this article.) 7. Origin, of the Heart and Gill-clefts.-The heart arises in the mesoderm, at the tailward end of the cervical re- gion and on the ventral side. The heart develops out of the anastomosing embryonic connective tissue (mesen- chyma) of the splanchnopleure. The first step is the ac- cumulation of cells, forming the undifferentiated heart- mass. Next in the centre of the mass the cells draw apart; there results a lighter space traversed only by the fine protoplasmatic processes of the cells; these processes disappear, and the cavity of the heart is thus produced ; the cells immediately about the cavity transform them- selves into the lining epithelium of the heart. Outside the endothe- lium, the cells again draw apart, leaving a space with only protoplasmatic threadsand a few cells ; outside the space follows an external wall of closely compacted cells, which develop into the mus- cles of the heart. The heart of the embryo is, in fact, a double tube, hav- ing an inner endo- thelial canal, and, widely separated from it, a muscu- lar tube (see Figs. 1256 and 1257). (These figures show only the gross relations, and are incorrect from omitting al- together the tissue between the endo- thelial heart, ihh, and the muscular heart, Fig. 1256, hzp, and 1257, ahh.) Although the heart is a median and unpaired organ, it really consists of two halves, one be- longing to each side of the body. When the head end of the embryo is early separated from the yolk, the ventral closure of the neck precedes the appearance of the heart; when, however, the neck is completed very late, the two halves of the heart ap- pear separately, and afterward unite in the median line. In birds, the two halves arise just as the neck is about to close below, the two halves then meet (Fig. 1254), and fuse, com- mencing at the head end ; for a short time the septum, s., between the two endothelial heart-cavities is maintained. The coelom ex- tends up into the neck on each side, and forms by subse- quent division both the pericardial and the pleural cavities. In mammals the separation of the two halves of the heart reaches an extreme, in consequence of the very great retardation of the development of the neck. In the rabbit, for instance, the heart forms at first two distinct tubes (Fig. 1255, h), which lie far apart. Fig. 1257 repre- sents portion of a section through an embryo, such as is shown in Fig. 1255. The body cavity, ph, extends into the section ; the mesoderm, dfp, of the splanchnopleure forms a thickened mass which nearly fills the entire cav- Fig. 1254.-Transverse Section of an Advanced Embryo of a Shark. Scymnua lichia, through the Abdominal Region. (The dots represent nuclei.) Sp., spinal process of the vertebra ; Ar., arachnoid space ; Md., spinal cord ; n., a„ neural arches of the vertebra ; a., inner sheath of the noto- chord ; s'., outer sheath of the notochord ; Ch, notochord ; t., p., transverse process of the vertebra ; v.car., cardinal vein ; Ao., dorsal aorta ; mes.. mesentery ; Gen., genital fold ; W. d., Wolffian duct; W., Wolffian body with tubules; c., young cartilage ; Msc, muscles developing. 180 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. ity and is already separated into two layers, the inner en- dothelial tube of the heart, ihh, and the outer muscular wall, ahh, which does not form a closed tube, but is in- terrupted on the ventral side ; consequently it appears as a fold of splanchnopleuric mesoderm. Unfortunately side of the neck, and after reaching the dorsal side again bends backward and runs toward the tail, approaching the median line (cf. Fig. 1251, ao), which it soon attains, meeting there its fellow ; the two vessels unite into a single median dorsal aorta, which runs toward the tail and gives oft' branches (of. vol. i., p. 302, Fig. 233) to the posterior end of the embryo, and to communicate with the vessels of the area vasculosa (see Area). As soon as all these channels are open, or in the chick even before, the heart commences beating. The aorta soon undergoes important changes in the neck in front of the heart; in order to understand these changes it is necessary to study the development of the gill-clefts. Although, in reality, the gill-clefts do not arise until a later stage than that in which the heart is a simple straight tube, it will be more convenient to take up their development now. The intestinal canal ends blindly in front (Fig. 1259, A); the mouth appears after the head is developed as a small invagination, which grows in on the under side of the head toward the blind end of the alimen- tary canal, until only a thin partition is left between the two cavities ; this partition subsequently disappears. Be- fore this the gill-clefts commence their development ; close behind its front end the entodermal canal (pharynx) forms two Literal pouches, which grow out from the ventral walls of the pharynx, one on each side, toward the external lateral surfaces of the neck ; behind this first pair appears a second, then a third, and a fourth pair. The pouches grow out quite close to the ectoderm ; oppo- site each pouch the ectoderm also forms an invagination ; in the lower vertebrates the dissepiments between the inner and outer pouches disappear, so that there is a series of openings at the side of the neck leading directly into the pharynx ; these are the branchial clefts or gill- slits. In birds and mammals, according to Kolliker and His, the pouches never communicate, and the clefts are always imperforate. In man the pharynx is very wide, and the pouches relatively small (Figs. 1258, 1, 2, 3, and 4). In the same figure appear the thick masses of tissue between every two adjacent clefts ; between the first cleft and the mouth is a similar column, and behind the fourth cleft is another, less perfectly marked out than the rest. These columns are the so-called " visceral " or branchial arches ; there are four clefts and five arches. Each arch is trav- ersed by a large vessel, known as the aortic arch, as shown in the figure by the dotted outlines. The relations are more clearly shown by the diagram (Fig. 1259, A). The wide pharynx, Ph, is shaded, to suggest its rounded form ; the four gill-clefts of the left side are also indicated, 1, 2, 3, 4. From the heart, lit, runs out the aorta, which soon forks ; Fig. 1255.-Area Pellucida and Embryo (Eight Days Fourteen Hours) of Rabbit. X ten diameters. (After Kolliker.) To show the double ori- gin of the heart, A, and the eight protovertebraj, uw ; vh, fore-brain ; at), optic vesicles ; af, border of the proamniotic area ; mh, mid-brain; AA, hind-brain; pz, parietal zone ; stz, Kdlliker's stammzone ; ap, area pellucida ; rf, medullary groove; uw, myotomes; vo, vena omphalo- mesenterica ; A, heart; pA, coelom of the neck (parietalhbhle of Kol- liker). the tissue between the two walls of the heart is not repre- sented at all, the figure giving an impression of absolute separation between the two walls, which is false. When the splanchnopleure bends down, as described in section 5, to meet its fellow in the median line below, and so close the pharynx ventrally, it, of course, carries the heart with it; thus after the closure of the pharynx the two heart halves come together and fuse, to make the single median heart. The two muscle tubes unite where they are open, edge to edge, into a single tube, but the en- dothelial tubes being completely closed, have at first a septum between them, which soon dis- appears. Immediately after fusion the heart in the rabbit is disposed essentially like that of the bird, as shown in Fig. 1256. The heart, when first formed, is in all cases a nearly straight median tube with double walls ; very soon after the veins grow in from each side of the area vasculosa, and, after entering the embryo, the two main stems (venae om- phalo-mesaraicae) unite with the posterior end of the heart (of. Area, particularly Figs. 233 and 234). From its front end the heart gives off, or is continued into, a large vessel, the aorta, which runs forward on the ventral line and then forks; each branch runs up around the Fig. 1256.-Chick Embryo of Thirty-nine Hours : Transverse Section througli the Region of the Heart. X Sixty-one diameters. (After Kolliker.) hp. hp, Mesoderm of the somatopleure ; A, h', ectoderm ; m, medullary canal; a, a, aortae ; ph. pharynx : hh, pericardial cavity (cervical coelom) : s, septum of the heart; ihh, endothelial heart-tube ; hzp, muscular heart-tube ; uhg, ventral mesocardium ; Ent, entoderm ; dfpf, mesoderm of splanchnopleure ; g, g, blood-vessels. each fork gives off five branches, I, II, III, IV, V, one in front of each cleft, and a fifth behind the fourth cleft. On the dorsal side the five arches unite into a common trunk, which joins the corresponding trunk from the op- posite side to form the median dorsal aorta, Ao. Now, as the clefts develop from in front backward, so the first branchial arch arises first, the second next, and so on 181 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. until the series is completed ; shortly after each arch is formed the aortic vessel appears in it. The disposition in the human embryo corresponds entirely to the diagram, for the relations are all the same, comes the artena innominata, a ; part of the right fourth arch remains as the right subclavian artery, b; the corre- sponding left subclavian being given off from the corre- sponding left arch, that is to say, by the great arch of the aorta. The ventral stem between the right third and fourth arches becomes the common carotid of the right side. Thus the aortic system of man is found to be evolved from the very dissimilar aortic sys- tem of a branchiate vertebrate. Part II. History of the Hu- man Embryo.-8. Ova of the Second Week.-Several human ova of the latter part of the second week have been described, but none of them satisfactorily according to the pres- ent standards of embryology. As far as can be inferred, these ova are in the stage called the close of seg- mentation. Of these ova the best preserved was that of Reichert; the most thoroughly studied, those of Kollmann; the descriptions of Breuss, Wharton Jones, Beigel, and Ahlfeld leave very much to be desired. Reichert's ovum was a flattened spheroid with a short diameter of 3.3 milimetres, and an equatorial diameter of Fig. 1257.-Rabbit Embryo of Eight Days and Fourteen Hours ; Transverse Section through the Re- gion of the Heart. X 152 diameters. (After K611iker.) ?np, Medullary plates ; rf medullary groove ; no, medullary ridges : h, ectoderm ; sp, undivided mesoderm ; hp, mesoderm of the somatopleure ; men, undivided mesoderm ; dd, and Sie, entoderm ; ahh, muscular wall of heart ; ihh, endothelial wall of heart; dfp, mesoderm of the splanchnopleure ; dd', notochord not yet separated from the entoderm. although, owing to the rolling up of the embryo, the primitive topography is disturbed ; thus in Fig. 1258 we at once recognize the four clefts and the five arches. The homologies of this complicated aortic sys- tem, with that of the adult mammal, are shown in the diagram (Fig. 1259, B). The shaded parts are preserved in the adult; the others disappear. The parts lost are the first and second arches ; tlie dor- sal connection between the third and fourth left arches ; the upper part of the left fifth arch ; there disappear on the right side tlie upper part of the fourth and the whole of the fifth arch, and also the dorsal connection of the arches with the me- dian dorsal aorta, Ao. There remain parts as fol- lows : 1. The heart aorta, which by an internal sept- um is divided into two aortae, one of which main- tains a communication with tlie left ventricle, and is continuous centripetally with the fifth arch of the left side ; from the middle of this arch springs a vessel which soon forks, to make the two pul- monary arteries, P ; during foetal life the upper part of this arch, d, a, persists as the well-known ductus arteriosus, so that there is a direct commu- nication between the pulmonary and the body aorta. Soon after birth the lumen of the ductus is obliterated. 2. The left fourth arch, which is very much enlarged, to constitute the permanent aortic arch ; as shown in the diagram, the oblitera- tion of parts is such that the left fourth arch is the only permanent channel of communication between the heart and the dorsal aorta, Ao ; hence the aorta of the adult springs from the heart, and gives off to the right a branch, then makes itself a great arch on the left side up to the back, where it is continued down, i.e., tailward. 3. The third arches on both sides, appearing, as the figure clearly shows they must, as portions of the in- ternal carotid, In.c; the ventral stem between the third and fourth arches is the common carotid of the adult on each side, while the continuation of that stem headward becomes part of the external carotid. 4. The right fork of the aorta be- Fig. 1259.-A, Diagram of Pharynx of an Amniote Vertebrate. 1, 2, 3, 4, gill-pouches (clefts) of the pharynx, Ph ; Oe, oesophagus ; I. II, III, IV, V, aortic arches springing from the fork of the aorta of the heart, Ht; on the dorsal side the five arches again unite into a single trunk, which joins its opposite fellow to form the median dorsal aorta, Ao ; AC, invagination of the ectoderm, to form the mouth; Ex.c, external carotid, springing from the ventral side of the first aortic arch ; In.c, internal carotid, springing from the dorsal side of the first aortic arch ; om, omphalo-mesaraic veins emptying into the heart. The arrows indicate the direction of the blood-currents. B, Diagram of gill- arches as preserved in mammalia; the shaded portions are those re- tained, the unshaded vessels are lost; da. ductus arteriosus ; P, pul- monary artery. The other letters are the same as above. 5.5 milimetres (Fig. 1260); smooth around both poles, and with a marginal or equatorial zone of villi separating the two smooth areas. The smaller and flatter of these two areas faced the uterine wall, and bore on its inner surface (i.e., within the ovum) a small accumulation of rounded cells. The opposite area was more convex. The villi were short (0.2 mm.), thick cylinders, with rounded ends and no branches. The ovum was a vesicle with thin walls, which apparently consisted only of epithe- lium, which also formed the simple hollow villi; the con- tents of the vesicle were : 1, the inner cell-mass lying, as before mentioned, at one pole; 2, a network of threads, apparently the result of coagulation of the contained fluid, for no nuclei were found in it. It is probable that this ovum is normal, and also the youngest human ovum yet known; except for the presence of villi it agrees with Fig. 1258.-Anterior Wali of the Phar- ynx of a Human Embryo of 3.2 mm. length. X 50. (After His.) 1 to 4. gill-pouches; the ectodermal pouches are separated by thin walls from the entodermal; the gill arches, show the aortic arches drawn in dotted lines, and arising from the heart aorta, Ao ; if, mouth ; Ent, entodermal or alimentary canal; Coe, body cavity. 182 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. other segmented mammalian ova, and presents the same difficulties to homologizing it with the ova of other verte- brates (see Blastoderm). From our present knowledge we can advance the fol- lowing statements as probably correct: The result of segmentation of the human ovum is the production, by the twelfth or thirteenth day, of a rounded sac of epithe- lium, three to four millimetres in diameter; at one point there lies against the inside of the vesicle a little accumu- lation of rounded cells, which, from analogy with the ova of mammals (cf. vol. i., Figs. 423 and 424), must be con- sidered as marking the germinal area out of which the embryo is to be formed. The epithelial sac, to which the name of chorionic vesicle, or ectochorion, may be ap- plied, bears an equatorial zone of short villi. This stage is represented by Reichert's ovum, Fig. 1260. In the next stage the villi have spread over the ger- minal area and have become slightly branched ; the villi soon develop also over the opposite pole of the ovum, and rapidly increase their length and ramifications. The germinal area in Jones's ovum faced the uterine wall. By the time villi are present over the whole vesicle there is probably always a layer of connective tissue un- derlying the epithelium (Breuss, Ahlfeld, Lowe, etc.), but no embryonic structures have been recognized. The ova of twelve to fourteen days are already completely enclosed by the decidua (reflexa and serotina): only the tips of the villi adhere to or are even in contact with the decidual surface ; this is the only connection between the maternal and foetal tissue, for neither does the uterine mucosa grow in between or over the villi, nor do the villi penetrate the cavities of the uterine glands (see Chorion and Decidua). The epithelium of the chorion and its villi is only imperfectly marked with boundaries for the single cells ; its nuclei all occupy a basal position, leaving a distinct outer layer, often mistaken for a separate structure. The epithelium forms buds, which become the branch- es of the villi; these buds may grow out to a con- siderable size without connective tissue (hollow villi), or the connective tissue may penetrate into them from the start (solid villi). The human ovum, then, is remarkable for its preco- cious development of the chorion as regards both the villi and the connective tissue, or mesodermic layer, and for its early complete encapsulation by the decidua. All these developments, according to the scanty observations yet made, precede the appearance of the embryo. We come now to a great and most unfortunate gap in our knowledge, for no human ova have yet been found and studied which show the origin of the entoderm and primitive streak, or the formation of the medullary groove ; the next youngest known ova having an already well-marked medullary groove and yolk-sac, and, had they been sufficiently examined, some of the myotomes wrnuld have been found to have been formed. 9. The Youngest Known Human Embryos.-The num- ber of human embryos with an open medullary groove thus far known is four. Their probable age is about fourteen to sixteen days. The least is His's embryo E, of which only Professor His's sketches are available, the at- tempt to microtome the specimen not having been fortu- nate. Two were described by Allen Thompson long ago (1839), and have since been constantly referred to; neither of them can be considered perfectly normal, but the second one is more nearly so than the first. These embryos measure about 2.2 mm. in length ; they are especially characterized by the relatively enormous size of the medullary ridges (Fig. 1261, A and B), and the narrowness and depth of the medullary groove. The embryo is but little longer than the yolk-sac, which is a round vesicle with a very broad attachment to the em- bryo, and is already furnished with blood-vessels (Fig. 1261, upper figure). The embryo gives off from the un- der side of its posterior end the thick allantois stalk, Al; in Thompson's ovum (Fig. 1261, B) this was broken off, so that there was a hole leading directly into the entoder- mal cavity ; in His's embryo the exact disposition of the allantois stalk, Al, was not ascertained. For the supposi- titious formation of the allantois stalk, see vol. i., p. 139. The chorion forms a relatively large vesicle, its average diameter being about eight millimetres, but the four specimens vary from 5.7 to 15 millimetres. The chorion bears villi over its whole surface ; they are considerably branched (the villi in the figure are purely diagrammatic as to their number and shape). Probably the villi are formed chiefly, if not solely, by epithelium, and probably also there is a layer of connective tissue, very likely al- ready vascular, which lines the chorion but does not ex- tend into the villi. The amnion springs from the body of the embryo and the sides of the allantois stalk, and covers over the dorsal surface of the embryo. From analogy w ith other verte- brates, and from thestudyof older human embryos, we have no diffi- culty in recog- nizing in the chorion and am- nion the extra - emoryon- ic portions of the somato- pleure, and in the yolk-sac the extension of the splanch- nopleure, and accordingly, in the space between the yolk-sac and chorion, part of the primitive coelom, or body cavity. • The fourth embryo of this group is His's SR, which measured 2.2 mm. and showed a considerable ad- vance of development. The neck of the yolk-sac is al- ready somewhat contracted, or, in other wrnrds, the con- nection between the embryo and the yolk-sac is not so long and broad as it was. The head end is considerably en- larged ; between it and the anterior wall of the yolk-sac is a large thickening corresponding to the heart; the am- nion lies quite close to the embryo ; the medullary ridges are still separated by a narrow^, open groove ; myotomes have appeared, but their number was not ascertained. 10. Embryos of the Third Week.-During the third week most of the organs are differentiated, or at least begin their development. Fortunately, the splendid investiga- tions of His have given us considerable information con- cerning the history of this important period. We learn much also from Coste's figures of an embryo supposed to be eighteen days old. Other descriptions, though con- taining little of value, have been given by Schroder van der Kolk, Hennig, Schwabe, Remy, Allen Thompson, C. E. von Baer, Alexander Echer, Beigel, Hecker, and Bruch. Of all these descriptions a critical analysis by C. S. Minot may be found in the New York Medical Jour- nal, October 10 and 17, 1885. In embryos of presumably fifteen to twenty days, and from 2.3 to 4.0 mm. in length, we see the progressing development of the gill-clefts. Of embryos with two or Fig. 1261.-Upper Figure, His's Em- bryo E, Diagrammatic. A and B, Allen Thompson's second ovum; A, from above, B, from the posterior end. (Thompson's figures give no clue to the rela- tions of the amnion or allantois.) Fig. 1260.-Reichert's Ovum. A, from above ; B, from the side. 183 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. three clefts several are known, the most important be- ing Coste's, Fig. 1262 ; also, vol. ii., Figs. 652 and 653; His's embryos L, Fig. 1263; M, Fig. 1265; Lq, Rf ; Sch, Fig. 1264; BB and Lr. Most of these have the back concave, and even drawn way in over the yolk-sac, as in the embryo Sch, Fig. 1263. This singular bend has been so frequently ob- served that it must be consid- ered normal. It reaches its maximum when the constriction of the neck of the yolk-sac is first nearly completed. Subse- quently the embryo undoes this bend, and as the back is much longer than the ventral side, it necessarily becomes rolled up the other way, with the back convex, as in Fig. 1264, and in Fol's embryo, Fig. 1266, D. His's embryo L, Fig. 1263, is quite straight, but may have been originally bent and arti- ficially straightened out. Such bending has not been observed in any other vertebrates, but in many insects the embryo is first rolled up with a dorsal concave, later with a dorsal convex, cur- vature. As regards man, the curve, as shown in Fig. 1264, is probably the result of the modi- fied development of the yolk- sac accompanied by the retarded growth of the ventral tissues of the embryo ; the back has to bend, and bends down on ac- count of the strain produced by the yolk-sac. It gives the em- bryo a very singular appear- ance, but cannot be considered a really important or sig- nificant phenomenon. It has, doubtless, often led observ- ers to miscall embryos in this stage abnormal. increasing separation of the embryo and the yolk-sac (see vol. ii., Fig. 652); consequently the head, and to a less extent the tail end of the embryo, is free from the yolk- sac, and projects considerably. At first the sac has a wide communication with the intestinal cavity (Fig. 1262), but it soon grows smaller (Fig. 1263, A and B, V, also Fig. 1264). It results that the connection between the yolk-sac and the embryo is narrowed until it is merely a small tube (as in Fig. 1266, B, 17), which is commonly designated the vitelline stalk, and after growing out to a great length is included in the umbilical cord (Fig. 1276). The alteration is essentially this : at first the cavity of the intestine opens throughout its whole extent into the yolk-sac, but finally, by the folding down of the splanchnopleures, sec- tion 5, the intestinal cavity is shut off, and only at a single point does the intestine open into the yolk-sac (Fig. 1271, Fs). This connection apparently fastens the intestine so that in that region it cannot move ; hence in the development of the in- testines the fixed vitelline attach- ment is a prime factor in determining the topography (compare Fig. 1268). The allantois stalk is thick and large ; it springs from the under side of the embryo, between the caudal ex- tremity and the hind margin of the yolk-sac (Fig. 1262, Al). It carries four large blood-vessels, two arteries, and two veins, which branch out over the surface of the cho- rion, where they form a rich capillary network. In the al- lantois stalk there also runs, to the chorion, but not be- yond, the small tubular al- lantoic cavity, which springs from the hind end of the in- testinal tract, and is accord- ingly lined with entodermal epithelium. The allantoic extension of the digestive cavity is shown in Figs. 1268 and 1271, Al, and others. To the dorsal side of the stalk the amnion is attached (c/. Fig. 652, vol. ii.). For further account of the al- lantois stalk, see Umbilical Cord. The chorion forms a vesicle very much larger than the embryo ; its entire. surface is beset with branch- ing villi, somewhat con- stricted at their base (vol. ii., Fig. 653) ; the chorion itself consists of the ectoderm, which also covers the villi, and a layer of mesoderm which probably extends into some, but not all, of the villi ; see Chorion. Turning to the embryo it- self, we see that the head is very large, both wide and long; it constitutes fully one-third of the whole length (Figs. 1263, 1264); under the posterior part of the head Fig. 1262.-Coste's Embryo of Eighteen Days, seen from the ventral surface, the yolk-sac having been cut open. Am, amnion ; Ht, heart ; Spl, splanchnopleure ; .S', noto- chord, with the myotomes alongside; Al, allantois. (For a view of this embryo in pro- file, with the yolk-sac and chorion, see vol. ii., Fig. 652.) Fig. 1264.-His's Embryo Sch, 2.2 mm. Fig. 1263.-His's Embryo L, 2.4 mm. long. A, in profile ; B, from below; C, in longitudinal section ; D, from above. Jf, mouth ; Mie, mandible or first gill arch ; 2, 3, 4, second to fourth gill arches; Vd, anterior part of digestive canal; V, splanchnopleure of the yolk-sac; Am, somatopleure bending out to form the amnion; Coe, coelom; Op, optic vesicle ; Au. auditory vesicle ; a, portion of the medullary canal not yet closed. (The allantois stalk was broken away and is omitted from the figures altogether.) Turning to the consideration of the embryos, we notice, first, that steady growth is going on, accompanied by an 184 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus, Foetus. two or three gill-clefts (Fig. 1263, A) have appeared, while in front and on the ventral side is the large square ectodermal mouth cavity (Fig. 1263, A and B, The medullary canal is nearly or quite closed ; in Fig. 1263, D, it is still partly open at a. It has already undergone enlargement at its anterior end to begin the brain. The enlargement is complex, and comprises two separate dila- tations ; the posterior and wider lies just in front of the auditory vesicles (Fig. 1263 D, Au), and tapers off poste- riorly into the spinal medullary canal; this broad dilata- tion, often called the third primary vesicle of the brain by embryologists, is the embryonic medulla oblongata; it produces ultimately both the medulla and the cerebel- lum. The anterior enlargement is separated (Fig. 1263, D) by a well-marked constriction from the posterior; it also curls over toward the mouth and gives off two diver- ticula, one on each side, Op, the optic vesicles, out of which certain parts of the eye take their origin (see Eye, Development of the, vol. ii., p. 781). This anterior en- largement presumably includes both the fore- and mid- brain of embryologists ; hence the human embryo is char- acterized by a striking modification in the early development of the brain, in that there are at first only two dilatations (vesicles), the foremost of which subsequently divides into two median vesicles, after which there are three primary vesicles as commonly described. The entodermal canal consists of a very wide pharynx (Fig. 1263, 0), extending nearly half the length of the whole tract; behind the wide opening into the vitelline sac, A and B, V, the canal is continued into the caudal ex- tremity, and, as before stated, gives off the al- lantoic diverticulum from its ventral side. The space, Coe, between the body walls and the alimentary canal is quite wide. The heart is a tube slightly flexed (Fig. 1262, lit) toward the right, its two ends remaining in the median line ; its caudal end receives the veins, its headward end gives off the aorta, a short trunk from which spring the aortic arches (compare the diagram, Fig. 1259) ; the first arch appears first, and, as before stated, section 7, is in front of the first cleft; the second arch is between the first and sec- ond clefts. The heart itself is very large ; it has an outer muscular wall, within which lies the very much smaller endothelial tube ; the wide space between the muscle and the endothelium is crossed only by a few trabeculae of meso- dermic cells. Above the gill-clefts the aortic arches unite and run backward on each side, as previously described, section 7, and the stems, one from each side, unite to form the single dorsal aorta. The disposition can be equally well followed in a more advanced stage (Fig. 1265), when all the five arches have appeared. The branching of the aorta, and the disposition of the veins, will be better considered in describing the next older stage. The study of sections across the embryo shows further, 1, the otocysts as still open invaginations, at least in the specimen, Fig. 1263 (Fig. 915, A, shows the otocyst of this embryo in section, see vol. ii., p. 567); 2, the notochord with a small lumen ; 3, the Wolffian duct, as the only part of the urogenital system yet present. In the next stage, the sixth of the enumeration adopted in this article, the embryo is characterized by the forma- tion of the head bend and of the Woltfian bodies ; also by the convexity of the back, the great asymmetry of the heart, and the presence of the full complement (five) of aortic arches. Of the embryos to be considered, His's M, BB, and the somewhat older Lr (4.2 mm.) are the chief. M and BB measured respectively 2.6 and 3.2 mm. The age of the latter, BB, from the data given by His, I think was probably twenty to twenty-one days. The following description refers to M only (Fig. 1265). The back is convex, and the whole embryo is some- what spiral, the tail being bent to the right, the head to the left. The allantois stalk has lengthened out; the neck of the yolk-sac is much restricted, V. The allan- tois stalk, All, containing the allantoic diverticulum as shown in the second figure, is considerably lengthened out; there are four gill-arches distinguishable externally; the otocyst has become pear-shaped, ot; the neural canal is completely closed; the mouth is large. The wide pharynx is bounded on each side by the five gill-arches, 1 to 5, each containing an aortic branch. The body cav- ity, Coe, is large and wide, and has at its back on each side a longitudinal ridge, the commencement of the Wolf- fian body traces of the canals of which can be seen. Of special interest is the arrangement of the circulatory sys- tem, shown in the first drawing, Fig. 1265, the arteries are shaded dark. The heart is a double-walled, S-shaped. tube ; the venous (posterior) end is convex toward the head ; the arterial end convex toward the tail; when viewed from in front the position of the heart is recog- nized to be asymmetrical, the venous portion lying to the left, the arterial to the right, of tlie embryo. The heart is continued forward by the large aorta, A, which gives off five branches on each side of the neck ; as the aorta takes a ventro-dorsal course, when we look at the ventral floor of the pharynx, as in Fig. 1258, the aorta is seen mount- ing straight up and giving off its branches forward and backward, as is also shown in Fig. 1265. The live aortic arches unite dorsally, run backward, and join with the opposite fellow-stem to form the single median dorsal aorta, Ao, which runs way back and terminates in two large branches, Au, which, curving round, pass out through the allantois stalk and ramify upon the chorion. The veins are: 1, the jugular, Jg, and cardinal, Car, which unite with the umbilical vein on each side, and so form a single tranverse stem, the ductus Cuvieri ; the car- dinal veins receive chiefly the blood from the Wolffian bodies, and atrophy later with the bodies; 2, the large umbilical veins, FA, which pass up from the allantois and open into the ductus Cuvieri, being first joined by the common stem of the jugular and cardinal; 3. the om- phalo-mesaraic veins, Ora, which come up from the yolk- sac, and open into the ductus Cuvieri close to the posterior end of the heart. The allantoic and omphalo- mesaraic veins are not quite symmetrical. From this stage on the asymmetry increases, the left allantoic (um- bilical) and the right mesaraic undergoing enlargement while their fellows undergo atrophy. These changes are very rapid, and in embryos of fifteen millimetres there is 185 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. only the very large left umbilical vein, and the quite large right mesaraic (vena portae) still remaining. 11. Embryos of the Fourth Week.-During the fourth week the embryo grows from about 4 to 7.5 mm. It has during this period somewhat the form of a letter C authors. For this article it will suffice to give an account chiefly of the embryo at twenty-five days (5.6 mm.), based upon the observations of Fol and Coste (Figs. 1266 and 1267), the latter being perhaps a little older. The external form is shown in Fig. 1266, D. The head Fig. 1266.-Fol's Embryo of 5.6 mm., about Twenty-five Days. A, B, C, reconstructions froi.i the sections ; D, view of the alcoholic specimen, left side. All magn. 14 diam. H, or pre. cerebral hemispheres ; V, fore-brain ; in, mid-brain ; Hi, hind-brain ; cA, notochord ; of, otocyst; 1, 2, 3, 4, branchial pouches of pharynx seu entodermal portions of the gill-clefts ; jV, spinal cord : Ao, aorta ; oe, oesophagus ; lu, lung ; st, stomach liver ; ig, intestine; vi, vitelline duct; Al, allantoic diverticulum; cl, cloaca; lt?>, Wolffian body ; Wd, Wolffian duct; op, optic vesicle; md, mandible; a.l., anterior, p.l„ posterior limb ; ba, bulbus aorta; ; ven, ventricle; vvi, left omphalo-mesaraic vein ; vu, umbilical vein ; avi, arteria vitellina ; j, jugular vein ; cd, cd', cardinal vein : D. ductus Cuvieri dexter ; D', vena cava inferior ; au, arteria umbilicalis ; ad, dorsal aorta. (Fig. 1266, D), the head being approximated to the tail. The length given above is taken on the longest straight line, the only feasible measure yet proposed. His has de- scribed seven embryos, Coste three, Fol one of this week, and there are besides some data to be gleaned from other is large, and makes an angle with the body ; it is also itself bent in the region of the mid-brain (Fig. 1266, A and B, m). The back is curving ; the body terminates in a dis- tinct tail, turned to the left; the anterior and posterior limbs have appeared, al aud pl, as small buds ; a ridge 186 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. (the Wolflian) runs between the two limbs ; the first branchial arch (mandible) is large and well developed ; the second (hyoid), 1, and third, 2, are also in view, but the fourth and fifth are turned in and covered over by the anterior arches. Fol has not elucidated this point in his paper, but His has shown that in man this invagination of the entire posterior branchial area takes place, and that the invaginated ectoderm of the region is transformed into the epithelial elements of the thymus gland. The thymus gland of the child is, however, mainly a meso- dermal organ, the ectoderm almost disappearing, being represented only by the concentric corpuscles of the gland. This account of the development of the thymus is essentially different from any previously given, but no reason for doubting its accuracy is apparent. To return very thin ; it constitutes half the length of the brain, and is fully one-third as long as the spinal cord, N; at its side, near the middle of its length lies the pear-shaped otocyst, ot. (Compare Ear, Development of, section 3.) The mid- brain, m, commonly described as the second of the three primitive dilatations or vesicles of the brain, appears rather as the more restricted region between the fore-brain, F, and hind-brain, Hi, and is the region of the so-called head bend. The fore-brain, F, is quite large ; its long axis forms an acute angle with that of the medulla, Hi ; it shows traces of two anterior lateral outgrowths, the fu- ture cerebrum or hemispheres, pre (Eig. A), and has two optic vesicles, for the further history of which see Eye, Development of. At this stage, or at least in one slightly younger (five millimetres), His has found the cells of the central nervous system already elongated spindles, which stretch from the inner to the outer surface of the medul- lary walls ; the ends of some of the fusiform cells have already grown out beyond the wall proper as naked axis- cylinders, entering into the composition of the nerve-roots. The notochord is very small, only five or six cells in each section. The mouth is very large and communicates di- rectly with the pharynx ; on its dorsal side is a little diver- ticulum which runs off, B, lip, toward the mid-brain, and is the commencement of the hypophysis cerebri. It subsequently loses its connection with the mouth, and lies as a closed sac under the brain ; still later, bones are formed between it and the mouth, so that it comes to lie within the cranial cavity and has no trace of its origin. The course of the entodermal canal is well shown in B. It commences with five lateral diverticula, 1, 2, 3, 4, and lu, the four gill-pouches of the entoderm and the lung, the latter appearing as a modified gill-pouch. The pouches all spring from the wide pharynx, which is fol- lowed by the long oesophagus, oe, leading insensibly into the slightly wider stomach, 8t; just below the stomach is the large ventral outgrowth,/, of the liver, and the smaller dorsal one, pa, of the pancreas; there follows a short piece of intestine, ig, to the point of origin of the very contracted neck of the yolk-sac, i.e., the vitelline stalk, ri ; the intestine continues back until it forms in the tail its terminal enlargement, the cloaca, cl, from the ventral side of which springs the narrow allantoic diverticulum, Al, running out into the allantois stalk, as shown also in the cross section of the stalk, All, Fig. 1267, A. It will be convenient to indicate here the further development of the digestive tract, which may be easily followed by the four drawings, Fig. 1268. Here A represents the digestive tract of an embryo of 4.2 millimetres, which is somewhat younger than Fol's embryo; the drawing is enlarged twenty-four diameters ; B is from an embryo a little older than Fol's, being seven millimetres long, and here drawn enlarged twelve diameters ; C is from an embryo of 13.8 millimetres, perhaps thirty-five days old, enlarge- ment eight diameters. In B, as shown by the course of the notochord, Ch, the curvature of the body is at its maximum in embryos of seven millimetres. In compar- ing these figures we are struck first with the rapid growth in length of the entodermic canal, especially in the por- tion between the pharynx and, the cloaca ; by the exten- sion of the oesophagus the stomach moves far down to- ward the tail, while the intestinal tract proper finds scope for its lengthening by coiling itself ; the coiling commences by the drawing down (toward the umbili- cus) of the point, where the vitelline stalk, Yk. 8, joins the intestine ; the intestine between this point and the stomach grows very much, ultimately producing most of the small intestine ; the part between the insertion, C, Yk. s, and the cloaca'produces a small stretch of the small intestine and the whole of the large intestine, col, the de- marcation between the two being given by the small blind outgrowth, C, coe, which gives rise to both the coe- cum and the appendix vermiformis. In amniota the al- lantoic diverticulum is the first differentiation of the ento- dermic canal to appear, the pharynx second, the cloaca B, E, third, the liver fourth. In Fig. 1268, A. these parts, including also the lungs, which are derivatives of the pharynx, are all present. In B, the stomach and pancreas have been added, the former as a slight dilata- Fig. 1967.-Coste's Embryo; Twenty-five to Twenty-eight Days ; magn. about ten diam. A, front view of the embryo straightened out and dissected ; B, pharynx and part of digestive tract ; C, heart viewed from behind. Ol, olfactory pit; M, mouth; Md, mandible ; Ao, aorta, springing from the heart ; a, I, anterior limb ; Li, liver ; In, intestine ; met,, mesentery; Wb, Wolffian body ; All, base of the al- lantois stalk ; pl, posterior limb ; 1, 2, 3, 4, gill-arches; Lu, lung ; Au, auricle; a, veins ; V, ventricle of the heart. -the head of Fol's embryo shows some traces of the in- ternal form of the nervous system, and of the optic ves- icle and the otocyst; the thinness and transparency of the dorsal wall of the medulla oblongata is especially note- worthy. The nervous system (Fig. 1266, A and B) is tubular ; in the region of the future spinal cord, NN, it gradually tapers, and the lumen as seen in cross sections is a narrow slit. The passage of the medulla spinalis into the medulla oblongata is marked by a sharp bend at almost right an- gles, about at the reference line 4 of A. The oblongata, Hi, the hind-brain (metencephalon or fifth vesicle, or region of the fourth ventricle, auct.) of embryologists, is an enormous vesicle of epithelium, the dorsal wall being 187 Foetus. Fretus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion of the canal, the latter as an impaired dorsal out- growth a little nearer the head than the liver. In B, also, the proximal portion of the allantois, Al, has begun to dilate as the first step toward the development of the bladder. Into the cloaca opens the Wolffian duct, W, from which, in B, has commenced the small outgrowth, W, which has greatly increased in C, having separated into a tube, Ur, the future ureter, and a series of blind terminal branches, W, which constitute certain portions The urogenital fold is quite advanced, and projects well into the body cavity (compare Fig. 1253, ante). It contains a series of transverse tubules, about two to each segment of the body, all opening into the longitudinal Wolffian duct (Fig. 1266, B, Wd), which opens into the primitive cloaca. The tubules open into the duct nearly at right angles, and run first straight inward toward the median line, then bend ventralward, making a somewhat spiral hook, and end each in a glomerulus, in a different Fig. 1268.-Digestive Tracts of Four Human Embryos. (After His.) A, embryo of 4.2 millimetres ; B, embryo of seven millimetres ; C, embryo of 13.8 millimetres ; D, embryo of 12.5 millimetres. Hy, hypophysis cerebri; 1, 2, 3, gill-clefts ; Lu, lungs; Mx, maxilla inferior; T. tongue; Th, thyroid gland ; Ep, epiglottis ; La, larynx ; oe, oesophagus ; St, stomach ; P, pancreas ; Li, liver ; Li.d, liver-duct ; Yk.s, yolk-sac : Al, al- lantois : E, end darm, or extension of the cloaca ; in, small intestine ; coe, ccecum ; col, colon ; N, kidney ; Ur, ureter ; IK, Wolffian duct; Ch, notochord. of the permanent kidney. In C all the parts have in- creased in size and complexity, in a manner sufficiently clear from the drawing. A fewr words, however, are needed to explain the changes in the cloaca; in D a stage intermediate between B and C is represented, to in- dicate how the end darm, E, is gradually reduced, while at the same time the deepening and increase of the flex- ure between the end of the intestine proper and the base of the allantoic diverticulum, Al, brings into connec- tion with the latter the openings of the Wolffian duct and ureter. In C the cloacal dilatation has entirely disap- peared, and the intestinal canal makes, just at the point where the anus is to be formed, a sharp bend, beyond which it is con- tinued as the allantois stalk ; otherwise described, there are tw'o tubes which meet and become continuous at the anal point; the more ventrally situ- ated of these is the allantois, which receives also the Wolffian duct, W, and the ureter, Ur; the dorsal tube is the future large intestine. Where the anus is to be formed, there is a shallow ectodermal invagination, by which the ectoderm is brought into direct con- tact with the entoderm (rabbit); subse- quently the partition breaks through ; it is not yet known when the anal per- foration is established. Returning to Fol's embryo: The liver, f, is large, with numerous and large blood-channels. Between the liver and the pericar- dial cavity is a partition of mesodermic tissue representing the primitive diaphragm. At the sides and along its ven- tral border this diaphragm is directly continuous with the body walls, while on the dorsal side, although it is united with the mesodermal coat of the lungs and oesophagus, it leaves a free space on each side, which constitutes an open passage past the lungs, between the body cavity proper and the pericardium. transverse plane from the opening of the tubule; the glomerulus is a vesicle, one part of which is invaginated into the other. All the blood-vessels consist of an endothelium, and neither arteries nor veins have media or adventitia. The single aorta arises from the large ventricle, Fig. 1266, A, ven, its portion nearest the heart being dilated into the so- called bulbus aortas. The veins empty into the bilobed auricles. The heart itself is very large, and its endo- thelial wall is still separated by a considerable space from its muscular wall. Its general shape is shown in Fig. 1267, C. In embryos of seven millimetres the heart (Fig. Fig. 1269.-Heart of an Embryo of 7 Mm. (After His.) A. Aorta from behind ; B, in section ; C, from in front. D.C, ducti Cuvieri ; D.C.d, opening of the ductus Cuvieri dexter; D.C.s, opening of the ductus Cuvieri sinister ; Vel, opening of the vena cava inferior ; Ao, aorta. 1269) is slightly more advanced. It consists of a large ventricle with thick walls, B, from which ascend two canals, one, Ao, from the ventral aspect of the organ, running obliquely from the right toward the median line, and giving rise to the aorta; the other leading into the large bilobed auricle and running obliquely from the left toward the median line. The auricle is divided into two thin-walled lobes or recesses, the ultimate separation of which is indicated by the outgrowing median septum 188 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. shown in B ; the division of the ventricle has commenced by a similar septum. The veins all empty into the right side of the auricle by a common open- ing, imperfectly subdivided into an upper part, D. C.r, for the right duc- tus, and a lower part for the left duc- tus Cuvieri, D.C.s, and a middle part, Ve.i, for the vena cava inferior. In such a heart the blood-stream enters the right side of the auricle, passes obliquely down into the left side of the ventricle, crosses to the right side, and passes obliquely upward into the aorta. The aorta commen- ces with a thickening (Fig. 1266, A, ba), the bulbus aor- tae, and runs, aa, in a ven- tro-dorsal direction straight toward the pharynx, on each side of which it pro- duces in Fol's embryo two aortic arches, the third and fourth (Fig. 1266, C, 3 and 4); in man all the five arches (see Fig. 1259) are not always present at one time, but the first and sec- ond may atrophy before the fifth has formed, and the maximum number present at one time is then four (see Fig. 1265). In Fol's embryo remnants of the first and second arches were still dis- tinguishable ; both the ex- ternal and the internal, aci, carotids are distinct. The aortic trunks from each side unite at about the level of the anterior limb ; the me- diandorsalaor- ta, A, Ao, and C, ad, runs along to the level of the leg, and there forks to form the two umbilical arteries, au, which run out, one on each side of the allantoic diverticulum, to ramify upon the chorion ; opposite the yolk-stalk, vi, springs the right omphalo-mesaraic ar- tery, A, avc, and C, ao; its singular course is well shown in both figures ; its fellow of the left side has already disap- peared. The venous system is much changed from that shown in Fig. 1265 ; there has been added the vena cava inferior, while the left omphalo-mesaraic is partly atro- phied, and the right umbilical is a little smaller than the left; the first step in its atrophy, which ensues in slightly older embryos. The cava is known to arise by the fusion of two small veins, which also unite with the umbilical veins and so develop a single short median stem between the liver and the heart. The umbilical veins in Fol's embryo (Fig. 1266, A and C, vu) enter the body symmetrically from the allantois stalk, curve round, and after taking up some vessels, run to the liver in a ridge of the abdom- inal wall (somatopleure); in the liver they break up into irregular sinuses, the left side having predomi- nance. The omphalo-mesaraic vein of the left side, A, wi. takes the course shown in the figure, and likewise opens into the liver sinuses; the much smaller right omphalo- mesaraic, C, vo, opens into the left vein just before its reaching the liver. The ductus Cuvieri, C, D, receives the cardinal veins, cd", from the rump, and two veins, cd' and j, from the head, an arrangement different from that found in both older and younger embryos ; normally there are two jugulars on each side, which unite to a single stem ; this stem descends to meet the cardinal vein, cd!', of the same side ; the ductus results from the joining of the two venous trunks into a single stem. For the sake of clearness, wre consider in this connec- tion the ultimate metamorphosis of the abdominal veins. As indicated by the above description, the liver by its ex- pansion comes to grow around the veins passing by it. The venous system within the liver undergoes a series of complicated metamorphoses, which have been beautifully worked out by His, wdiose account differs essentially from that hitherto current. The final result of these metamor- phoses is that the left omphalo-mesaraic and the right um- bilical veins entirely disappear ; the left mesaraic persists for some time in the vitelline stalk, but opens into the right mesaraic before entering the liver ; the right mesa- raic atrophies in the vitelline stalk. The right omphalo- mesaraic, which ultimately becomes the main stem of the vena portw, enters the liver, and joins within that organ the very large trunk of the left umbilical vein, which trav- erses the liver as the so-called ductus venosus Arantii, to empty into the cava inferior ; both the portal and umbil- ical veins give off branches as they enter the liver, and this double portal circulation is gathered up by other branches, which open into the ductus just before it leaves the liver; the ductus persists until after birth. At the beginning of the fifth week we find the venous system es- sentially as shown in Fig. 1270. From the head descend the two jugulars, j,ji, they are joined by the vein of the arm, the subclavian, s, and meet the ascending cardinals, Fig. 1270.-Diagram of the Venous Circulation of a Human Embryo at Four Weeks. (After Kolliker.) The head and body are represented straightened out and seen from in front, j, External jugular ; ji. in- ternal jugular ; ci, cava inferior ; il, iliac ; cr, crural; ft, lower end of right cardinal : c, ductus veno- sus; de, ductus Cuvieri of the left side ; s, subclavian vein ; u, u', left umbilical vein ; c, left cardinal; om, right omphalo-mesaraic vein. Fig. 1271.-Anatomy of an Embryo of Seven Millimetres. (After His.) La, larynx ; Ep, epiglottis; Ch, notochord ; Ot, otocyst; Lin, tongue ; Cb, cerebellum ; Hp, hypophysis ; Mh, mid-brain ; Zh, Zwi- schenhirn or thalamus; Op, eye ; H, cerebral hemisphere; Fs, yolk- stalk ; Au, auricle ; V, ventricle of the heart; Al, allantoic diverticu- lum ; Ms, mesentery ; TF&, Wolffian body ; Li, liver ; D, ductus venosus, or stem of the umbilical vein ; Ven, stomach ; Ao, aorta ; Lu, Lung. h and c; these veins all unite in the transverse ductus Cuvieri, de; there is a long median cava inferior, ci, the terminal forking of which constitutes the crural veins, cr ; while its anterior end opens into the heart inconjunc- 189 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion with the Cuvierian ducts (see Fig. 1269, B) ; it is, however, first joined by the large left umbilical, u, which arrives from the allantois (chorion and placenta), and takes up on the way the right omphalo-mesaraic (portal) vein. The blood of Fol's embryo consists of nucleated red blood-globules (cf. vol. i., pp. 301, 302, article Area Em- bryonalis), which are multiplying by division. A few points remain to be noted in regard to the em- bryo at the end of the fourth week (7 to 7.5 mm. long). These are sufficiently shown in Fig. 1271. Besides the progress of the parts and the growth of the whole, we note that the embryo is still coiled up, the head being near the tail. The brain has undergone important changes ; the mid-brain, Mh, has become a distinct vesicle at the apex of the head (compare Fig. 1265); the fore-brain is distinctly subdivided into a median portion, Zh (the " Zwischenhirn " of German writers), next the mid- brain, and two anterior outgrowths, H, the future cere- bral hemispheres ; the portion, Cb, of the third primitive vesicle, or of the primitive medulla oblongata, lying in front of the otocyst, Ot, has a dorsal outgrowth which is the commencing cerebellum ; the wall of the medulla un- der the cerebellum, and next the pharynx is converted into the pons Varolii. The course of the digestive canal is characteristic, and is perhaps better shown by the lines of heart and the liver ; the umbilical cord is relatively very thick ; the limbs are considerably advanced, the fore-limb has the division into upper and fore arm and hand, the Fig. 1273,-Embryo, supposed to be early in the fifth month. Drawn in the natural attitude within the membranes. lower limb the division of the foot from the leg, already plainly shown. In the embryo, B, of thirty-four days the body has grown more than the head ; the neck bend has dimin- ished from an acute to nearly a right angle; the eye and the ear have both progressed toward the adult form. Fig. 1272.-Three Human Embryos, Nearly or Perfectly Normal; after His; all magnified three diameters. A, embryo of about thirty days ; B, of about thirty-four days ; C, of about fifty-two days. the entoderm, Fig. 1268, B, of the same embryo. Finally we must refer to the outgrowth from the Wolffian duct (cf. Fig. 1268, B and C, W), close to the cloaca, to form the kidney. This outgrowth extends itself forward within the urogenital fold and above the hinder end of the Wolffian body. 12. External Form of the Embryo.-We have already indicated the changes in the appearance of the embryo from the twelfth to the twenty-eighth day. Fig. 1272 illustrates the changes from thirty days, A, to about fifty-two days, C. At thirty days the embryo is about nine millimetres long ; the head is very large, the eye is small, the maxilla and mandible are well marked ; the external ear is just beginning around the first gill-cleft (meatus externus); the remaining clefts and the arches behind them have disappeared by invagination to form the thymus gland ; the head bend corresponding to the mid-brain, and the neck bend corresponding to the ce- phalic end of the medulla oblongataare both well marked ; as seen in profile, the area of the body is about the same as that of the head ; the line of the back is still very con- vex ; there is a distinct tail; the ventral outline is very protuberant owing to the precocious development of the A. B. Fig. 1274.-Development of the Face. A, Embryo of eight millimetres, about twenty-eight to twenty-nine days old ; after His ; X ten diam- eters. B, Embryo of fifteen millimetres, about forty to forty-two days old ; after Minot; X about seven diameters. and the limbs have grown very considerably, while the hand is expanded and shows traces of its subdivision into five fingers. By the eighth week the embryo, C, already has a dis- tinctly human appearance, all the parts, despite the very obvious and great differences of proportion, resembling 190 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. the corresponding adult forms. The head is still over- large, while the facial region is smaller than it will be in the adult; the rump will become more slender, and the limbs will elongate very much, both absolutely and rela- tively. For more convenient comparison we add a figure of an embryo of a little over four months, drawn of the natural size, and in the natural position in utero. It shows the changes just alluded to. The external development of the face can be explained with the aid of Fig. 1274. In A the mouth is a wide opening, bounded below by the mandible ; above, it is bounded by the so-called frontal process (Stirnfortsatz), which has two nodular protuberances, one at each of its lower corners; the frontal process is marked off laterally by the small nasal pits, which are on the same level with upon that of the frontal process, which forms not only the protuberant nose, but also the middle portion of the upper lip. The maxillary processes unite with the corners of the frontal process, thus separating the opening of the mouth from the nasal pits and making a continuous up- per lip, of which the middle is derived from the lower edge of the frontal process; by further growth the mouth is closed, the two lips coming into contact, B, but we can still distinguish the lobular processes. The double origin of the lips is well shown in Fig. 1277, L and Mx. When the maxilla and frontal process unite, the groove between the nasal pits and the mouth is not closed over, but is converted into a canal, so that the pits open inter- nally into the buccal cavity. The external openings of the pits remain small, while the pits themselves continue Fig. 1275.-Six Embryos of Higher Vertebrates as nearly as possible at the same Stage. (After His.) All the figures are magnified nearly five and a half diameters. A, human ; B, rabbit; C, guinea-pig ; D, deer; E, domestic pig ; F, chick. the eyes ; these pits are shallow invaginations of the ecto- derm, and communicate by a shallow groove with the mouth cavity ; the sides of the mouth are bounded by the oblique maxillary processes, which run from the cor- ners of the mouth toward the nodular protuberances (pro- cessus globulares, His) of the frontal processes. Between the eye and the nasal pit, on each side, runs a shallow groove, which was formerly supposed to close over and form a canal, the lachrymal duct; it is now maintained, however, that the groove disappears, and that the lachry- mal duct is developed later, along the same line, as a thickening of the under side of the epidermis; the thick- ening afterward separates from the mother layer and ac- quires a lumen. The development of the face depends to a large extent to enlarge, even until considerably after birth, to form the great nasal cavities. The external nares face directly forward at first; as the nasal protuberance grows up it assumes at first somewhat the form of an equilateral pyramid with three sides, two the sides of the nose, one the inferior and median narial area. The adult form is gradually adopted. In the broad nose of certain negro races the embryonic form is somewhat preserved. The eyes are at first far round at the side (Fig. 1274, A, and 1276). They subsequently move nearer the median line in front. They remain long uncovered, the eyelids not being fully formed until after the second month. During the third month the edges of the two lids meet and grow together by union of the epidermis; they usu- ally separate again some time before birth. 191 F«tus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It has often been asserted that vertebrate embryos are all much alike, and that embryos of various mammals are so very much alike that they are hardly distinguish- able. This gross error becomes immediately apparent when the actual objects are compared with one another (Fig. 1275). The parts are, of course, essentially the same in all the embryos, but the proportions and forms are ex- tremely different. We notice great variations in the size and outline of the head : it is very large in man, small in the pig; equally noteworthy are the variations in the head bend and the corresponding ones in the prominence of the region of the mid-brain, scarcely noticeable in man, so excessive in the pig and chick. In short, each of the species presents already a specific character, and the em- bryos are alike only in this-that their organs are all homologous, and within certain rather wide limits at the same stage of development; but the organ which is most advanced in one species may be the least so in another. It will be noticed in Figs. 1266, 1267, 1272, A, and 1276, that the human embryo has a distinct tail, which sub- sequently disappears externally. Morphologically, the four or five vertebrae of the adult coccyx represent a the common stem of the omphalo-mesaraic veins, it ap- pears as the ductus venosus Arantii. In external form the embryo differs but little from Fig. 1272, B, but the Fig. 1276 shows that the protuberance of the chest and abdomen is due to the precocious size of the heart and liver ; between the two organs is seen the developing dia- phragm. The intestine makes but a single considerable bend, which, however, is sufficient to bring it into the umbilical cord proper. For a considerable period a part of the intestine is found in the cord, and when, by an arrest of development, it is not retracted within the ab- domen before birth, so-called congenital umbilical hernia results. The lungs, Lu, are very small ; the Wolffian body, W.b, still very large. The nasal cavities of the embryo at first are not sepa- rated from the mouth, but by the middle of the second month, about the time the ridge of the gums has begun to show the dental groove (D, Fig. 1277), there grow out two lateral shelves, Pal, which gradually extend themselves further and further toward the median line, until they true tail. Now, al- though the adult has only thirty-three or thirty-four verte- brae, embryos of nine millimetres have thirty-eight, of which four or live disappear in the course of further de- velopment. It will be remembered that the number of ver- tebrae (segments') in- creases by additions at the hinder end. The maximum number is not reached until quite late ; thus in Fol's embryo (Fig. 1266), of 5.6 mm., there are 32 vertebrae; in His's, of 7 mm., 33; and in Fol's, of 9 mm., 38. The caudal vertebrae constitute a rudimen- tary organ, inherited presumably from man's long-tailed ancestors. 13. Embryos of the Second Month.-At the beginning of the second month all the principal organs are present, at least in a rudimentary form. There are, however, some parts, the essential phases of the development of which fall within the second month ; of these the most important are considered in this section. The anatomy of an embryo of about thirty-five days is shown in Fig. 1276. The umbilical cord is completely formed, but still contains a large cavity within the am- nion which forms its outer covering. It contains the vitelline, and allantoic stalks. The former is very long and small ; it ends in the highly vascular, hollow yolk-sac, Vit; it carries two large vessels, the left om- phalo-mesaraic vein and the right omphalo-mesaraic artery ; it arises from the apex of the loop of the primi- tive intestine (cf. Fig. 1268, B, Yk.s}. The allantoic stalk carries the two arteries, Al.a, and the single vein, Al.v ; the latter enters the abdomen and passes forward, much increased in size, owing to the abdominal veins it takes up, and enters the liver, where, after being joined by Fig. 1276.-Embryo of Thirty-five Days. (After Coste.) Enlarged about five diameters. Fit, vitelline sac ; V.S, yolk-stalk ; Am, amnion ; Ch. chorion : Vi, chorionic villi: Al.v, allantoic or umbilical vein ; Al.a, allantoic or umbilical artery; W.&, Wolffian body; n, venous duct of the liver ; Lu, lung; Uy, hyoid; Md, mandible; Mx, maxilla ; 01, olfactory or nasal pit. (Compare Fig. 1271, B.) there meet and unite ; failure of development in this case is by no means rare, cleft palate being often encountered. The closure is said to be normally completed by the mid- dle of the third month. For the dental developments, see Teeth. The tonsils arise much later, appearing during the fourth month as an evagination of the pharynx (Kolli- ker). The oesophagus early acquires a many-layered epi- thelium, which in embryos of the fifth month is partly ciliated, and does not acquire the horny layer until later. The nerves arise as outgrowths of the medullary canal. The posterior roots and the anterior roots of the spinal nerves grow out separately. The posterior roots grow from the neural ridge of Marshall, a line of cells which project from the dorsal summit of the medullary canal ; paired outgrowths arise from the ridge, each consisting of nerve-fibres and cells, to form a ganglion ; each outgrowth is a sensory root; a little later arise the anterior roots as simple outgrowths of fibres from the medulla ; but the anterior root rises a little lower, i.e., farther from the 192 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. head than its dorsal fellow, which it joins to complete the spinal nerve. The morphology of the cranial nerves is not yet fully elucidated ; they are probably serially homologous with the spinal nerves ; but most of them have undergone much modification ; the majority, viz., the olfactory, third, fifth, seventh, auditory, glosso-pharyngeal, and vagus arise from the encephalic continuation of the spinal neural ridge, and therefore correspond in their development with spinal posterior roots. The origin of the sixth nerve is not quite satisfactorily worked out. The hypoglossus is really, as shown by Froriep, a com- pound nerve, arising by the fusion of at least three sepa- rate nerves, which are evidently true spinal nerves, and are added to the head by the absorption into the occipi- tal region of several segments originally cervical. The eleventh nerve (accessorius) is, of course, also spinal in origin ; for a discussion of its homologies I must refer to Marshall's and Froriep's memoirs. In order to understand the disposition of the cranial nerves it is necessary, first, to examine the morphology of the head. For a long time an erroneous theory of the composition of the head was taught. According to this theory (Oken's, afterward appropriated by Goethe) the head was supposed to be composed of a small number of vertebral segments, still recognizable in the bones of the skull. Three segments were generally accepted, the bodies of the corresponding vertebrae being the basi-oc- cipital, basi-sphenoid, and prae-sphenoid bones. Some writers even assumed other similar vertebrae (one, two, Now, all the nerves we have just considered arise from the part of the brain behind the hypophysis (pituitary body), hence we call this region of the head the pseudo- segmental region. That the part of the head in front of the pituitary body is really segmented is improbable, al- though it has been suggested by certain writers. On the other hand, we know that behind the vagus, in the occip- ital portion of the head, there is a clearly segmented re- gion. Hence the head must be divided into two parts : 1, the unsegmented prae-pituitary region ; 2, the seg- mented post-pituitary region, which may be subdivided into an anterior part, extending to and including the va- gus, which has the segmentation obscure, and a posterior part, which is clearly segmented. The number of seg- ments in the pseudo-segmental part is presumably at least twelve, while the segmental part has certainly three. It seems to me safe to assert with considerable confidence that the post-pituitary region comprises fifteen or more segments (see Segmentation of the Body). In fact, we must assume that the head has grown at the expense of the cervical region by repeated annexations. The final decision as to the number of segments must depend on the determination of the number of myotomes, both in the higher and lower vertebrates. Leaving now the abstruse and difficult problems of ce- phalic morphology, we give a figure, 1278, and descrip- tion of the cephalic nerves as found by His in an embryo of 13.8 mm. The outline of a portion of the central Fig. 1277.-View of the Roof of the Foetal Mouth, the lower jaw having been removed. (After His.) Magnified eight times, na, Nares ; Op, eye ; L, portion of lip developed from the frontal process ; Mx, portion of the upper lip developed from the maxillary process ; D, dental groove; Pal, palate. Fig. 1278.-Part of the Nerves of a Human Embryo of 13.8 mm. (After His.) V to XII, cephalic nerves according to the usual enumeration ; 1 to 8, cervical nerves ; 1 to 3, dorsal nerves ; P, recurrent laryngeal. or three) in front of these. The first step toward a more truthful conception was made by Gegenbaur, who showed that some, at least, of the cranial nerves formed a regular series ; and that these nerves corresponded one to each of the gill-clefts, and that each nerve had two branches, one running to the cephalic, and one to the caudal edge of the cleft to which it was related. The subject has since been much studied by others. The vertebrate mouth we must regard as the equivalent of two ectodermal pouches (gill-clefts) fused in the median line. The nerve of the mouth is the trigeminus, which gives off a branch to both jaws, that is, to both edges of the mouth gill-cleft. The mandibulo-hyoid cleft is supplied by the facial, of which one branch (chorda tympani) runs in front of the cleft to the mandible, the other (facialis, 8.str) to the hyoid arch. The glosso-pharyngeal is similarly related to the first branchial slit, or second gill-cleft. The vagus has been proven to be, by its comparative anatomy and embry- ology, really a compound nerve, resulting from the fusion of several branchial nerves. It may be regarded as es- tablished that the lower vertebrates had more gill-clefts than we find in the amniota, several of the posterior clefts having disappeared, while the nerves of them all have united with the nerves of the third and fourth clefts into the great and important vagus. It seems now not improbable that the trigeminus, facialis, and glosso-phar- yngeus, are likewise compound nerves, that is to say, have been evolved by the fusion of two or more segmental nerves. nervous system is shown, and of part of the face ; the outline of the palate, tongue, and pharynx are indicated by dotted lines. The trigeminus, V, bears its large ganglion, from which runs off the ophthalmic branch to the eye, and the two rami to the upper and lower jaw, respectively. The eighth, or auditory nerve, is, for the sake of clearness, not represented ; it is usually held to be morphologically a part of the seventh, VII. The ninth, IX, nerve with the two ganglia, is shown entering the tongue, but the pharyngeal branch is omitted. The va- gus, X, which is the nerve of the posterior cleft, and therefore of the lungs, has already elongated with the downgrowth of the lungs into the chest, and has become a large nerve-trunk; it still supplies the pharynx, etc., but owing to its elongation some of its branches have to turn back, li, to reach their destination. The sympathetic nervous system arises from the spinal nerves as a series of separate ganglia, a row on each side. The ganglion arises, as an ingrowth or bud, from the nerve-trunk, somewhat ventralward of the level of the vertebrae ; it extends from the nerve toward the median line. In the bud ganglion cells are developed, probably from cells which have grown out with the nerve from the medullary canal. It must be added that the sympathetic of the human embryo has not yet been studied ; the above account is based on observations on sharks and mammals. The supra-renal bodies of mammalia are known to 193 Foetus. Foetus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. arise from two sources, the first an outgrowth connected with, and apparently coming from, the sympathetic sys- tem, and the second a differentiation of the mesenchyma ; the first forms the medulla in the embryonic capsule, and the second the cortex. It has been commonly supposed that the two parts persisted in adult life. My own obser- vations on the development of the supra-renals in man lead to the conclusion that the embryonic medulla of sympathetic origin disappears about the middle of foetal tebr® are marked out from the start. The appearances in a human embryo of fifteen millimetres are shown in Fig. 1279, which represents a longitudinal section through the ninth, tenth, and eleventh vertebrae. The specimen was not quite normal; the chorda not well preserved. Here the sheath of the chorda or the condensed tissue has begun to form the cartilaginous body of the vertebrae ; at the same time the spinal arches have commenced their differentiation. Later, other processes grow out, the ver- tebra gradually assumes its definite form, and ossification commences in the body of the ver- tebrae in the seventh week, in the neural arches a week or two later. The manner in which the notochord disap- pears is characteristic for each of the vertebrate classes with ossified vertebrae. In mammals (Fig. 1280) the notochord is constricted in the centre of each vertebra, and remains wider in the intervertebral spaces. In birds and reptiles the constrictions of the chorda are interverte- bral, the dilatation vertebral in position-the exact reversal of the mammalian relations. When the notochord disappears in man is not known to me. At each end of the vertebral column impor- tant modifications occur; the four or five ter- minal vertebra; found in embryos of 9 mm. fuse a little later into one mass, the last coccy- geal vertebra of the adult. At the head the ver- tebral column reaches morphologically to the end of the chorda, but the vertebra; are fused together very early and converted into the great cartilaginous investing mass, which, together with the otic capsules, forms the post-pituitary portion of the primitive cartilaginous skull, and out of which are developed the occipital, basi-sphenoid, and pra'-spheuoid bones. (See Skull, Development of.) The urogenital system, with exception of the external genitalia and the bladder, is derived from the urogenital fold (Fig. 1253). The sexual gland appears first as a longitudinal protuberance on the medial side of the fold, and is distinguished by its thicker epithelial covering ; the sexual ridge does not extend the whole length of the urogenital fold, but begins near the anterior or cephalic ends, and runs about three-fifths or two-thirds of the way back toward the caudal end, thus leaving a caudal division which is not genital, but contains the gen- ital ducts ; it may be called the gubernacular division of the fold. The genital ridge acquires greater prominence by its own growth and by the atrophy of the Wolffian body, which at first (Fig. 1253) constitutes the main bulk of the urogenital fold. During the second month the Wolffian body begins to atrophy, and by the beginning of the fourth month only a small remnant is left in either sex, so that at this time, and for a con- siderable period anterior, the genital gland is the chief constituent of tho urogenital fold (Fig. 1281, o). At first the testes cannot be distinguished from the ovaries ; by the end of the second month they differ in form, the testis being shorter and broader than the somewhat elongated ovary (Fig. 1281, o) ; about this time, or a little later, the ovary acquires a distinctly more oblique position than the testis. By the eighth week also (embryos of 21 mm.) the male and female glands are easily dis- tinguishable microscopically, the testis having cords of cells (tubules) more or less uniform in diameter; the ovary, on the other hand, has a network formed by irregular trabeculae of cells (market range). The origin of the tu- bules of the testis is under dispute. Waldeyer considers that they have grown in from the Wolffian body proper ; while Bornhaupt traces them to ingrowths of the cover- Fig. 1279.-Human Embryo of about Thirty-five Days; Longitudinal Section of the Ninth to the Eleventh Vertebra?, as numbered IX. to XI. IV, nervous system, wall of the spinal marrow ; cl, meningeal layer ; CA, notochord ; Ao, aorta. life, and that the so-called medulla of the adult is a dif- ferent structure, resulting from a modification of the em- bryonic cortex ; but, as my observations are incomplete, my conclusion may be incorrect. The mesoderm cells arrange themselves in cords, with spaces between them chiefly occupied by wide capillaries, so that the appear- ance of sections under the microscope reminds one of the liver. At the periphery of the organ the cords run in nearly parallel radial lines, but toward the centre they form an irregular network. The supra-renals commence their development during the first month, and are found at the beginning of the third month occupying their characteristic position as a cap fitted over the head end of the kidney ; they rapidly acquire a very large size, and at birth have about their permanent volume. The skeleton is produced entirely from the mesenchy- ma. The first step in the formation of a skeletal part is a local condensation of the cells ; their numbers increase, and consequently they lie closer together, and are con- nected by shorter anastomosing processes, than the ordin- ary mesenchymal cells (Fig. 1245). The condensed skel- etal tissue is, for the most part, first converted into cartilage, but in certain sites, e.g., membrane bones, di- rectly into bone. (See Cartilage and Bone, Ossification.) We can consider only the disappearance of the noto- chord and development of the vertebral column, and must confine ourselves to a general history for the development of these parts in mammalia, the observations on man be- ing fragmentary. The notochord enlarges somewhat by the expansion of the primitive cells which form it, and acquires a thin anhistic sheath, which is seen in Fig. 1253, s, the secondary fibrous chorda sheath of sharks, Fig. 1244, s', is not found in the higher vertebrates. The notochord is nearly cylindrical, and ends in front just behind the hypophysis. Around the chorda arises a very thick sheath of condensed tissue, the beginning of the vertebral column. It has been currently believed that this sheath was a continuous envelope, but Froriep's ob- servations on the chick show that in that animal the ver- Fig. 1280.-Longitu- dinal Section of the Vertebral Column of the Human Embryo of Eight Weeks. (After Kol- liker.) v, Vertebra; ch, notochord ; li, ligamentum inter- vertebrate. 194 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foetus. Foetus. mg germinal epithelium (Fig. 1253, G. ep}. It will, per- haps, be found hereafter that the seminiferous tubules proper come from the epithelium, and that the collect- ing tubules which make the communication between the seminiferous tubules and the epididymis are rem- nants of the Wolftian body; a view which is suggested by what we know of the development of the testis in lower vertebrates. In the ovary, also, we have two kinds of cords of cells: 1, the markstrange, which are supposed, but not certainly known, to come from the Wolffian body, and which we must, at least hypotheti- cally, regard as homologous with the collecting.tubules of the testis ; 2, the peritoneal ingrowths (Pfliiger'sche Schlauche), which produce the ova and Graafian follicles, as described in every anatomy. The traditional account of the development of the ova, however, has been called in question by Kblliker. The genital ducts differ in the two sexes ; the Wolffian duct persists in the male as the vas deferens, but is par- tially or wholly atrophied in the female. The female passages arise from two canals, the so-called Mullerian ducts, which appear, one in each genital fold, and consid- erably later than the Wolffian ducts. Their exact origin is still uncertain ; in sharks they arise by direct splitting off from the primitive Wolffian (segmental duct), but re- cent writers maintain that, in the amniota, Muller's duct arises at the front end of the genital fold as an invagina- tion of the mesothelium; the point of the invagination grows backward alongside the Wolffian duct as a cord of cells, which afterward ac- quire a lumen ; the end of the cord reaches the urogen- ital sinus and grows together with the walls thereof ; the anterior funnel-shaped open- ing of the canal into the peritoneal cavity is retained. The Mullerian ducts are found alike in the embryo of both sexes. In the female the Mulleri- an duct is preserved; the Wolffian duct, on the other hand, is wholly or partially aborted. The relations are shown in Fig. 1281. The ovary, o, is the largest com- ponent of the fold ; the Wolffian body is very much reduced, and is subdivided into two parts, e and IF. Of these the upper, e, per- sists, and is still to be found in the adult in the broad liga- ment between the ovary and that part of the Mullerian duct knowm as the Fallopian tube. This Wolffian remnant is variously named the organ of Rosenmuller, after its discoverer, the parova- rium of Kobelt, the epo-ophoron of Waldeyer and His. The second portion apparently disappears, per- haps by simple atrophy, perhaps by inclusion in the ovary. A remnant, w', of the Wolffian duct can be seen associated with the parovarium ; sometimes a much longer piece, sometimes even nearly the whole length of the duct, is retained, and it is then spoken of as the duct of Gartner. Finally, the fold contains the wide Mullerian duct, M. We find in the female, in earlier stages than this, that the two ducts from each side, leaving the urogenital fold near its caudal extremity, bend toward the median line, and become surrounded by a common mass of tissue be- tween the urachus (allantois diverticulum, bladder) and the rectum. This mass of tissue is known as the genital cord ; it contains at first the two laterally-placed Wolf- fian ducts, and the two Mullerian ducts, which lie nearer the median line and more dorsally; the genital cord de- velops into both the uterus and vagina. Within the cord the two Mullerian ducts unite in the median line, forming a single canal. The headward portion of this canal be- comes dilated into the uterine cavity, and its epithelium becomes the lining of the uterus ; the tailward portion de- velops into the vagina; the mesenchymal tissue of the cord is converted into the muscular and connective-tissue layers of the adult passages ; finally, the Wolffian ducts atrophy, usually completely; but they sometimes, as stated above, persist, to a greater or less extent, as rudi- ments-the above-mentioned canals of Gartner, which when present lie in the walls of the uterus, on either or both sides. The fusion of'the Mullerian ducts commences at the end of the eighth week, about two-thirds of the way down from the upper end of the cord ; the fusion progresses from that point both upward and downward ; but the upper two-thirds are united before the lower third. The process is completed, according to Furst, by the end of the third month. The simple utero-vaginal canal thus produced undergoes its further differenti- ation later than the period we are considering, in this article. In the male the fate of the ducts is reversed ; the Mullerian atrophy, the Wolffian remain. The Mullerian ducts disappear in part only, their lower united portions being retained, though in an undeveloped stage, as the inconspicuous tesicula . prostatica (uterus masculinus, Auct.); their upper ends also remain as little sacs close to the testis, and known as the hydatids of Morgagni. When the testis descends from its original abdominal site into the scrotum the hydatid descends with it. The Wolffian duct becomes the vas deferens ; the lower part of the Wolffian body disappears, but the upper part re- mains ; it is probable, though not yet demonstrated, that it is the latter which by changes in its tubules is con- verted into the rete Halleri, by which the communication between the seminiferous tubules and the Wolffian duct is established and maintained. The communication is not effected until the third month. We have only to add that the epididymis is produced chiefly by the extreme coiling and twisting of the testicular end of the Wolffian duct. The lower end of the urogenital fold becomes the gubernaculum; the muscle of the gubernaculum is rep- resented by the round ligament of the female. The bladder begins to develop very early, as a simple dilatation of the intra-abdominal portion of the allantoic diverticulum (see Fig. 1268, B, Al). It enlarges rapidly during the second month, becoming a vesicle with a pointed upper end, connnected by the thin undilated stalk, urachus proper, with the umbilicus, and a rounded lower end, connected by a short duct, the commencement of the urethra, with the urogenital sinus. The urachus is known in the adult as the ligamentuni vesicae medium, and often contains permanent remains of the epithelial allantoic canal which passed through it. The kidney begins to grow out from the Wolffian duct during the latter part of the fourth week (embryos of seven millimetres) (Fig. 1268, B, N). It rapidly grows upward on the dorsal side of the parent duct, and before long be- gins to branch (Fig. 1268, C, N) and dilate at its upper end, clearly marking out the separation of the ureter and kidney proper. The terminal enlargement rapidly ex- pands and represents the primitive pelvis of the kidney, and occupies a large space on the dorsal side of the Wolf- fian body. Numerous outgrowths arise from the dilatation, which produce, according to Kolliker, all the tubules of the kidney. This account I am not prepared to accept, but for the present deem it more probable that only the collecting tubules are diverticula of the renal di- verticulum, and that the remaining tubules are differ- entiated from the mesodermic blastema surrounding the branching end of the renal diverticulum. The matter can be decided only by more exact investigations than have yet been made. The kidney early acquires a fibrous capsule, and from its rapid growth soon protrudes into the abdomen. Charles Sedgwick Minot. Fig. 1281.-Urogenital Fold of a Human Female Embryo of about Fourteen Weeks (3X inches long). (After Waldeyer.) Magnified, o, Ovary ; e, tubes of the upper part of the Wolffian body forming the epo-ophoron (Kobelt's parovari- um) ; IF, the remnant of the lower part of the Wolffian body (paro- ophoron) ; M, Muller's duct; m', its funnel-shaped peritoneal open- ing , w', remnant of the Wolffian duct. 195 Fomentations. Food. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FOMENTATIONS. Under this title will be included the discussion of poultices, which are allied methods of applying heat and moisture externally. * A fomentation or stupe is the use, as a remedial meas- ure, of a cloth or other soft fabric wrung out of hot water. Spongiopiline and absorbent cotton are sometimes used. A poultice or cataplasm is a warm, moist application of some unirritating vegetable tissue made into a thick paste or pap, and retaining its shape by means of a linen or other envelope. The side next the skin may be " bare," or, better, be covered with a layer of thin, gauzy material, as lawn or tulle. This prevents the poultice from adher- ing to the hairs and skin. Either fomentation or poultice should be covered with cotton wadding, and this with oiled silk, mackintosh, paper, or other non-conductor, to retain heat as well as to prevent soiling the clothing. Poultices should be thick and not too consistent. Nurses commonly make them too dry. The substances in most common use for poulticing are ground flaxseed, powdered slippery-elm bark, corn-meal, and bread-crumb with milk or water. Of these, flaxseed and corn-meal probably retain heat best. Elm-bark is the lightest, and hence best for infants. Many other sub- stances are used occasionally-for example, hops, boiled onions, potatoes, carrots, turnips, apples, okra, starch, etc. The term "ice-poultice " is sometimes applied to the com- bined application of cold and moisture. Both fomentations and poultices are ofttimes medicated, and then receive names more or less vague having refer- ence to the supposed action of the medicinal agent. For instance, they are said to be discutient, resolvent, absorb- ent, detergent, emollient, refrigerant, liquefying, etc. Probably heat and moisture accomplish most of the good effected. Counter-irritant poultices are very commonly used. Mustard-flour mixed with the poultice is as efficient an agent as any, and accomplishes all that a " spiced" poul- tice can do. In cither case the volatile oil is the irritant. Turpentine or brine stupes are commonly used to meet the same indication. Narcotic and analgesic poultices are those combined with opium or other drug having such properties. Anti- septic poultices contain carbolic acid, boric acid, mercu- ric chloride, Labarraque's or Condy's fluid, etc. Astrin- gent ones are made with tannin, Goulard's extract, etc. As deodorants, besides the antiseptics named, and others like them, poultices made with yeast or powdered char- coal are used. [Why fermenting poultices should be of especial value is a question of some interest. That they are, js attested by numerous writers on surgery. Gross, for example, recommends that yeast be spread upon a poultice as an application to " foul, fetid, and painful ulcers, in hospi- tal gangrene, and in mortification." And Ashhurst says of the fermenting poultice-one made with half its weight of yeast-" it is an excellent application to sloughing sores." Possibly a plausible explanation of the modus operandi may be found in an antagonism between the round yeast-plant and the rod-like plant of putrefaction. Concerning such antagonisms, the terse statement of Ros- well Park 1 may be quoted : ' ' The sphero-bacteria seem to be more or less inimical to the more poisonous rod- shaped bacteria; the former very rapidly exhaust the nutritive fluid in cultivating solutions and starve out the latter. It may be a most fortunate thing, then, when the former are present in the blood and wound secretions, for they may serve thus to make things unpleasant for the latter, and either prevent their appearance or hasten their disappearance."] In preference to the use of poultices, I employ the rub- ber coil. It is light, less troublesome to prepare, more efficient as a means of maintaining a steady hot or cold temperature, and far neater. The poultice is generally gratuitously nasty. The coil, furthermore, enables the patient to rest undisturbed at night, the frequent changing of poultices being avoided. First apply a fomentation- moist cloth, spongiopiline, or absorbent cotton-medi- cated or not, and over it place the coil, held in place by a turn or two of bandage. In water-supplied rooms, the inlet end of the coil is fastened over the hot-water faucet and the outlet end carried into the sink ; the temperature of the application being regulated by the thickness of the fomentation. Cold may be applied from the cold-water faucet in the same way. In rooms not water-supplied, siphonage is to be used. To discuss the action of fomentations upon the circu- lation, it is first necessary to give a brief account of the nerves regulating the calibre of the arterioles.2 The amount of blood in an arteriole is governed, when the heart is acting normally, by vaso-motor nerves : a con- strictor nerve, acting constantly, through small ganglia upon the vessel causing a certain degree of contraction or " tone" of the arteriole ; a dilator, acting occasionally and being inhibitory to the first. For example, it is pre- sumable that blushing is due to a sudden action of these last. Besides these two nerves, conveying from the me- dulla to the vessel a centrifugal influence, there is a nerve of common sensation hy which a centripetal influence may be sent from vessel to medulla. The capillaries, possessing no muscular layer, are dependent upon the arterioles and heart for the relative amount of blood with- in them. Regarding our knowledge of the exact effects of heat and cold upon vessels, the margin is wider than the text thereof. Carefully conducted experiments are needed here. I will formulate, however, what seems to me a rational explanation. Heat and cold have, in many respects, identical effects. There may be a momentary contraction of the arterioles when irritated by either, but very quickly a marked dila tation succeeds. This may easily be proven by plunging the hand into hot or cold water. The cutaneous vessels dilate, and the skin becomes rosy. (This effect may be due to a temporary paresis of the vasoconstrictors, caused by the shock, or perhaps to sudden inhibitory ac- tion.) If, now, the limb be allowed to remain indefinitely in either hot or cold water, the arterioles after a time be- gin to contract, probably from the tonic effect upon the vaso-constrictor ganglia of either heat or cold, in modera- tion. This state of things must have been commonly ob- served by everyone in the " washerwoman's fingers ; " and such a shrinking and wrinkling is also produced by the continued application of cold water. The same result is noticeable in the appearance presented by ulcers which have been poulticed too long-they are anaemic, with pale, flabby granulations. We have last discussed the effect of heat or cold ap- plied in moderate degree. Now, suppose we use an in- tense degree of either. As a result, the arterioles sub- jected thereto, instead of recovering from the shock, remain in the same congested condition in which we no- ticed them when the member was first exposed to heat or cold ; the paresis of the vaso-constrictor ganglia-if this is the real cause-is continuous. This state of the circu- lation we see constantly beneath a very hot poultice, or beneath the ice-coil; in either of these cases the skin being commonly red. We may also observe it upon scalding or scorching the skin even slightly. But it is evident that the extreme degree of heat or cold cannot pene- trate the body deeply while the circulation is maintained, and a short distance beneath the surface there is felt merely the effect of heat or cold in moderation ; so that a hot poultice dilates the superficial arterioles, but contracts the deeper ones. Just how deeply the dilating or para- lyzing influence extends will depend in each case upon the degree of intense heat or cold, the amount of subcu- taneous adipose tissue acting as a non-conductor, the rapidity and freedom of the circulation, etc. Dry heat and cold differ from moist mainly in that the moist have a deeper effect. And this brings us to the query, What are the effects of the moisture in a poultice or a fomentation ? Undoubtedly the skin absorbs some of it, and the wa- ter reaches subcutaneous parts, which, by long exposure to unusual degrees of warmth and moisture, become soft- ened and water-soaked, and, while still anaemic, swollen by imbibition. 196 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fomentations. Food. It now remains to point out those respects in which heat and cold are not alike in their effects upon inflam- mation. 1. Either is a sedative to painful nerves; but as a rule cold is more grateful early in acute inflammations, and heat later. 2. When the vitality of a part is endangered, local heat aids the maintenance of life by sustaining that normal degree of temperature at which the necessary cell-proc- esses can best go on; whereas, cold applied under the same circumstances may result in local death, by depress- ing cell-activity. 3. Inflammatory products are better absorbed under the influence of heat, probably for the reason just given: namely, that cold depresses vital activity. As an exam- ple we may mention epididymitis, after the acute stage has passed. Here the induration subsides more quickly under hot poultices ; and it is probable that, as there is here very little non-conducting tissue between the heat and the tubuli, the vessels of the epididymis are dilated throughout thereby. It is universally admitted that, to promote absorption of inflammatory products, poultices should be used as hot as can be borne. When we draw a line of cauterization with our Paque- lin, it will be observed that for days thereafter the cutane- ous arterioles, for several inches surrounding this mark, arc dilated, and the skin is red. It is probable that this dilatation is not produced by direct heat-injury to the vaso-coustrictors from the momentary contiguity of a dull-red heat; it might possibly be due to a continuous reflex inhibition ; but it seems most likely that the vascu- lar dilatation and congestion are the result of shock to the vaso-constrictor ganglia in the neighborhood, caused by the sudden destruction of vitalized tissue ; such a shock as higher sympathetic centres feel when larger parts are suddenly injured or destroyed-when, however, the sur- face is pale because the heart also feels the shock. Practically, I have found that the effects of hot poul- ticing and of light actual cautery over the epididymis are identical in promoting dilatation of the vessels and rapid absorption of the deposit. 4. Local heat, by increasing cell-activity, promotes emi- gration of the leucocytes-their amoeboid movements being more active-and, further, aids their multiplication. Their escape is rendered more easy than usual, also, by reason of the softening and diminished extra-vascular resistance resulting from the unusual degree of heat and moisture. Poultices, then, promote suppuration. Cold, on the other hand, diminishes cell-activity; the movements of the amoeba growing more sluggish, or ceasing entirely, in cold water. Cold, then, tends to check suppurative processes. 5. Cold may prevent, and heat aid, coagulation. To apply these facts to practice: It is better to use cold than heat in the first stage of a phlegmon; if, however, it is found that inflammation is so intense that suppuration is inevitable, then heat will promote pus-formation, and thereby hasten recovery. In the foregoing study of the vascular effects of heat and cold it is presumable that several factors of impor- tance have not been touched upon. For example, the lymphatic and venous flow may be obstructed. Fibrin- ous plugs in the absorbents, and thrombi in the veins, may cause an inflammation to terminate by suppuration which would otherwise have ended more favorably in absorption and resolution. Moreover, we know nothing of the part played by the trophic nerves during inflam- matory action, supposing them to exist. Therapeutics.-Fomentations and poultices are of value in the treatment of visceral as well as of compara- tively superficial affections. When, as in the former in- stance, heat and moisture are employed to modify the circulation and nutritive changes at a point distant from the application, it may perhaps be that dermic irritation induces, by reflex action from the centre, contraction of vessels beyond the reach of the tonic effect of the warmth. Poultices have been used for the relief of inflammation of every viscus. Other therapeutic indications are to allay pain, and to facilitate removal of inflammatory deposits, whether su- perficial or deep; but the heat is undoubtedly of more value when it can act directly. Superficially, heat and moisture favor suppuration, aid the separation of sloughs, soften scar-tissue and permit of its stretching, and maintain vital heat where local death is threatened. They are of value in cases of irritable and inflamed ulcer. Here the morbid vascular dilatation is succeeded by a tonic contraction which, if the poulticing be too long continued, may, as already mentioned, actu- ally delay or prevent healing, the granulations growing more and more pale, although exuberant, and the process of cicatrization failing to advance. Robert II. M. Dawbarn. 1 Reference Handbook, vol. i., Antiseptics, p. 258. 2 See Nouveau Dictionnaire de Med. et de Chirurg. Pratiques, tome 38, Vaso-moteurs. FONCAOUDE, or Font-Caouada, a mineral spring two miles from Montpellier, France. The temperature of the water is 77° F. In salts it is very feeble, containing only 2.9 parts in 10,000, and it is probable that it owes the reputation which it bears for curative properties to the presence of a considerable amount of free carbonic acid. The carbonate of lime is its chief solid constituent. It is recommended for bathing in nervous affections and in eczema. The temperature of the bath is usually raised to from 90° to 95° F. J. M. F. FOOD (FOOD AND DRINK), ADULTERATION OF. The increasing magnitude of this crime against society and the public health has led to the adoption, in England and on the Continent, of national laws, and in the United States of State laws, more or less stringent, for the pre- vention of this dangerous and widely spread custom. In this country the formation, in 1879, of a National Board of Health led to an increased interest in the matter, and somewhat later a bill to prevent the adulteration of food and drugs, for enactment by State Legislatures separately, was prepared, at the instance of the National Board of Trade, by a committee consisting of the Vice-President of the National Board of Health and three others, repre- senting the States of New York, New Jersey, and Massa- chusetts, respectively. This bill provides : 1. That no person shall manufact- ure, have, offer for sale, or sell any article of food or drugs which is adulterated within the meaning of the act. 2. The term food, as used in this act, shall include every article used for food or drink by man. 3. An article shall be deemed to be adulterated, within the meaning of this act, in the case of food or drink : (a) If any substance or substances has or have been mixed with it so as to reduce or lower or injuriously affect its quality or strength ; (i) if any inferior or cheaper substance or substances have been substituted wholly or in part for the article ; (c) if any valuable constituent of the article has been wholly or in part abstracted ; (d) if it be an imitation of or be sold under the name of another article ; (e) if it consist wholly or in part of a diseased, or decomposed, or putrid, or rotten animal or vegetable substance, whether manu- factured or not, or in the case of milk, if it is the product of a diseased animal; (/) if it be colored, or coated, or polished, or powdered, whereby damage is concealed, or it is made to appear better than it really is, or of greater value; (g) if it contain any added poisonous ingredient, or any ingredient which may render such article injuri- ous to the health of a person consuming it; Provided, that the State Board of Health may, with the approval of the Governor, from time to time declare certain articles or preparations to be exempt from the provisions of this act and provided further, that the provisions of this act shall not apply to mixtures or compounds recognized as ordi- nary articles of food, provided that the same are not in- jurious to health, and that the articles are distinctly labelled as a mixture, stating the components of the mixt- ure. 4. The State Board of Health shall take cognizance of the interests of the public health, as it relates to the sale of food and drugs and the adulterations of the same, and make all necessary investigations and inquiries re- 197 Food, Food. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lating thereto. It shall also have the supervision of the appointment of public analysts and chemists. The act further specifies that " every person selling or offering or exposing for sale, or delivering any article to purchasers, shall be bound to supply any public analyst or other agent of the State or local Board of Health ap- pointed under this act, who shall apply to him for that purpose, and on his tendering the value of the same, with a sample sufficient for the purpose of analysis of any ar- ticle which is included in this act." Furthermore, the act provides that "any violation of this act shall be treated and punished as a misdemeanor ; and whoever shall impede, obstruct, hinder, or otherwise prevent any analyst, inspector, or prosecuting officer in the perform- ance of his duty shall be guilty of a misdemeanor, and shall be liable to indictment and punishment therefor." This comprehensive act, which appears well adapted for the purpose, has been made a law by several States, notably New York and Massachusetts, and by the ap- pointment of competent chemists, and with suitable ap- propriations much good work has been done even in the few years during which it has been in force. Legislation by itself will avail but little ; the most care- fully-worded laws are not sufficient to put an end to this nefarious business; life and health are nothing in the eyes •of the adulterator, if the profits only justify the means ; what is needed, in addition, is adequate appropriation for the establishment in every State, and better yet, in every large city, of a municipal laboratory where food products and drugs can be analyzed and their merits determined. Or, if this be inadmissible, let arrangements be made with the laboratories connected with various educational institutions, by which the same results can be attained. If other States would but follow the lead of New York and Massachusetts in this matter, life and health would be safer, the poor man would have a far better chance of obtaining full value for his hard-earned money, and the State more than compensated for the necessary appropria- tions. England,1 more than any other country, has leg- islated much upon this matter during the last hundred years, wholly, however, by special statutes. The first general act was passed in 1860, when permission was given for the appointment of public analysts. Up to this date, certainly, adulteration was carried on as exten- sively in Great Britain as in any other country. The act of 1860, which was soon found inadequate, was fol- lowed by the acts of 1872, 1874, and finally by the act of 1875, amended 1879, which latter is the existing law, and which provides for the appointment of suitable pub- lic analysts and inspectors. This plainly indicates that any law regulating adulteration, to be of value to the pur- chaser and consumer of adulterated goods, must be en- forced by suitable inspection, the purchaser, moreover, of any suspected article having the right, for a small fee, to demand an examination by the public analyst. In this way only can the necessary convictions be obtained, the public protected, and the rights of society maintained. Extent of Adulteration.-Unquestionably much that is sensational and wholly false has been written re- garding adulteration. The public mind has been from time to time greatly exercised over the reported discovery of enormous frauds, or at the occasional loss of life in some specially aggravating case; but the attempt so fre- quently made by well-meaning persons to magnify the existing evil beyond all bounds of reason, frequently the result of ignorance, or to make some rare and special case the text of a rabid homily upon hidden causes of death, has done much to render thoughtful people careless of the evils which really do exist on all sides. In Great Britain, during 1879, about - eighty public analysts, ap- pointed under act of Parliament, analyzed 16,772 sam- ples of various kinds of food-stuffs, and detected and exposed 2,978 adulterations.2 In 1878 the German gov- ernment had 231,478 samples of different articles ana- lyzed for adulterations, and obtained 3,352 convictions in the courts.2 In New York State, in 1881,3 the sanitary committee on the adulteration of food reported, under the working of the new law, the following results obtained by the various chemists in the short time which they had been at work : Of 40 samples of butter examined, 1 was a mixture of butter and oleomargarine ; 1 was adulterated with water, 5 were considered suspicious, and 14 con- tained fatty matter other than genuine butter ; of 28sam pies of lard examined, 15 only were up to the standard of purity ; of 16 samples of olive-oil, 9 were considered as adulterated ; of 180 samples of spices, 112 were impure, the adulterations in some cases extending to eighty-one per cent.; of 280 samples of bakers' chemicals, breadstuff s, etc., only 35 were adulterated ; of 117 samples of dour, 8 were found to be adulterated ; of 21 samples of ground coffee, 19 contained foreign substances, chiefly chiccory and beans, with occasionally wheat or other grain coarsely ground, while the unground coffee was found to be pure; of 3 samples of chiccory, 1 contained caramel ; of 3 samples of maple sugar, 1 contained thirty live per cent, of artificial glucose ; of 3 samples of honey, 1 contained fifty per cent, of glucose ; in confectionery, glucose, terra alba, and chromate of lead were detected ; of 67 samples of brown sugar, 4 were adulterated from twenty-two to thirty-three per cent.; the white sugars were all pure so far as examined; of 25 samples of brandy, 16 contained fusel-oil, and in whiskey the addition of water and color- ing matter was frequently apparent. In the report of the analyst of food under the new law in Massachusetts 4 it is stated that of 96 samples of milk examined, only 11 reached the standard of solids (thirteen per cent.) fixed by law ; of 205 samples of spices, 135 were adulterated. These facts, taken from authentic sources and the results of examinations made within a few years, plainly show how extensively adulteration is carried on. Most of those quoted simply affect the pocket of the pur- chaser, for it would appear that by far the larger amount of intentional adulteration is harmless to health. But a limited number of exceptions to this statement is to be found on all sides, as in the addition of aniline dyes to wines or the adulteration of confectionery with gypsum, and no one will question the intimate connection between infant mortality and the adulteration of milk by the addi- tion of water. Food adulterations can be conveniently classified under four heads, viz. : A, those which are simply fraudu- lent ; B, those which are both fraudulent and unwhole- some ; C, those which are accidental, and D, those which are incidental to methods of preparation or preservation. The following table shows some of the more common forms of adulteration so classified : Article adulterated. Nature of the adulteration. Sugar Glucose (pure), water. Butter Oleomargarine, animal fats, water. Cheese Annotto (pure). Lard Water, potato flour or starch. Coffee Chiccory, roasted grains, and roots. Chiccory Roasted corn, wheat, ground acorns. Cocoa Starch, sugar, flour, animal fats. Tea Various prepared leaves, sand, coloring mat- ters for facing. Flour (wheat) Bean-meal, barley and rice flours, white peas, etc. Bread Water (excessive amount), potatoes, boiled rice, etc. Oatmeal Barley-meal, corn-meal, etc. Arrow-root Cheaper forms of starches, as corn and potato starch. Sago and tapioca Cheaper forms of starches, as corn and potato starch. Mustard Indian meal, flour, turmeric. Cinnamon Cassia. Pepper (black) Flour (pea and wheat), linseed-meal, woody fibre, etc. Pepper (cayenne) Ground rice, turmeric, etc. Allspice Mustard husks. Honey Cane sugar, glucose, starch, water. Confectionery Starch, flour, etc. Milk * Water, removal of cream. Cream Skim milk. Potted meats and fish Starch and flour as paste to increase weight. Olive-oil Cotton-seed oil. Vinegar Water and burned sugar. A. Simply Fraudulent. * While the addition of water or the withdrawal of cream does not ren- der milk strictly unwholesome, such adulteration is to be considered as something more than fraudulent, since the food value of milk so treated is greatly diminished, and thus children and infants correspondingly starved. 198 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Food. Article adulterated. Nature of the adulteration. Malt beverages Cane sugar, glucose, licorice, caramel, water, quassia. Wines Caramelized sugar, various flavors, cheaper wines. Brandy Water, extraneous spirit, as potato and corn, burned sugar. Rum Water, cayenne, burned sugar. that fraudulent adulteration is due mainly to admixture of the flour of the cheaper cereals, as barley, corn, etc., which form of adulteration is easily distinguished by the microscope, since the starch grains of the different cereals vary greatly in form and size. By the same method of examination accidental adulteration, due to the pres- ence of animal or vegetable parasites (occasionally noticed in flour from carelessly cultivated cereals) can be distin- guished. The only other form of adulteration at all com- mon, and which appears to be seldom practised in this country, is the addition of mineral matters, as gypsum, clay, etc., simply to increase the weight, or alum added to disguise the presence of damaged flour. The alum in this case acts as an antiseptic, arresting the decompo- sition of the gluten by which the flour is rendered dark in color. These forms of adulteration are easily discov- ered by simply determining the amount of ash or inor- ganic matter left on ignition. Oatmeal, rye, barley, buckwheat, corn-meal, etc., when adulterated at all, are simply treated with either inferior meal or else become the subject of accidental adulteration (wormy, musty, etc.) from being kept too long. Arrow-root, tapioca, sago, corn, rice, and potato-starch are frequently found adulterated with each other, the more expensive with the cheaper, and in this as in the preceding case the micro- scope must be relied upon wholly for their detection. Bread, the form in which wheaten flour is mainly con- sumed, appears to be more subject to adulteration than the flour. In England, where bread is sold by weight, much stress is laid upon the amount of water contained in it. Wanklyn claims that good bread should not contain more than thirty-four per cent, of water. Of ten samples ex- amined by Dr. E. S. Wood, of Boston, one contained forty-four per cent, of water, while the average amount of water was 40.5 per cent. In a similar number of samples of freshly-baked wheaten bread, Dr. E. G. Love, of New York, found the average amount of water to be 42.8 per cent., while no sample contained less than 41.5 per cent. These figures show a much larger percentage of water in baker's bread than should be allowed, but until there is some definite standard fixed by law, and until bread is sold by weight, it cannot well be prevented. Potatoes, which are sometimes used when Hour is high, enables bread to hold more water than it otherwise would. The amount of water is determined by simply drying a weighed amount of bread at 100° to 110° C. until of constant weight, and calculating the amount from the difference in weight. Of the various mineral adulterants, alum, copper, and chalk are most generally sought for, but of these alum is the only one of practical importance, Bread seldom con- tains more than 1.5 per cent, of mineral matter, and Blyth considers that anything beyond two per cent, is suggestive of mineral adulteration. Regarding alum, much has been written of late, as to whether it constitutes a dele- terious adulteration. It is frequently added, in small quantity, to flour, both by the miller and by the baker, particularly in England. In this country, however, alum is more frequently introduced in baking powder. As an agent in remedying the defects of damaged flour its use should certainly be discouraged, for its purpose is simply to render salable, flour unfit for use as food. In damaged flour the gluten is rendered more or less soluble by the acid fermentation developed, and as a result bread made from such flour is extremely unpalatable-heavy and sour. The addition of alum, however, renders the gluten insoluble, or tougher, and prevents the undue conversion of starch into dextrin and sugar ; by this means the flpur can be utilized, for in appearance the bread manufact- ured from it is unusually white and of normal consistency. This certainly constitutes both a fraudulent and unwhole- some adulteration. The use of alum in baking powders, however, is not quite so clear a case. In this country bak- ing powders are largely used in bread-making, and in a large number of them alum is an important constituent; its use in this manner, therefore, is not in the nature of an or- dinary adulteration. Whether its use should be allowed, therefore, depends solely on the injurious or non-injuri- ous action of the alumina salts on the digestive system. On this point there is a large amount of contradictory Article adulterated. Nature of the adulteration. Tea Prussian blue and black-lead used in facing. Cocoa Venetian red and other ferruginous earths. Butter Oleomargarine or other animal fats from dis- eased animals. Oleomargarine Manufactured from unwholesome fats. Lard Caustic lime. alum. Cheese Venetian red, impure annotto. Flour Alum, gypsum, magnesium carbonate. Bread Copper sulphate, alum. Sugar Calcium sulphate (gypsum). Confectionery Gypsurn, barytes, lead chromate, Scheele's green, etc. Preserved vegetables Copper sulphate for color. Bottled fruits and jams... Artificial essences, copper salts. Pickles Acetate of copper for color, alum. Vinegar Sulphuric acid to counteract dilution. Lemon-juice Sulphuric, tartaric, and other acids. Malt Beverages Cocculus indicus, strychnine, picric acid, etc. Wines Aniline colors, crude brandy. Spirituous liquors Fusel-oil (as a component of inferior brandies and whiskeys). B. Fraudulent and Unwholesome. Article adulterated. Nature of the contamination. Flour Parasites of the grain, as rust, darnel, and ergot. Cheese Fermentation of the substance of the cheese. Meat Rendered poisonous by the food upon which the animal had fed before being killed, par- asites. Water Disease germs, lead, or other mineral poison. Vinegar, cider, etc Lead, copper, by coming in contact with the metal, as when drawn through a lead pipe. C. Accidental, mainly Contamination. D. Incidental to Preparation or Preservation. Article adulterated. Nature of the contamination. Preserves and jellies Lead, zinc and tin from preservation in un- suitable cans. Canned meats Bacteria by partial decomposition,metal from can. Cheese Arsenic in the rind, fungi, insects. Acid fruits Copper, lead, etc., by cooking in unsuitable dishes Vinegar Copper acetate, by cooking in a copper ket- tle. Glucose Sulphuric acid, when not completely neutral- ized by lime in the preparation. It is to be understood that many of these forms of adulteration are not very common, particularly some of those which are especially deleterious to health ; but since all have been observed more than once, it follows that the health officer, in suspicious cases, needs to consider the possibility of their presence. The addition of a poi- sonous substance, or one injurious to health, to any article of food, is a far more serious matter than a merely fraud- ulent adulteration, and one such case is deserving of more attention than a score of the latter. Some of the more Common Forms of Adulteration, with Suggestions as to Methods of Detection.- In an article of this description it is of course impossible to even make mention of the large number of chemical processes necessary for the successful study of food-adul- teration. The public analyst must necessarily be a skilled chemist as well as familiar with the use of the micro- scope. There are, it is true, numerous forms of adultera- tion in which the application of a few simple tests is all that is needed to prove the purity or non-purity of the ar- ticle in question ; but, as a rule, accurate decisions are to be reached only as the result of painstaking labor. In speaking, however, of methods of detection in the present article, space will admit mention only of such methods as are easily explainable and readily comprehensible. Cereals.-Of the various cereal foodstuffs, wheaten flour naturally occupies the first place. In England this article of food appears much more subject to adulteration than in this country. Analyses of American flours indicate 199 Food. Food. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. evidence, based in part on the probable form in which the aluminium compound would exist in the baked bread. In an alum baking-powder the reaction between the so- dium bicarbonate and potassium, or ammonium alumin- ium sulphate, induced by the addition of water, would lead to the formation of aluminium hydrate. This, it is claimed, would ultimately combine, in baking, with the phosphoric acid of the flour, forming an insoluble phos- phate, by which the aluminium would be rendered inert. This conversion into a phosphate, however, is considered by many improbable; but assuming that it does occur, it follows that the amount of nutritious phosphates in the bread is just so much diminished, while, on the other hand, there is the probability of any aluminium phos- phate formed being converted by the acid of the gastric juice into a soluble and absorbable condition. Until there is conclusive proof of the form in which aluminium does exist in bread it seems idle to discuss the therapeutic action of the aluminium salts.5 They are, without doubt, more or less astringent in their properties, and to persons troubled with dyspepsia or kindred disorders, even very small amounts of a soluble aluminium salt might act injuriously. But so long as the physiological action on the healthy organism of such amounts of alum as are present in baking-powders is problematical, legislative ac- tion can hardly be looked for. In view, however, of possi- ble danger, it would seem the part of wisdom to avoid the use of an agent not at all necessary to the successful man- ufacture of pure and wholesome bread. In both France and Germany the use of alum in bread-making is forbid- den by law. Alum in bread can be detected by soaking a strip of pure gelatine in a little water, to which three hundred grains of the suspected bread have been added, for twelve hours, then dissolving the gelatine in a little logwood solu- tion (freshly cut logwood in methyl alcohol), to which an equal volume of a ten per cent, solution of ammonium carbonate has been added. The alum, if any is present, is taken up by the gelatine, and then, when dissolved in the logwood solution, colors it blue. Magnesium car- bonate will give a similar reaction. Gluten flour and bread are becoming important articles of diet for persons suffering with diabetes, and their com- position is, therefore, a matter of considerable importance. Bread containing an excess of gluten, with but five to ten per cent, of starch, often constitutes a valuable article of diet; but there should be some safeguard by which the ad- vertised composition can be guaranteed. A recent sample of "diabetic bread," brought to the writer for analysis, and which the manufacturers claimed contained but three to five per cent, of starch, was found to actually contain 31.1 percent, of starch. A sample of infant's lactated food, said to contain no starch whatever, was found to contain 26.8 per cent, of starch. Such cases as these, whether they be the result of ignorant or fraudulent adul- teration, call for most hearty condemnation ; for though foods which are comparatively but seldom used, they are designed for people in enfeebled condition whose sys- tems can ill stand the effects of unsuitable nourishment. Saccharine Foods.-Among the purely saccharine foods the only adulteration of any importance practised in this country is the substitution of glucose syrup for, or admixt- ure with, the natural products. This is a purely fraudu- lent adulteration ; for glucose, if properly manufactured and uncontaminated with other substances, is a wholesome article of food.6 That this adulteration is a common one is manifest from the enormous quantity of corn annually converted into the artificial sugar. Much of this is, with- out doubt, sold as glucose or glucose syrup ; much is used in the wine-growing districts and in the manufact- ure of beer, but large quantities are employed in falsify- ing sweeter and more expensive products. The white sugars, granulated and powdered, are seldom adulterated ; but the light and dark-brown sugars frequently contain even thirty per cent, of added glucose. The most exten- sive adulteration, however, is to be found in table syrups. Thus in a report made to the State Board of Health of Michigan, in 1874, Dr. R. C. Kedzie reported on the analy- sis of seventeen samples of syrups, in which fifteen were mostly glucose. The same adulteration is extensively prac- tised with strained honey, and indirectly also with comb- honey by feeding the bees on glucose. The sweetening power of glucose is estimated as two and a half to three times less than that of good cane sugar; its admixture, therefore, providing it be pure, is simply fraudulent. If carelessly prepared, however, it may contain considerable gypsum oi- sulphate of lime, and even free sulphuric acid. Glucose can be readily detected, and the amount estimated by determining the specific rotary and reducing power of the sugar solution.1 Glucose enters very extensively into the composition of confectionery, particularly the cheaper grades. Flour, starch, and "terra alba," either gypsum or china clay, are also frequently found. Of much more importance, however, is the occasional presence of poisonous mineral colors, such as the yellow chromate of lead, the green aceto-arsenite of copper, etc. These can be detected by any of the well-known methods used in testing for lead and arsenic. Oleaginous or Fatty Foods.-Among this class of foods butter naturally occupies the most conspicuous place, and its adulteration is a matter much discussed. In this coun- try the main adulteration of butter is the fraudulent sub- stitution of oleomargarine, or butterine, for the natural product. This, like the use of glucose in sugar adultera- tion, is a purely fraudulent act, for the artificial product, when properly made, is perfectly wholesome, and often more palatable than an inferior grade of the natural prod- uct. It should be sold, however, on its own merits and not under fictitious names, nor at the price of dairy but- ter. The most reliable method for the detection of oleo- margarine consists in the determination of the percent- age of soluble or volatile fatty acids liberated on the addition of hydrochloric acid to the saponified butter fat. Blyth considers that 88 per cent, of insoluble fatty acids associated with 6.3 to 5 per cent, of soluble acids is a fair standard of butter calculation. Average butterine does not contain more than 0.6 to 0.8 per cent, of soluble fatty acids. Butter sometimes contains an excess of water ; the average amount present in good butter is 12 per cent. Lard is apparently but little adulterated, although it frequently contains some water ; thus Professor Caldwell8 found in an examination of twenty-eight samples, ten which contained from 1 to 7.5 per cent, of water. Lard is occasionally incorporated with skimmed milk in the manufacture of cheese, mainly for export. The imitation is said to be such as to defy detection. The most dangerous adulteration of cheese is the acci- dental contamination, only rarely seen, occasioned by the presence of unknown organic poisons (irritant in their na- ture) apparently developed by some abnormal process in ripening. Physiological tests constitute the only methods of detection. Olive-oil is an article of food subject to very extensive adulteration, the most common in this country being the substitution of refined cotton-seed oil, which is manufact- ured in large quantities for the purpose. Sesame and ground-nut oil are also frequently found as adulterants. The methods used for the detection of these adulterations are somewhat unsatisfactory. The chemical tests are, per- haps, the best for the purpose. Maumene's test, which is one of the most reliable, depends on the elevation of tem- perature produced by the addition of concentrated sulphu- ric acid of 66 B. to a definite quantity of oil. Pure olive- oil gives a smaller rise of temperature than any of the oils with which it is commonly adulterated ; thus fifty grams of olive-oil gave Maumene, on the gradual addition of ten cubic centimetres of sulphuric acid (1.84 sp. gr.), a rise in temperature of 42° C., while other oils under the same conditions raised the temperature 52° to 103° C. The nitric-acid test also works well for the detection of cotton-seed or other seed oils. This depends on the shade of color which the oil takes on after the addition of nitric acid. Pure olive-oil gives no appreciable color whatever. For cotton-seed oil the test is best applied by adding ni- tric acid of 40° Baume (equal volumes oil and acid), and noting the color the oil assumes on standing. The pres- ence of cotton-seed oil is shown by the gradual appear- 200 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Food. ance of a coffee color, varying in intensity with the amount of adulteration. For sesame and ground nut oils one volume of nitric acid, of 1.33 sp. gr., is added to five volumes9 of the oil to be tested, and the color noted. The appearance of a red color, particularly if the two preceding tests have in- dicated adulteration, may be considered as at least sug- gestive of adulteration with the above-mentioned oils or poppy-seed oil, which is likewise used as an adulterant. Milk.-No species of adulteration, as commonly prac- tised, is of greater detriment to the community than the watering of milk. Consisting in itself merely of the ad- dition of a perfectly harmless fluid, it naturally constitutes the most frequent form of adulteration, and one which is apparently practised without a thought of the very seri- ous indirect danger attending it. Forming, as milk does, almost the sole food of infants and children, at an age when their slender constitutions will not bear the loss of needed nourishment, such a form of adulteration is to be considered as something other than merely fraudulent, to be punished accordingly. While popular opinion credits the milk producer with various forms of adulteration, experience shows that but two are commonly practised, viz., the withdrawal of cream and the addition of water, with, perhaps, the occa- sional addition of milk from a diseased cow. The known variability in the composition of milk, depending upon the breed of the cow, the nature and amount of food, etc., make it somewhat difficult to decide whether a given sample of milk has been intentionally diluted, or whether it is simply the product of an inferior animal, or of an animal improperly nourished. The public, however, has a right to demand that this staple article of food shall conform to some reasonable standard of composition. Such a standard, based upon average composition of a large number of samples, has been fixed by various States and societies. The English Society of Public Analysts has adopted as a standard 11.5 per cent, of total solids, of which 2.5 per cent, are to be composed of fats. This, however, is considered as too low,10 admitting of con- siderable dilution with water. In Massachusetts the statute standard calls for 13 per cent, of total solids. The police inspection of market milk in Germany demands a specific gravity of 1.0285-1.034, a content of 2.5 percent, of fat, and at least 10 per cent, of total solids. The fol- lowing table shows the average composition of pure milk11 and constitutes a standard below which good milk should not fall : Specific gravity 1.030 -|- Creain, percent., by volume 8.0 -f- Per cent, by weight. Sugar 4.40 Casein 4.30 Ash 0.60 Solids, not fat 9.30 Fat 3.20 Total solids 12.50 Water 87.50 100.00 Usually the purity and quality of milk are judged simply by a determination of its specific gravity and the quantity of fatty matter or cream which it will yield. Specific gravity alone will, in many cases, satisfactorily deter- mine the addition of water ; but it is to be remembered that an exceptionally rich milk (in fat or cream) may pos- sess a specific gravity as low as that of badly watered milk. The specific gravity is generally taken by an ordi- nary hydrometer or lactometer, graduated in various ways. The New York Board of Health assumes pure milk to have a specific gravity of 1.029, and the stem of their instrument, calling this point one hundred, is divided into one hundred parts (0°-100°), in which each degree represents one per cent, of milk in the sample tested ; hence, with this instrument, a specimen of milk registering eighty-five would contain 15 per cent, of added water. The lactometer, however, is best considered sim- ply as an instrument for making a preliminary examina- tion. There are also various convenient methods for esti- mating the amount of fat or cream in milk, as by the use of the creamometer, a graduated cylinder containing say 10 c.c., by the use of which the amount of cream rising to the surface in twenty-four hours can be measured directly ; or on the principle that the more cream a milk contains the greater its opacity, its amount can be estimated by de- termining the quantity of water necessary to add to a given amount of milk, say 5 c.c., to render it sufficiently transparent to see through a layer of a given thickness some standard object, as the outline of a candle, or black lines on a white background, as in the Feeser lactoscope. While these methods may be used to advantage in many cases, it is far better, when practicable, to obtain, in addi- tion, more exact quantitative results, particularly of the total solids and fat. In fact, except in the grossest cases of fraud, such an analysis is the only reliable way of detect- ing adulteration. Total solids are readily determined by mixing ten grams of the milk, in a weighed platinum dish, with twenty grams of freshly ignited sand (using a small, weighed, porcelain spatula), and evaporating the mixture to dryness on a water-bath, with occasional stirring. The residue is then further dried in an air-bath at 100° to 110° C., until of constant weight. The weight of the residue, minus the weight of the dish, sand, and spatula, multiplied by ten, gives the percentage of total solids. The fat in milk can be determined gravimetrically by extracting the dried residue obtained in the above pro- cess with ether, in a suitable extraction apparatus, and weighing the fat left on evaporation of the ether solution.12 The fat can also be determined more quickly, and with nearly equal accuracy, by the use of the lactobutyrometer, a method which is especially applicable where large num- bers of determinations are to be made.13 Where specific gravity and the percentage of total solids indicate the addition of water, Blyth 14 considers it advantageous to examine the milk for nitrates and sul- phates. Pure milk contains but a slight trace of the latter, and none of the former, while natural waters con- tain both, particularly if they are at all bad. Hence the presence of nitrates in a sample of milk would be very decisive evidence of the addition of water. The practice of exposing skim-milk for sale is becoming quite common in this country. Milk partially deprived of cream is undoubtedly frequently sold as pure milk; but the establishment of large creameries through the country leads to the production in large quantities of milk almost wholly deprived of fat. There seems, how- ever, to be a general feeling of opposition against the sale of such milk. The nutritive value, however, of this fluid, providing it be sweet and fresh, is such as to suggest that it is doubtless one of the cheapest sources of the proteid food-stuffs. It contains, naturally, all of the constituents of milk, aside from the fat, and the completeness with which this is removed depends upon the method employed. In Germany, in the large milk-factories, fresh milk is at once deprived of its cream (in one to two hours) by means of a centrifugal apparatus. Such milk, according to Dietzsch, has the following average composition : Specific gravity 1.035 to 1.037 Water.... 90.5 " 91.5 per cent. Fat .... 0.2 " 0.6 Albuminate 3.0 '• 3.15 " Suga- 4.0 " 4.5 •* Ash 0.65 " 0.70 " Total solids, 8.4 per cent, (average). A laboring man needs per day at least one hundred and twenty grams of proteid matter, fifty-six grams of fat, and five hundred grams of carbohydrates (sugar, bread, etc.) (Voit). Of these the proteid matter is abso- lutely essential, and Dietzsch has calculated that in Switzerland, placing the value of skimmed milk at one- third that of pure milk, one kilogram of proteid matter in the form of such milk costs but one-fourth what the same amount of albumin in the form of beef would cost, and less than one-half what an equivalent amount of pure milk costs. There can therefore be no objection whatever to the sale of this article, provided it be sold at a price commen- 201 Food. Food. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. surate with its food value, under its own name, and un- mixed with water. It is, of course, understood that such milk is not adapted to the wants of infants, but is a cheap, blood- forming food-stuff, well worth the price at which it is usually sold. In some portions of Germany the sale of half-skimmed milk is sanctioned by law, a standard being fixed (specific gravity, 1.030 to 1.035; fat, at least 1.5 per cent., and total solids, 9.5 per cent.) to which it must conform. Such milk, practically, consists of the night's milk skimmed, and the fresh morning's milk, and as that portion of the milk which is skimmed can stand but twelve hours for the ris- ing of the cream, it follows that the mixed milk actually contains more than half of the original amount of fatty matter. It would seem better, however, to recognize but two grades of milk, pure milk and skim-milk ; certainly the detection of adulteration would be less difficult. Buttermilk is likewise a nutritious drink, and differs but little from skim-milk, except in containing more, fat {1.7 per cent.) and less sugar. Milk from diseased animals, or milk which has been rendered impure by careless handling, is occasionally found in the market, and when suspected it is to be ex- amined with the microscope for vibrios, micrococci, ba- cilli, etc. Where milk is heated to 60°-70° C. such germs, if present, are, of course, rendered inert. Spices.-Ground spices and the various grades and qualities of pepper are seldom found in the market un- adulterated ; even if not intentionally weakened, they de- teriorate rapidly from the volatilization of the essential oil. Hence it is always better to purchase the unground spices and grind them as needed. When adulteration is suspected, examination with the microscope, and com- parison with samples of known purity is the best method of detection ; the amount of ash can also be determined by which mineral adulteration may be detected. Tea, Coffee, Cocoa, and Chocolate.-Tea is variously adulterated with the leaves of other plants or shrubs con- taining tannin, with tea-leaves which have been previously extracted, and also with various mineral substances, such as Prussian blue, graphite, and gypsum, sometimes used in facing teas. It is estimated that fully 20 per cent, of the tea an- nually imported into the United States is adulterated. The presence of foreign leaves can only be detected by comparing under the microscope portions of the leaves with those of the tea-plant. This is best accomplished by soaking the rolled-up leaves in a little water, then spreading them on a glass slide in a few drops of glyce- rine, in which form they can be preserved for future ref- erence. Unadulterated tea contains on an average 33 per cent, of matter soluble in water, 7.5 to 12 per cent, of tannin, 5 to 6 per cent, of ash, of which at least 2 per cent, should be soluble in water, and 1 to 2 per cent, of thein.15 Tea containing less than 1 per cent, of thein is presumably adulterated with leaves already extracted. It is to be hoped that the time will come when tea will not only be subjected to the examination of the tea-taster, but also be subjected to a trial assay before being allowed to pass through the custom-house. Coff ee berries are naturally but little adulterated, while ground coffee, and especially the so-called package coffee, is frequently composed entirely of chicory, or a mixture of chicory and some other adulterant, such as roasted beans, peas, or roots, suitably ground. The best chem- ical method for the detection of such adulteration consists in the determination of the extractive matters soluble in water, and also of 'the amount of sugar and dextrine, or other matter convertible into sugar by treatment with boiling acid (hydrochloric or sulphuric). Pure coffee contains on an average 25 to 30 per cent, of matter solu- ble in water, of which 0.2 to 1.5 per cent, is sugar ; chic- ory, on the other hand, contains 60 to 70 per cent, of soluble matter, of which about twenty-five per cent, is sugar, while roasted grain contains 30 to 35 per cent, of soluble matter, and but a trace of sugar (Dietzsch). Fur- thermore, according to Krauch, the amount of sugar in pure coffee is increased even to 25 per cent, by the invert- ing action of boiling acid (due to the presence of dextrine and starch), while in chicory the amount of sugar is not increased at all. Chocolate, as a manufactured article, can naturally contain many substances which, so long as they are not injurious to health, cannot properly be termed adultera- tions. Pure chocolate, however, should be composed of about equal parts of cocoa and sugar, and should yield at least 15 per cent, of fat. Pure cocoa, when properly prepared from the cocoa bean, should contain 45 to 50 per cent, of fat (cocoa butter), a volatile oil formed in the roasting of the bean, and which gives to cocoa its flavor, 1 to 2 per cent, of the alkaloid theobromine, 10 to 15 per cent, of fibre, together with 10 to 20 per cent, of starch, dextrine, and inorganic salts. The adulterations of both cocoa and chocolate are very numerous, and consist mainly in the addition of roasted grain, flour, starch, and cheaper meals, while the fat so diminished is brought back to the normal amount by the addition of either animal fat or some cheaper vegetable oil. Cocoa powder frequently contains an undue amount of the ground shells ; this can be easily detected by deter- mining the amount of cellulose in the preparation ; in pure cocoa there should be but 3 to 4 per cent, of cellu- lose, while the shells contain 15 to 20 per cent. Cocoa powder, moreover, when pure, should contain 1 to 2 per cent, of theobromine. Canned Articles of Food.-Cases of sickness are occa- sionally reported from the use of canned articles of food, both meats and vegetables. Such articles of food may be- come contaminated in three ways : 1, Through the absorp- tion of metallic salts-as lead, tin, or zinc-from the sub- stance of the metal cans, or more generally from the solder; 2, by improper methods of canning, in which either air enters through carelessness in sealing the cans, or else through improper preparation of the material; and 3, by the use of material already tainted. Practically, examination shows that metallic salts are rarely present in tinned goods, although occasionally cases of poisoning from such cause are reported. At the same time it seems hardly proper to preserve acid fruits or veg- etables in receptacles which may possibly give up poison- ous salts. Undoubtedly of much greater importance is the condition of the material, particularly meats, which is to be canned. That it should be sound and fresh is ob- vious, and that great care should be taken in preparing and sealing is equally plain. If the contents of a can are at all decomposed, it will be manifest from the convex appearance of the head, which will be pushed outward by the pressure of the gas. In cans properly sealed the heads will be slightly concave. It would, moreover, seem the part of wisdom to compel manufacturers of canned goods to stamp the date of preparation upon their cans, in order to prevent the sale of stale goods. Animal Foods.-With meat and fish the examination of the health officer consists mainly in seeing that the ma- terial exposed for sale is fresh, and in no sense of the word putrid. In addition, it is frequently necessary to make an examination of pork for the presence of trichinae ; this is best done by making thin sections of the suspected sam- ple with a razor, so cut that the sections will be parallel with the muscle fibres. A section is picked apart with needles, in a drop of glycerine, on a glass slide, and exam- ined under the microscope, with a magnifying power of 50 to 100, when the trichinae, if present, will be seen in the form of closely coiled spirals. The parasite may be made more plainly visible by treating the section with a drop of caustic potash (one part to fifteen parts of water) by which the muscle fibres are made transparent. If the trichinae are enclosed in capsules, the addition of a drop of acetic acid will dissolve the calcareous envelopes. Water.-Drinking-water as an article of food is a pri- mary necessity, and its purity should be assured if the health of the community is to be preserved. Impure water is the source of many epidemic diseases, and to it is often due the transference of disease from one section of a city to another widely remote. This is not the proper 202 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Food. place, however, to discuss the subject in its entirety, but simply to call attention to what constitutes a pure water for drinking purposes, and to some of the methods for detecting impurities. From a chemical stand-point it is somewhat difficult to decide as to what constitutes a proper drinking-water. That it should not contain much organic matter is obvi- ous, at the same time it is to be remembered that organic matter in itself is not necessarily injurious or at all un- healthy ; for there are many cases recorded in which water containing considerable organic matter has been drunk by whole communities without noticeable injuri- ous effects, while by the use of water, apparently much purer, epidemics have arisen. Evidently it is the charac- ter of the organic matter, more than the quantity, which determines its injurious properties. Furthermore, it is probable that impure water owes its deleterious effects not wholly to the mere presence of organic matter, but also to the presence of various germs, bacteria, special disease germs, etc., which through its medium are taken into the system. The water containing the most organic matter, however, is the best lodging-place for such germs, and the larger the amount of organic matter the more probable becomes the presence of such organisms; while, on the other hand, water which contains less organic mat- ter is correspondingly less liable to contain disease-germs; hence the amount of organic matter in a water may be taken as an indication of its purity or unwholesomeness, and so, by common consent, a water which contains or- ganic matter beyond a certain proportion, is condemned as unsuitable for domestic purposes. Obviously, how- ever, water which contains but the merest trace of organic matter, in the shape of excreta from a cholera patient, is liable to be far more injurious than ten times the amount of vegetable organic matter, and this is doubtless true, even if we assume the absence, in the first case, of a specific sep- tic poison. But in all cases water charged with organic filth, whether it be animal or vegetable, is decidedly dan- gerous to health. Good drinking-waters should not contain organic mat- ter in such proportion as to yield by the ammonia pro- cess more than 0.10 part of albuminoid ammonia, and 0.05 part of free ammonia, per million. Waters yielding more than 0.10 part of albuminoid ammonia per million are to be considered as suspicious, while the presence of organic matter in sufficient quantity to yield over 0.15 part of albuminoid ammonia ought to condemn.a water absolutely (Wanklyn). Very pure waters, such as have been thoroughly filtered, either naturally or artificially, do not yield more than 0.01 to 0.03 part of albuminoid ammonia per million. When a sample of water yields more than 0.08 part of free ammonia, it is probably con- taminated with urine, the urea present having been by fermentation converted into ammonium carbonate. The amount of solid matter in drinking-waters ought not to exceed 35 to 40 grains per United States gallon. Pond and river waters seldom contain more than 3 to 5 grains per gallon, while spring waters, such as flow through limestone, etc., may contain 15 to 30 grains, and this without necessarily being injurious. Excessively hard waters, however, such as contain large amounts of lime and magnesia, are, if possible, to be avoided. The amount of chlorine in a sample of water is sometimes of considerable significance ; thus, in a pond or river water, the presence of considerable organic matter, with 6 to 8 grains of chlorine per gallon, would be considered as sug- gestive of contamination with matter from privy vaults, urine, etc., in which chlorine as sodium chloride is present in large quantity, for river and pond waters, if pure, sel- dom contain more than 1 grain of chlorine per gallon. Near the seaboard, however, well waters and many spring waters will naturally contain 8 or 10 grains of chlorine per gallon, and be quite pure organically. In making an examination of drinking-water the poi- sonous metals should be sought for ; iron should not be present in larger amounts than 0.2 grain per gallon, while zinc, manganese, lead, and copper should be wholly wanting. These metals are occasionally found in waters from mineral districts, or are sometimes introduced acci- dentally, as in the passage of water through a lead pipe, or by the flow of refuse matter from factories into streams which constitute a part of the water supply. Nitrates should also be tested for in making an examination of water, since nitrogenous organic matter is frequently ox- idized by contact with the air and water, and would thus escape detection by the ammonia process. Nitrates, how- ever, cannot always be considered as having their origin in the oxidation of deleterious organic matter, since they also find their way into it from the various geological strata traversed by the water (Wanklyn). In collecting a sample of water for analysis great care should be taken : 1. That the bottle itself, which should hold at least two quarts, be perfectly clean. 2. That the water collected be a fair sample ; if a well water, it should be freshly drawn; if from a pump or faucet, a portion should be allowed to run away, so as to clear the pipe, be- fore filling the bottle ; if from a river, pond, or reservoir, it should be taken from near the middle of the stream or pond, and care should be exercised that scum or other floating matter does not enter the bottle. 3. That the bot- tle be securely stoppered with a clean cork, wrapped with a piece of writing-paper, to prevent any particles falling into the water. 4. That the water be analyzed as soon after its collection as possible. For sanitary purposes it is, as a rule, only necessary to determine the amount of total solids, chlorine, free and albuminoid ammonia, ni- trates, and poisonous metals. This, together with a bac- terioscopic or biological examination, constitutes all that is generally necessary to decide whether a given sample of water is suitable for domestic purposes. The presence of micro-organisms or other suspended particles is best ascertained by allowing a moderately large sample of water to stand quietly for twenty-four hours in a stoppered bottle ; then, after carefully siphon- ing off the upper portions of fluid, the last two or three inches of fluid remaining, together with any sediment present, are poured into a conical-shaped vessel, provided with a ground glass cover, where it is allowed to stand until all the sediment has settled into the conical bottom. A drop of this sediment can then be withdrawn by a clean pipette for microscopical examination. Any organisms, germs, spores, or bacilli present, can be further studied by cultivating them in a properly prepared and sterilized gelatine-peptone mixture, either in a suitable reagent glass or on a glass plate.16 With a pure culture so obtained in- oculation experiments can be tried. Total solids are best determined by evaporating 58.37 c.c. (a miniature United States gallon) of the water in a weighed platinum dish on a water-bath, and finally drying for a short time in an air- bath at 100° C. Every milligram of residue so obtained corresponds to one grain of solid matter in a United States gallon. Chlorine is determined in a like quantity of water by means of a standard solution of silver nitrate, with a few drops of potassium chromate as an indicator. The or- ganic matter is most satisfactorily estimated by the ammo- nia process, or by the moist combustion process of Wank- lyn, for the details of which reference must be made to the proper chemical books.11 Wines.-Wine considered as the fermented juice of the grape consists essentially of an aqueous solution of alco- hol (formed in the fermentation of the grape sugar), tar- taric acid, traces of ether-like bodies which give to the wine its bouquet, a little albumin, gums, sugar, glyce- rine, tannin, coloring matters, and inorganic salts, as phos- phates, chlorides of calcium, potassium, etc. The several constituents, combined in various proportions, make up the different varieties of wines produced throughout the world. With variations in climatic influence, in the extent of the fermentation, in the age of the wine, etc., products are obtained in all degrees of excellence. The increased consumption of wine, the fact that the de- mand for particular grades or brands far exceeds the production, and the progress of chemistry in devising new methods for artificial production has naturally led to wide- spread manufacture of artificial products. Unfortunate- ly, too, so closely does the artificial approach the real in composition, and even in aroma, that it is extremely diffi- cult to detect a skilful deception. Where a chemist is 203 Food. Food. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. personally acquainted with the vintage of a certain year, and is familiar with the composition of the wine, he can naturally detect a false product with a reasonable degree of certainty. But with the great bulk of common wines to be found in the market, falsification is extremely diffi- cult of detection.18 Furthermore, it is well understood that many kinds of wine actually produced from the grape, such as port, sherry, and champagne, contain many added substances aside from the fermented grape juice. Thus the two for- mer are almost invariably fortified (generally with cheap brandy), and as a result contain 18 to 25 vol. per cent, of alcohol, of which fully one-third is added alcohol. Again, wines, particularly those which are produced in Southern France, are extensively plastered. This is ac- complished by adding to the grape juice a certain quan- tity of gypsum (calcium sulphate), which by the fermenta- tion of the juice is dissolved and in part decomposed. The object accomplished by this addition is a precipitation of certain organic matter, by which the wine is rendered clear and less liable to become turbid by age. While this may be desirable, there are, however, decided objections to the practice. The acid potassium tartrate of the grape juice decomposes the calcium sulphate, forming an insoluble calcium tartrate which settles out, and a soluble potas- sium sulphate which ultimately is further changed into the acid potassium sulphate ; hence plastered wines con- tain little if any tartrates, but instead, frequently as much as seven grams of acid potassium sulphate per litre. Natural wines at the most do not contain over one gram of neutral potassium sulphate per litre. Such plastered wines must necessarily be very unhealthy. Again, sugar is frequently added to the must, particularly when the grapes are of poorer quality ; in this manner the amount of alcohol is increased, and by judicious adding of water the ultimate percentages of acid and alcohol are made to correspond with that of wine from the more favored grapes of other years. Glycerine is sometimes added to thin wines to give body and to aid in its preservation. In examining a sample of wine the amount of alcohol should be determined. This is best done by the distilla- tion of one hundred cubic centimetres, and then ascertain- ing the specific gravity at 15° C. of the distillate made up to the original volume. Total acidity, calculated as tartaric acid, should be determined by titration with a normal so- lution of sodium hydroxide. The finest grades of wine contain 0.45 to 0.50 per cent, of acid. The extractive matters are determined by evaporating fifty cubic centi- metres of wine in a weighed platinum dish on a water- bath, allowing to cool over sulphuric acid, and then weighing the residue. This determination is frequently of considerable importance in showing whether the wine has been diluted. The extractives are composed mainly of sugar, albumin, inorganic substances, glycerine, and acids (non-volatile). The pure white wines contain gen- erally fifteen to twenty grams per litre, the red wines twenty-five to thirty grams, while the sweet wines, owing to the large amount of sugar present, yield from thirty to one hundred grams of extractives per litre (Dietzsch). Professor Nessler, from a large number of analyses consid- ers that ordinary white wines must contain at least 1 per cent, (average 1.28 per cent.) of extractive matters, aside from the acids present, in order to be considered as pure unadulterated wine, while red wine must contain at least 1.2 per cent. Naturally, plastered wines, even when di- luted, will contain an excess of extractives, but in such a case examination of the residue will reveal the presence of an excess of potassium sulphate. Natural wines should not contain over 0.04 per cent, of sulphuric acid (SO3) (Fresenius). Nessler, however, considers that 0.06 per cent, may occasionally be present, but never more. Next in importance comes the coloring matters of wine. A large number of extracts are used to impart a desired color to wines deficient in natural color, or to the manu- factured products, the majority of which, however, are perfectly harmless. Thus, cochineal, the juice of huckle- berries, cherries, etc., are freely used, More serious, however, is the use of fuchsine or magenta. The natural coloring matters of wine will not dye wool without a mordant, hence if wool dipped in wine assumes a pink or red color, fuchsine may be suspected, though cochineal will also give the same color. Salicylic acid is some- times added to wine, as well as to beer and other fluids, on account of its preservative properties. Beer.-Beer is to be examined in much the same man- ner as wine. Particular attention, however, is to be paid to the presence of bitter principles, which are frequently added to increase the bitter of the hops. Some are quite harmless ; others, such as quassia, aloes, picrotoxin, and picric acid, are more dangerous adulterants, and probably are but seldom used. Whiskey, Brandy, and Bum.-Saccharine or amylaceous substances, as corn, wheat, or potatoes, yield, after com- plete fermentation and distillation, a mixture of alcohol and water,with which is mixed a little ethereal oil, com- monly called fusel-oil. This latter, by proper rectifica- tion and treatment with bone-black, can be wholly re- moved. It constitutes, however, the most deleterious contamination of whiskey.19 Brandy, when pure, is sim- ply alcohol distilled from wine, with flavor and color acquired by age and contact with the wood of the cask. As ordinarily manufactured, however, it is simply alco- hol, colored with caramel, and flavored with cognac and a little syrup. Traces of free acid are to be found in brandy, but a good sample should not contain over 0.3 to 0.6 gram per litre. Fusel-oil, in either brandy or whis- key, is best detected by adding a few drops of potassium hydroxide to a little of the sample, evaporating to dryness, and adding a drop or two of concentrated sulphuric acid to the residue. The characteristic odor will then be ap- parent if any oil is present. Pure rum (Jamaica) contains, on an average, sixty-nine per cent, of alcohol, and from 0.5 to 4.0 per cent, of ex- tractive matters. Artificial rum is manufactured by mix- ing together dilute spirits, sugar, caramel, a little "rum ether," and other substances, to which is also added more or less genuine rum. By the addition of concen- trated sulphuric acid (3-4 c.c. acid to 10 c.c. rum) arti- ficial rum, manufactured as above, will lose its aroma in a short time, while in the case of genuine rum the aroma will remain for at least twenty-four hours (Dietzsch). Bibliogbaphy. Report of the National Board of Health, 1879. Edward R. Squibb : Proposed Legislation on the Adulteration of Food and Medicine. Reprint from Transactions of the Medical Society of the State of .New York for 1879. Statutes of Massachusetts relative to the Adulteration of Food and Drugs, 1884. Laws of Michigan relating to the Public Health, 1884. A. W. Blyth : Foods ; Composition and Analysis. 1882. Arthur Hill Hassall: Food ; its Adulterations and the Methods for their Detection. 1876. Report No. 199, Forty-sixth Congress, Third Session, House of Represen- tatives, Evidence by George T. Angell, Esq. Second Annual Report of the State Board of Health of New York, 1882. Fifth Annual Report of the State Board of Health. Lunacy, and Charity of Massachusetts, containing the First Annual Report on the Adultera- tion of Food and Drugs. Fifth Annual Report of the Connecticut State Board of Health, 1882; also for 1884. S. P. Sharples: Adulteration of Food, in vol. ii. of Hygiene and Public Health, Buck. Alfred H. Allen : Commercial Organic Analysis, vol. i. 1885. Report on Glucose, prepared by the National Academy of Sciences, 1884. Dr. Otto Dammar : Illustriertes Lexicon der Verfalschungen und Verun- reinigungen der Nahrungs- und Genussmittel. Lieferungen 1-3. 1885. H. Letheby : On Food, etc. 1872. F. W. Pavy : Food and Dietetics. 1874. Oscar Dietzsch: Die wichtigsten Nahrungsmittel und Getriinke, deren Verunreinigungen und Verfiilschungen. 1884. Edward Smith : Foods. 1873. Hermann Hager : Handbuch der Untersuchung, Prufung und Werth- bestimmung aller Handelswaaren, Lebensmittel, etc. 1871. Wanklyn : Milk Analysis; Bread Analysis ; Tea, Coffee, and Cocoa; Water Analysis. Thudichum and Dupre: Treatise upon the Origin, Nature, and Varieties, of Wine. A. Naquet : Legal Chemistry. C. B. Fox : Sanitary Examinations of Water, Air, and Food. 1878. Ii. IL Chittenden. 1 Compare Blyth, Legislation on the Adulteration of Food, p. 18, and 46, and Composition and Analysis of Foods. 2 Reiwrt No. 199, Forty-sixth Congress, Third Session, House of Rep- resentatives, Evidence collected by George T. Angell, Esq. 3 Second Annual Report of the State Board of Health, Report on the Adulteration of Food and Drugs. 4 FifSt Annual Report of the Work done in Compliance with the Stat- 204 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Food. tites of 1882 and 1883, relative to the Adulteration x>f Food and Drugs, in the Fifth Annual Report of the State Board of Health, Lunacy, and Char- ity of Massachusetts. 6 For the influence of alum on the digestive processes, see Bikfalvi, in Centralbl. med. Wissenschaften. 1886, p. 102. • Report on Glucose, prepared by the National Academy of Sciences, 1884. 7 See Albert L. Colby, New York State Board of Health Report, 18S2. 8 Second Annual Report of New York State Board of Health, p. 534. 8 See G. C. Caldwell, in Second Annual Report New York State Board of Health, p. 540 ; also Oscar Dietzsch : Die wichtigsten Nahrungsmittel und Getranke, p. 274. 10 See Blyth : Foods, Composition and Analysis, p. 260. 11 S. P. Sharples: Hygiene and Public Health, Buck, vol. ii., p. 366. 13 See Soxhlet's apparatus. Oscar Dietzsch : Nahrungsmittel und Ge- tranke, deren Verunreinigungen und Verfalschungen, p. 16. 13 See Caldwell and Parr, Amer. Chem. Journal, vol. vii., p. 238. 14 Loc. cit., p. 260. 15 See Squibb's Ephemeris of Materia Medica, etc., pp. 606, 637 ; also, Wanklyn : Tea, Coffee, and Cocoa. 18 See Otto Dammer's Lexikon der Verfalschungen. pp. 76-79. 1885. 17 See especially Wanklyn : Water Analysis; and J. W. Mallet, in Amer. Chem. Journal, vol. iv. 18 For all the details of wine analysis, see Thudichum and Dupr^ : A Treatise upon the Origin, Nature, and Varieties of Wines. 18 For the results of an examination of American whiskeys, see Clifford Richardson in Amer. Chem. Journal, vol. vii., p. 425. 1886. offence the offender's name and place of business could be published in addition to the fine. The Act was permis- sive as to the appointment of analysts, and was never satisfactorily enforced. In 1869, and again in 1871, bills were introduced in Parliament to improve the law, but failed to pass. In 1872, however, an Act was passed which obliged the local boards to appoint analysts and provided for inspectors. The penalty for adulterating articles of food was fixed at twenty pounds for a first offence, and for a second the name and residence of the delinquent could be published in a newspaper. The punishment for adulterating drugs was made fifty pounds for a first offence, and for a second imprisonment not ex- ceeding six months. Between the years 1860 and 1874 there were various attempts to enforce this law, but with- out noticeable success, owing to the lack of recognized standards of purity, the disagreement of analysts, and the varying decisions of magistrates in regard to the meaning of the term adulteration. In 1874 a new Parliamentary investigation was started, and more scientific examination made of the whole subject of adulteration than had been secured before. The report of this committee was reas- suring, and was to the general'effect that the public was more cheated than poisoned by the adulterations gener- ally practised. In 1875 a carefully digested measure was passed by Parliament (38 and 39 Vic., c. 63), and with the amendments of 1878 and 1879 is now the law for Great Britain. The principal provisions of the law are as follows : First. No person shall mix, color, stain, or powder any article of food with any ingredient or material injurious to health, with intent that the same shall be sold in that state, and no person shall sell any such article under a penalty not to exceed £50 for the first offence, and every offence after a conviction shall be a misdemeanor, to be punished by imprisonment not to exceed six months. Second. No person shall mix, color, stain, or powder any drug so as to affect injuriously the quality or potency of such drug, with the same penalties as provided in the case of food. Proprietary medicines and patented arti- cles are excepted, as are also substances which are added merely to make the compound fit for carriage or con- sumption, and are not injurious to health. Third. A person is not guilty, under the Act, who proves that he did not know of the adulteration, and could not have obtained such knowledge with reasonable diligence. Fourth. Mixtures containing articles not injurious to health, and not intended fraudulently to increase the bulk or weight, can be sold, if labels are affixed plainly stating that the substance is a mixture. Fifth. Analysts are to be appointed, and any medical officer or private person can bring articles to be analyzed. The seller is to be informed that the article is purchased for analysis, and it is to be divided into three parts, one of which is to be kept by the seller if he desires, one given to the analyst, and one kept by the purchaser. A penalty of £10 is imposed for a refusal to sell. Sixth. The seller cannot be convicted if the article sold is in the same state as when purchased by him, and he has a warranty from the manufacturer. Seventh. A person forging a warranty is liable to two years' imprisonment. A false warranty makes the giver liable to a penalty of £20, and the same penalty is im- posed for applying a warranty to a wrong article. Eighth. A person upon whom a fine is imposed can re- cover the amount with costs from the person from whom he bought the adulterated article, if it was sold to him as of the quality for which he sold it to the last purchaser, and that he did not know it to be otherwise. The result of this law, so far as concerns the articles analyzed, shows that, in 1881 and 1882, there were 32,708 different samples examined, and of these 5,418 were found to be adulterated. In addition to the general acts referred to. there have been frequent statutes passed in regard to sophistications of special articles. Adulterations of coffee were prohibited by acts passed in 1725, 1803, and 1822. Since the latter date there have FOOD AND DRUGS, ADULTERATION OF, LEGIS- LATION CONCERNING. Almost all civilized countries have found it necessary, in recent times, to frame laws bearing on the general subject of adulteration or on special instances of the evil, and these laws are of widely different degrees of rigor, and have had varying success in prac- tice. In England the earliest notice taken of adulteration was in reference to bread, and in 1203, in the reign of John, a royal proclamation was made throughout the kingdom enforcing the purity of this staple article. In the year 1267, in the reign of Henry III., a statute was passed styled the Pillory and Tumbrel, in order to prevent bakers, vintners, brewers, butchers, and others from injuriously adulterating or weakening their wares. This is the first statute expressly prohibiting the adultera- tion of human food, and was in operation until the year 1710, when it was repealed and another took its place. Liber Albus states that it was well enforced in the reign of Edward I. (1272 to 1307), and gives the following as the punishment for a baker selling unwholesome bread: "If any default shall be found in the bread of a baker in the city, the first time let him be drawn upon a hurdle from the Guildhall to his own house, through the great street where there be most people assembled, and through the great streets which are most dirty, with the faulty loaf hanging from his neck ; if a second time he shall be found committing the same offence, let him be drawn from the Guildhall through the great street of Cheepe in the manner aforesaid to the pillory, and let him be put upon the pillory and remain there at least one hour in the day ; and the third time that such default shall be found he shall be drawn, and the oven shall be pulled down, and the baker made to forswear the trade in the city forever." The bakers were not the only persons affected by the severity shown to sophistications in commodities intended for human use ; grocers, vintners, butchers, and others were liable to the same penalties. For a considerable period, about the time of the enact- ment of this law, the large companies or guilds had regu- lations governing minutely all commercial transactions, and from the power they had over the individual crafts- men a good standard of purity was secured, and statutes were, to some degree, rendered unnecessary. Adultera- tion was not a noticeable characteristic of commercial products or of human food until quite modern times, when middlemen came to be a recognized factor in busi- ness dealings, and the demand for food products increased to such a degree that adulteration opened up new channels for pecuniary profit. Between 1851 and 1854 there was quite an agitation on the subject in The Lancet, resulting in a Parliamentary inquiry. Upon the report of the com- mittee of investigation the first general English law was enacted, known as the Adulteration of Food Act of 1860. This Act authorized the appointment of analysts by local boards, and made five pounds the penalty for selling an adulterated article, knowing it to be such. For a second 205 Food. Food. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. been various Treasury regulations, the result of which was largely to permit the mixture of chicory and other ingredients with pure coffee, and in some cases an entire substitution of the imitations. Adulterations of tea were prohibited by an act passed in 1725, and other acts were passed in 1731, 1773, and 1824. Wines, liquors, ale, and beer have been the subject of frequent statutes from the earliest times. In the reign of Edward III. the Vintners Company was incorporated under the title of the " Wine Tonners," and power was given to examine wines and liquor offered for sale, and to confiscate any adulterated samples. They could also place the sellers in the pillory. The assize in regard to beer and ale is of early date, as has been stated, and in 1266 was well established. Liber Albus contains minute directions about the proper way for the brewers to carry on their business, and officers called " ale conners " were elected to see that everything was done as directed. These officers are still elected in London, but their duties are performed by the Excise. In the time of Queen Anne, cocculus indicus was forbid- den to be used in brewing beer, and further legislation was passed in 1816, 1830, and 1863. The Licensing Act of 1872 is the present law on the subject, and the penal- ties imposed are £20 for the first offence, and £100 for the second. Tobacco and snuff adulterations are men- tioned only in the more recent Parliamentary acts. The laws on the subject were passed in 1843, 1862, and 1868. The adulteration of seeds used in agriculture, has been found to be a serious injury to the farmers of Great Brit- ain, and by the act of 1869, the killing or dyeing of seeds is punished by a fine of £5 for the first offence, and £50 for the second, together with the publication of the of- fender's name at the discretion of the justice. The adul- teration of drugs is prohibited and punished by the gen- eral acts of 1860, 1872, and 1875, but there have been a number of special acts relating to the subject. In the city of London, by laws passed in the reigns of Henry VIII. and Queen Mary, power was given to the College of Physicians to search for defective or corrupted drugs and medicines, and to punish the offenders by imprison- ment and fines not to exceed £20. This power still be- longs to the College of Physicians, but has not been re- cently exercised. The Pharmaceutical Society of Great Britain, founded in 1841, has been very active and influ- ential in securing the passage of the recent laws relating to drugs and their enforcement. In France, as early as the year 1396, there was an or- dinance of the city of Paris forbidding the coloring of butter with herbs, flowers, or drugs, and there were laws, dating from about the same time, regulating the purity of bread, wine, and other food products. In France, at the present time, there is a law establishing laboratories in the principal cities for the analysis of articles bought by private persons, or secured by duly appointed inspectors, who have power to punish offenders. The officials provided for the laboratory work and the inspec- tion of the markets and stores are a director, inspectors, and chemists. In connection with the laboratories there are elaborate photographic apparatus provided, so that juries can judge by ocular demonstration of many forms of adulteration. In 1881 there were 6,517 samples exam- ined in the laboratories, and the percentage of adultera- tions was 50.43. In Germany there were enacted at a very early date laws inflicting severe penalties for selling adulterated bread, drugs, or wine. The statutes now in force were passed quite recently-one in 1872, regulating the sale of drugs, and another in 1879, relating to food. By the law of 1872, the German Pharmacopoeia was made the stand- ard of purity. In 1878 there were 231,478 samples of food, drink, drugs, etc., examined, and there were 3,352 convictions for violations of the law. The penalties are fines or imprisonment, and it is not necessary to prove that the seller was aware of the adulteration. In this country most of the States have laws prohibit- ing adulteration in general, or special forms of it, and many of the larger cities have, in addition, municipal reg- ulations to prevent the sale of harmful products. In some of the States, public sentiment has not been aroused so as to secure a thorough enforcement of the laws, or else adequate appropriations have not been made for the proper performance of the preliminary work of analysis. As a result, the effects accomplished by legal methods have not been as entirely satisfactory as could be desired. The condition of affairs is, however, steadily improving, the people are coming to see the great need for rigorous enforcement of the laws, and experience has shown in what directions the legislation already had has proved defective. Congress has passed no general law concerning adulter- ation of food and drugs, and such would not be greatly needed, except as regards the importation of adulterated articles, if all the separate States had adequate laws on the subject. A bill prepared under the auspices of the National Board of Trade was presented to Congress in 1880, but it has not yet been made a law. As early as 1848, Congress passed an act to prevent the importation of adulterated and inferior drugs and chemicals, and exam- iners were appointed. This law seems to have been much needed, for at New York alone, in nine years from 1848 to 1857, over 900,000 pounds of adulterated drugs were seized. For some time past the law does not seem to have been enforced, and the examiners have not made reports to the Treasury Department. No rules have been adopted to secure the systematic prosecution of the work. Soon after the passage of the English Adulteration Act of 1875, a general agitation on the subject was started in this country, and legislation soon resulted. The way for this had largely been paved by the previous examination of adulterations of food by the State Boards of Health of some of the States, such as Massachusetts and Michigan. The lead in this agitation was taken by the Sanitary Engineer, a paper published in New York City, and through its efforts three prizes were offered for the best essays on the general subject of adulteration of food, accompanied by drafts of a law. This competition was established in 1879, and in October, 1880, a report was made by a committee consisting of Dr. John S. Billings, U. S. A.; ex-chancellor Williamson, of New Jersey; Prof. Charles F. Chandler, of New York, and A. H. Hardy, Esq., of Boston, awarding the first prize to George W. Wigner, of London, one of the English public analysts. The law framed by the committee was submitted to the legislatures in several of the States, and in its material parts became a law in New York and New Jersey in 1881, and in Massachusetts in 1882. The committee, in making their report, stated that the investigation showed that the adulterations practised were not so injurious to health as had been claimed, and that legislation was needed more for commercial than sanitary reasons. As the law is substantially the same in the great States of New York, Massachusetts, and New Jersey, and it is likely to prove a model for many other States, the principal provisions of the New York law may be of in- terest. Section 1 is as follows : " No person shall within this State manufacture, have, offer for sale, or sell any article of food or drugs which is adulterated within themeaning of this Act, and any person violating this provision shall be deemed guilty of a misdemeanor, and upon conviction thereof shall be punished by fine not exceeding fifty dol- lars for the first offence, and not exceeding one hundred dollars for each subsequent offence. " Sec. 2. The term ' food ' as used in this Act shall include every article used for food or drink by man. The term ' drug ' as used in this Act shall include all medicines for internal or external use. " Sec. 3. An article shall be deemed to be adulterated within the meaning of this Act- " (a) In the case of drugs : " 1. If, when sold under or by a name recognized in the United States Pharmacopoeia, it differs from the standard of strength, quality, or purity laid down therein. " 2. If, when sold under or by a name not recognized in the United States Pharmacopoeia, but which is found in some other pharmacopoeia or other standard work on 206 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Food. Materia Medica, it differs materially from the standard of strength, quality, or purity laid down in such work. "3. If its strength or purity fall below the professed standard under which it is sold. " (6) In case of food or drink : " 1. If any substance or substances has or have been mixed with it so as to reduce, or lower, or injuriously af- fect its quality or strength. "2. If any inferior or cheaper substance or substances have been substituted wholly or in part for the article. "3. If any valuable constituent of the article has been wholly or in part abstracted. " 4. If it be an imitation of, or be sold under the name of, another article. "5. If it consists wholly or in part of a deceased, or de- composed, or putrid, or rotten animal or vegetable sub- stance, whether manufactured or not, or in the case of milk, if it is the product of a diseased animal. "6. If it be colored, or coated, or polished, or powdered, whereby damage is concealed or it is made to appear bet- ter than it really is, or of a greater value. "7. If it contains any added poisonous ingredient, or any ingredient which may render such article injurious to the health of a person consuming it: Provided that the State Board of Health may, with the approval of the Gov- ernor, from time to time, declare certain articles or prep- arations to be exempt from the provisions of this Act, and provided, further, that the provisions of this Act shall not apply to mixtures or compounds recognized as ordinary articles of food, provided the same are not inju- rious to health, and that the articles are distinctly labelled as a mixture, stating the components of the mixture. ' ' Sec. 4. It shall be the duty of the State Board of Health to prepare and publish, from time to time, lists of the articles, mixtures, or compounds declared to be exempt from the provisions of this Act, in accordance with the preceding section. " The State Board of Health shall also from time to time fix the limits of variability permissible in any article of food, or drug, or compound, the standard of which is not established by any national pharmacopoeia. " Other sections of the law provide for the appointment of public analysts, the adoption of rules for the examina- tion of samples of food and drugs, requiring every per- son selling such articles to furnish them to the analysts, under a penalty of $50 for the first offence, and $100 for the second, and declaring that any person hindering or preventing an analyst or inspector from doing his duty is guilty of a misdemeanor. This law was amended in 1885 so as to permit the action for violation of its provisions to be brought in the name of the people on the complaint of any citizen, and one-half of the recovery was directed to go to the prose- cutor and one-half to the county. The Board of Health was also directed to secure samples once each year of all spirituous, malt, or fermented liquors manufactured in the State, and analyze them for adultera- tions. The punishment for refusing to furnish such samples was made a misdemeanor, and, in all cases of violation of the law, the Board of Health was directed to notify the district attorneys in the various counties, so as to secure prompt punishment. This law has resulted, according to the Report of the State Board of Health, made in 1884, in securing the analyses of a large number of articles suspected of being adulterated. The enforcement of the law in the courts has not been as satisfactory as might be desired, owing mainly to a lack of funds sufficient to enable the Board to take an aggressive attitude. There has been a decision in one of the inferior courts, to the effect that a guilty knowledge on the part of the seller must be proved in order to secure a conviction. This decision was not con- sidered of sufficient importance to be appealed from, and has not affected other prosecutions. There were eight convictions under the act in 1883. The Legislature, in 1884, passed a law' prohibiting the manufacture or sale of oleomargarine, the previous laws for its regulation not having proved effective. A State Dairy Commissioner was appointed to enforce the law, and according to his report to the Legislature, made in January, 1885, about eighty per cent, of the traffic has been broken up. Sixty arrests have been made, forty persons are now under in- dictment, eleven convictions have been secured, and four persons have been discharged. The sections of the law of 1884 which prohibited the manufacture and sale of oleomargarine have recently been declared unconstitutional by the Court of Appeals, on the ground that oleomargarine was not necessarily injurious to health, if manufactured from pure materials in a cleanly manner, and that, consequently, the entire manu- facture could not be absolutely prohibited. This decision has had the effect of increasing the sales of oleomargarine until, now, for export purposes at least, they equal those of genuine butter. The law still prohibits the sale of oleomargarine under the name of butter, and the work of the legal prosecutors will hereafter have to be mainly directed toward detect- ing and punishing offences of this kind. In Massachusetts the law required two-fifths of the ap- propriation ($10,000) to be applied to the enforcement of the laws for preventing milk adulteration, and sufficient time has not yet elapsed to show how the law practically works. A large part of 1882 and 1883 was spent chiefly in making analyses of articles collected throughout the State. Some fourteen hundred in all were analyzed, in- cluding 300 samples of milk. The percentage of adultera- tion in milk was found to be seventy-eight per cent.; in articles of food, forty-seven ; and in drugs, forty. Seven- teen prosecutions were instituted by the Board of Health, one of which was withdrawn owing to the death of the de- fendant. In all the others adulteration was satisfactorily proved, but in two the defendants escaped conviction on technical grounds. In fourteen, convictions were secured. In 1884 there were 2,644 analyses made by the four anal- ysts employed, and there were fifty prosecutions for vio- lation of the law. Almost all of these prosecutions were ended by the conviction of the offenders. As a result there has been a decided improvement in the quality of food offered for sale, and in the case of milk the change is very noticeable. As the States of New York, Massachusetts, and New Jersey have essentially the same law, further reference need not be made to them. In the other States legislation is more or less advanced, and the following resume may be of interest: In Alabama the penalty for selling unwholesome bread is a fine of not less than $20, and not more than $200, with imprisonment for a period not to exceed six months. Adulterating sugar, syrup, or molasses, or selling such adulterations, is punished by the same penalties. " Adul- terating liquors with poisonous or unwholesome sub- stances is punishable by a fine not to exceed $500, and imprisonment for twelve months. In Arkansas there is no legislation. In California there is a general law pro- hibiting the adulteration of food, drugs, and liquors, under a penalty of six months, imprisonment and $500 fine. Selling oleomargarine, without branding or mark- ing it as such, is punished by a maximum fine of $200, or imprisonment for not less than fifty days, and not more than two hundred days, or both fine and imprisonment. In Colorado there is no legislation. In Delaware there is no general law, but the sale of oleomargarine without a proper label makes the seller liable to a fine of $50, half of which goes to the informer. In Connecticut adulteration is punished by a fine of $500, or imprisonment for one year. Boards of Health or medical officers may send suspected articles to the State chemist for analysis. If adulterated, the cost is to be paid by the seller; if pure, by the person or body causing the analysis to be made. Adulterating milk is punished by a fine of $25. Selling skimmed milk, without a proper label, is punished by a fine of $7, or imprisonment for thirty days, or both. Selling oleomargarine is pun- ished by the same penalties, and the person or firm sell- ing it must expose a sign stating the fact in letters four inches high. In Florida the penalty for selling articles of food adulterated with substances injurious to health is 207 Food. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a fine of $300 and imprisonment for one year. The pen- alty for adulterating drugs is a tine of $400, or imprison- ment for one year ; for adulterating liquors it is impris- onment for three years. Any person who knowingly sells oleomargarine for butter is liable to a fine of $100, or imprisonment for thirty days, or both. Hotel and boarding-house keepers must give notice of the use of oleomargarine, under the same penalty. In Georgia the law differs from that of other States in allowing the sale of adulterated articles if a correct analysis is attached, and notice is given that they are adulterated. Oleomargarine cannot be sold without marking it so as to be easily noticed, and giving notice to the purchaser. Hotels, restaurants, and houses of public entertainment cannot furnish guests with oleomargarine without first posting, in conspicuous places in dining and private rooms, the words, '' This house uses oleomargarine," and print- ing the same on the bill of fare. The maximum penalty is $1,000 fine, six months' imprisonment, or twelve months' work in chain-gang, and more than one of these penalties may be inflicted at the discretion of the judge. In Illinois the penalty for adulterating food and drugs and selling the same, or oleomargarine as butter, is not less than $25, and not more than $200 for the first offence; not less than $100, nor more than $200 for second of- fence, with imprisonment not to exceed six months. For subsequent offences the maximum penalty is $2,000 fine and five years' imprisonment. There can be no conviction if the person did not know he was violating the act, and could not with reasonable diligence have ob- tained such knowledge. In Indiana the maximum penalty for selling adulter- ated or diluted milk is $500, that for adulterating liquors is $100 ; but if poisonous ingredients are used it is seven years' imprisonment. Oleomargarine must be labelled in large letters upon the packages, under a penalty of $50. In Iowa no person can mix, color, stain, or powder any article of food, or drink, or any drug with a material in- jurious to health, and the same cannot be done with a harmless substance unless the mixture is sold under its true name, and notice given to the purchaser. Skimmed milk must be branded. Oleomargarine cannot be sold without a proper label and notice to the purchaser. The highest penalty for a first offence is $50 fine, and for a second $100, or imprisonment for thirty days; and for subsequent offences $500, or imprisonment for five years. In Kansas adulterating food, drink, or drugs is pun- ished by a fine not to exceed $300, or imprisonment not to exceed one year, and the articles are to be destroyed. Adulterations of milk are punished by a fine not to ex- ceed $100, and whoever is injured by such adulterations can collect twice the amount of the damage. In Kentucky the highest penalty for adulterating food, drink, or medicine is a fine of $500, or imprisonment for one year, or both. The use of cocculus indicus, or other injurious drug, in liquors is punished by a fine from $20 to $500 for each gallon of liquor adulterated. In Louisiana there is no legislation. In Maine a stringent general law against adulteration, enacted in 1883, makes the penalty not to exceed $1,000, or imprisonment for five years. Adulterated or diluted milk is punished by a fine of $20 for the first offence, and $50 for subsequent offences. Oleomargarine and imita- tion cheese must be distinctly labelled, under a penalty of $100 for the first offence, and $200 for subsequent of- fences. A general law against adulterations of articles of food and drink was adopted in 1883, with a penalty of a fine not to exceed $1,000, or imprisonment for five years. Adulterating sugar or molasses is punished by a maximum fine of $500, or imprisonment for one year. Oleomarga- rine must be conspicuously labelled, under a penalty for its sale of $100 for the first offence, and $200 for subse- quent offences. In Maryland there is no general law against adultera- tions. Selling oleomargarine for butter makes the offender liable to a fine of $100, one-half of which goes to the in- former. In Michigan a general law was adopted in 1881, framed somewhat after the English law of 1875. By it any per- son mixing, coloring, staining, or powdering articles of food, drink, or medicine with articles injurious to health ; or selling a mixture, whether made of substances harm- ful or not, without giving notice to purchaser ; or mixing glucose or grape-sugar with syrup, honey, or sugar ; or selling oleomargarine without a proper label and giving notice, is liable to a penalty of $50, or imprisonment for three months. In Minnesota any person fraudulently adulterating any article of food or drink with substances injurious to health, or knowingly selling the same, is liable to a maxi- mum fine of $200 and imprisonment for one year. Adulterating drugs is punished by a fine of $300, or imprisonment for one year. Adulterating or diluting milk is punished by a maxi- mum fine of $100 and thirty days' imprisonment. Oleo- margarine must be plainly marked, and the sale of it for butter is a misdemeanor punished by a maximum penalty of $100 fine and ninety days' imprisonment. Offering oleomargarine for sale is prima facie evidence of knowl- edge. In Mississippi inspectors of flour and other provisions are appointed, and unwholesome or damaged articles are forfeited to the State. Adulterating liquor is punished by a maximum penalty of five years' imprisonment. Oleomargarine must be stamped before sale, and any person selling it without paying a privilege tax of $50, is liable to a maximum fine of $100; In Missouri the adulteration of food, drink, or drugs is made a misdemeanor, and the highest penalty is a fine of $500, or imprisonment for one year, or both. The same penalty is imposed for selling oleomargarine. The adul- teration of liquors with poisonous ingredients is a felony, and makes the offender liable to imprisonment for five years. In Nebraska there is no legislation relating to articles of food, but adulterating liquors, or selling the same, is punished by a fine of $100, or three months' imprison- ment, or both. The manufacture or sale of oleomargarine, without dis- tinctly marking it, is punished by a fine of $100 for each offence. In New Hampshire the penalty for adulterating food is a fine of $300, or imprisonment for one year. For adul- terating milk it is $50 for each offence. For adulterating liquor it is a fine of $1,000, or imprisonmeni for one year. Selling oleomargarine for butter is punished by a fine of $50 for the first offence, and $100 for subsequent offences, one-half of which is to go to the complainant. In Ohio adulterating liquors is punished by a maxi- mum penalty of $100, or imprisonment for sixty days, or both. Selling oleomargarine for pure butter is punished by a maximum fine of $300, or imprisonment for ninety days, or both. The mixing of the oleaginous portions of a horse, hog, or dog with butter of a misdemeanor, and may be punished by a fine of $500, or imprisonment for one hundred days, or both. In Pennsylvania adulterating, or selling articles so adul- terated, of food, drink, or medicine, is a misdemeanor, and the offender may be fined $100, imprisoned for six months, or punished in both ways. Adulterating milk is punished by a fine of $10, or imprisonment for not less than eight days, or until the fine is paid. The selling of adulterated milk is punished by a fine of $20, or impris- onment for not less than fifteen days, or until the fine is paid. Selling milk purporting to come from a different locality from what it really does, is punished by a fine of $50, or imprisonment for thirty days, or both. In Rhode Island adulterating food or liquors is pun- ished by a maximum fine of $200, or imprisonment for six months. The sale of adulterated liquors is punished by a fine of $300, or imprisonment for six months. No person not a registered pharmacist can keep open shop, and such person is liable for first conviction to a fine of 208 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Food. Foot. $50, and $100 for second conviction. The adulteration of drugs, or sale of the same, makes the offender, in addi- tion to the above penalties, liable to a forfeiture of right to be a pharmacist. Selling oleomargarine without the proper mark is pun- ished by a tine of $100, one-half of which goes to the complainant. South Carolina has no legislation on the subject. In Texas a law was passed in 1883, largely modelled after the New York law, but requiring knowledge of adulteration to be proved against the offender. The max- imum penalty is a fine of $500. In Vermont the maximum penalty for adulteration of articles of food or drink is a fine of $300, or imprison- ment for two years, and the articles are to be destroyed. The adulteration of drugs is punished by a fine of $400, or imprisonment for two years. The sale of oleomarga- rine without proper labels is punished by a fine of $200. In Virginia the adulteration of anything intended for food or drink, or of any drug, is punished by a maximum penalty of $500 fine and one year's imprisonment, and articles are to be destroyed. The penalties in West Vir- ginia are the same as in Virginia. In Wisconsin the law is modelled largely after the Eng- lish act of 1875, and was passed in 1879. The penalty is fixed at $50 for the first offence, and imprisonment not to exceed one year for the second offence. The law contains a provision that any person putting up food, drugs, or liquors with labels intended to mislead as to name or quality, is liable to a fine of $500 for the first offence, and for the subsequent offences imprisonment from one year to ten years. Articles purchased for analysis are to be divided into two portions by the town or city clerk, one to be sent to the State analyst, and one to be retained by the clerk, subject to the order of the court. Refusal to sell for anal- ysis is punished by a fine not to exceed $50. Henry A. Riley. horse is different from that of the hindfeet on this ac- count. As the forelimbs come to be more-used for the Fig. 1283.-Hand and Foot of Man. (Vogt.) purposes of prehension and dexterity, the difference in structure becomes more marked. The higher apes were improperly called quadrumana, for no animal, speaking strictly, has four feet anatomically similar ; still less has any animal four organs that can properly be called hands. The differences a r e various, according to the adaptation of the anterior and posterior members for the special ac- tivities of the ani- mal. The bones of the carpus are never found to be the same as those of the tarsus, vary- ing either in number or in the union of the va- rious osseous elements. There is not, properly speaking, any opposabil- ity of the great toe in apes, as it cannot be car- ried around and placed at will against the vari- ous other toes ; but it is set at a wider angle than the others, so that it can be used like the curve of a pin- cers or of a cramp-iron for grasping and climbing. The posterior extremities of apes are merely feet adapted for walking upon trees, the resemblances of the foot or "hind hand" to a true hand being only skin deep (Huxley).' There seems from the struct- ure of the human foot no rea- son to doubt that it has been developed from an organ adapt- ed for the same use. Strong evidence of this is found in the foetal condition of the foot, which approaches in many re- spects that of the anthropoid apes, there being less develop- ment of the heel, an arrange- ment of the joints which permits more inversion of the sole, and a difference in the corresponding length of the FOOT. It is natural to compare the foot, as the distal member of the lower extremity, with the hand, the corre- sponding member of the upper ; and by such a compari- son we get most valuable aid to a comprehension of its structure. It has been said that the foot is merely a hand altered by the functions of support and locomotion which it has had to perform. While it is in general true that Fig. 1284. - Impression taken from the Sole of the Foot of a Child Ten Months Old. A, A, A, transverse markings caused by the action of the flexor muscles as a whole. Near these marks others still stronger are seen running obliquely toward the great toe ; these are caused by the independent action of the flexor longus digitorum. B, B, B, B, diagonal markings caused by the action of the peroneus longus and adductor hallucis. Fig. 1282.-Hand and Foot of a Chimpanzee. (Vogt.) foot and hand are constructed upon a similar plan, it must be remembered that the differentiation commences far down in the animal series. The similarity between the anterior and posterior extremities of a quadruped, such as the horse, for instance, disappears to a consider- able extent when the anatomical structure is closely ex- amined. Even in quadrupedal locomotion the posterior extremities are the ones most active in propelling the body, the anterior limbs being mainly for support and equipoise. The impression of the forefeet of an unshod 209 Foot. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. first and second metatarsal bones, indicating that the adult condition, in which the great toe is as long as, or longer than, the others, has been gradually acquired. Leboucq2 determined the average proportion of the first metatarsal to the second to be in the child before birth as 1 is to 1.37; at fourteen years, as 1 is to 1.21; and in the adult as 1 is to 1.17. Fig. 1282 shows the hand and the foot of the chim- panzee contrasted, while Fig. 1283 shows the same mem- bers in adult man. In the gorilla the resemblance to the human hand and foot is still greater. The feet of a child that has never walked show decided differences in power of using the toes, there being considerable grasp and the toes. The fact that walking in the erect position is learned only with difficulty shows that it is a late acquirement. The main characteristics of the human foot are, therefore, those which adapt it for support and locomotion. For this purpose a most beautiful structural arrange- ment has been effected, combining great strength with peculiar elas- ticity and lightness. The bones are set in the form of a vault supported at three points connected by arches, two of these starting from the same point of the heel (the tuberosity of the calcaneum), and extending for- ward, one to the ball of the great toe (head of first metatarsal), the other to a corresponding point on the little toe. The third arch is transverse, connecting the anterior ends of the longitudinal ones. The inner arch is formed by the calcaneum behind and the first, second, and third metatarsals, the cuneiform, and scaphoid bones in front, with the astragalus set at the vertex as a keystone (see Fig. 1285). The outer arch, which is much flatter, is formed by the calcane- um, cuboid, and two outer meta- tarsals which articulate with it. The transverse arch is formed be- hind by the three cuneiform bones and the cuboid (Fig. 1286), in front by the metatarsal bones. It should be noted that this arch becomes shallower and shallower as the toes are ap- proached, until at last upon reaching the heads of the metatarsals the weight is borne fully upon them all. The imprint of a normal human foot, shown in Fig. 1287, shows this clearly. The height of the arches forms the instep, a feat- ure peculiar to man, and which varies considerably in different races, being generally higher in the Indo-European than in others. Arabs are said to boast that their insteps are so high that water will run under them without wetting the sole, and the Andalusian instep is famous. A popular saying has it that the foot of the negro is so flat that it makes a hole in the ground. A very amusing proof of this primitive condi- tion of the negro foot may be noticed in Southern cities, where, during the heat of summer, it is customary to wet the pavements in the evening. It is not unusual to see bare- footed negro boys, whose feet are so flat that atmospheric pressure makes them adhere slightly when applied to the wet and smooth pavement, in the same way that a boy's leather sucker adheres to a smooth stone, and it is a favo- rite pastime with such gifted individuals to walk the streets, producing a somewhat star- tling report every time the foot is withdrawn from the pave- ment. Fig. 1288 shows the impression of a sole of this kind. It is perhaps not with- out some reason that the height of the instep is consid- ered a mark of pure blood, as it appears to be one of the Interosseous ligament. Inferior calcaneo-scaphoid ligament. Plantar fascia. Fig. 1287.-Outline of an Impression of the Sole of a Normal Adult Foot. (Rohmer.) same imperfect opposability of the great toe as is seen in apes. The markings upon the sole show this to some extent. Fig. 1284 is an impression from the foot of a child of ten months who had never worn a shoe, nor stood alone upon its feet. It will be noticed that the markings resemble somewhat those of the palm of the hand, indicat- ing considerable freedom of flexion and a certain amount of independent use of the great toe. These markings al- most entirely disappear after the foot is used as a support. The power of the great toe may, however, be kept up if the feet are not confined, and many savage tribes use the Dorsalis pedis artery. Middle cuneiform bone. External cuneiform bone. Extensor brevis digitorum. Cuboid bone. Internal cunei- form bone. Internal mus- cular group. A- External muscular group. Tendons of flexors. -B Fig. 1286.-The Transverse Arch of the Foot. Section through the an- terior row of tarsal bones. The line A B represents the surface upon which the foot rests when the individual stands erect. Plantar fascia. Middle muscular group. foot for grasping. Among Australian savages this grasp- ing power is of great assistance in climbing trees, and they habitually pick up a spear or similar object with the foot. Nubian horsemen are said to use the reins, and Chinese boatmen to pull an oar, by means of the great toe. Occasionally persons may be found who, either born without hands, or losing them early in life, have acquired the habit of using the foot for various acts ordinarily performed by the hands, and can thread a needle (as do the Hindoo tailors), use scissors, or even write, with the Fig. 1288.-Outline of an Im- pression of a Sole in which the Arch is Unusually Flat; con- genital. (Rohmer.) 210 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. Foot. signs of complete adaptation to the erect posture and to locomotion in that position. Man is the only animal that has the foot placed at right angles to the axis of the body, most mammalia not touching the ground with the calcaneum at all. The horse, for instance, lit- erally walks upon the points of the toes, the hoof being compar- able with the nails of the human foot, and the hock or "knee" being the tuberosity of the cal- caneum. There appears to be some relation between this ascen- sion of the calcaneum and the fleetness of the animal, as those which are the swiftest have the bones so arranged that they walk merely upon the tips. If sup- port alone were needed there would be no necessity for the metatarsal bones and toes, as may be seen in those who have had them amputated. The an- terior part of the arch is there- fore for purposes of locomotion, and it may be noted that in run- ning the heel is raised off the ground, and the anterior part only is used, the anatomical rela- tion of the bones to the soil being similar to that which occurs or- dinarily in the foot of the carniv- ora. The great swiftness and lightness of motion of a premiere danseuse is owing to her ability to dispense en- tirely with the posterior portion of the arch. Owing to this difference of formation the anterior and posterior pillars of the longitudinal arches differ-the pos- terior, being for support, is short, thick, and strong, being of but one bone ; the anterior, composed of several bones, is longer, so that the motion of raising the heel can be quickly performed. The length of the heel in the African race is merely apparent, and caused by the flatten- ing of the arch rather than by a real projection. The number of bones in the anterior arch greatly aids in the distribution of the force, as anyone may see who will take the trouble to note the difference in shock which occurs when alighting upon the heels rather than upon the balls of the toes. This system is sustained by ligaments, tendons, and fascial bands in such a way as to form a most elastic and adjustable sup- port. The longitudinal arches are held up by a strong sheet of connective tissue, one of the thickest aponeurotic structures in the body, the plantar fascia (Figs. 1285 and 1289), which is attached behind to the calcane- um, and in front divides into five slips, one for each toe, which pass forward and are mainly united to a band of transverse fibres which runs across the foot just behind the clefts of the toes. This braces up the arches of the foot in the same way that a tension-rod prevents the rafters of a roof from spreading. This arrangement is only found in the human foot, other animals having a plantar fascia movable like that of the hand, and usually with a special tensor like the palmaris longus of the arm. The little plantaris mus- cle of the human leg, which does not reach the foot, but unites with the tendo Achillis at the ankle, is the relic of such a muscle. When this fascia is very tense, it may draw the arch so closely together as to prevent the outside of the foot from touching the ground. This is the case with the impression shown in Fig. 1290. This condition is not usually found in the normal foot, being the re- sult of contracture of the fascia. Besides this arrangement, the longi- tudinal arches are braced at the top by strong ligaments. A glance at Figs. 1285 and 1291 will show how necessary these are. The astragalus at its inner side overlaps the calcaneum, and would, in case of a lateral thrust, be shoved downward and inward into the space between that Fig. 1289.-Dissection of the Foot showing the Plantar Fascia. (Marshall.) Long plantar ligament. Fig. 1291.-The Ligaments on the Inner Side of .the Right Foot. Inferior calcaneo-scaphoid ligament. bone and the scaphoid were it not for the inferior calca- neo-scaphoid ligament, which passes from the projecting shelf of the calcaneum known as the sustentaculum tali, forward, under the astragalus, to the scaphoid. Its up- per surface is lined with synovial membrane, and the cav- ity of the joint between the anterior part of the astragalus and the calcaneum is continued forward over it to the as- tragalo-scaphoid articulation. The tendon of the tibialis posticus passes forward under this ligament, and its fibres are united with it, strengthening it material- ly, and by its pull upon the scaphoid assisting the firmness of the joint ex- actly at that period of the step when the arch is most in danger ; that is to say, when the heel is being raised and the weight thrown forward upon the scaphoid. If this ligament becomes weak or the mus- cle atrophied, the arch is depressed, the head of the astragalus descends below its proper level, and flat-foot, or valgus, results. This is usually associated with arthritis, and is a very painful affection, differing much from the congenital form of the de- fect. It is found especially among those who stand for long periods of time. On the outer side of the foot the arch is trussed up by means of a strong band called the long plantar ligament (Fig. 1291), passing from the tuberosity of the calcaneum forward to the base of the second, third, and fourth metatarsals. To produce the transverse vaulting, certain short and oblique ligamentous bands are used, radiating from the scaphoid, the cuboid, and the external cuneiform bones, Peroneus longus. Flexor longus digi- . forum. Flexor acces- sorius. Fig. 1292.-Diagram of the Action of some of the Principal Tendons which Consolidate the Transverse Arch of the Foot. Fig. 1290.-Outline of an Im- pression of a Sole in which the Arch is Unusually High. (Rohmer.) 211 Foot. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and these are assisted in a marked degree by the action of the muscles. Fig. 1292 shows that the tendons of the peroneus lon- gus and of the flexor longus digitorum are so arranged that they pull obliquely upon the bones of the foot, crowding them together and consolidating them trans- versely. Duchenne3 was of the opinion that flat-foot is frequently associated with an insufficiency in the peroneus longus. The members of the inner arch are decidedly more movable than those of the outer, which recalls the fact that it is only the outer part that is used for support among anthropoids. The various interosseous ligaments assist considerably to keep the bones in place. The strongest of them is the one between the astragalus and the calcaneum (Fig. 1285), separating the articular surface into two distinct portions. It lies within a canal formed by grooves upon either bone, and known as the canalis tarsi, surrounded in that situation with fat. The joints of the foot are adapted to the arch-like form above described. An inspection of Fig. 1285 will show that there is an approximation in these joints to arcs of circles, the larger arcs being in the posterior part of the the joint between the astragalus and the calcaneum is double, with two synovial sacs, the anterior being con- tinuous with the astragalo-scaphoid articulation. The joint has been carefully studied by Miss Clark,5 who made many measurements of it, both in foetal and adult sub- jects. The facets on the astragalus are concave, and the axis of motion is a line extending from the insertion of the dorsal ligament binding the astragalus to the scaphoid through the head of the astragalus and the body of the cal- caneum obliquely downward and backward to about the point where the middle band of the external lateral ligament is inserted. The movements which take place are really a nearly simple flexion and extension about this oblique axis, the former turning the sole inward (supination), the latter slightly outward (pronation). The arrangement of the axis of motion with reference to the axis of the astrag- alus is different in the foetus, resembling that of anthro- poids (see Fig. 1293). The whole bone is quite differently shaped as regards the inclination of its articular sur- faces, they being adapted to the foetal position, which is that of dorsal flexion and inversion of the foot. The head of the astragalus is so directed as to make the axis of the bone more nearly coincide with that of the Adult. Foetus. Fig. 1293.-Comparison o£ Calcaneo-astragaloid Joint of Man with that of the Gorilla. A, A, axis of the astragalus ; B, B, axis of motion of the cal- caneo-astragaloid joint. (Aeby.6) Gorilla. arch, the smaller and more numerous forward. A study of the cancellated tissue of the bones shows that these arcs are continued to some extent by strengthening bars within the bone, showing that conditions of stress have occa- sioned this arrangement. The movements are generally those of rotation and not purely gliding (Bradley 4). A uniformity of distribution of pressure is thus obtained. The ligaments which unite the different bones are of two classes : those which are special, surrounding and supporting particular joints; and those which are general, mainly employed in bracing and sustaining the arches of the foot. To the first class belong the capsular ligaments which are found at every joint, and are strengthened more or less by special bands, which receive names from the bones which they unite. The principal ligaments of the second class have already been mentioned. The move- ments are of two classes, one of which is a simple flexion and extension, mainly expressed in the joint between the astragalus and the leg bones (see Ankle-joint), and in the various metatarsal and phalangeal joints ; the second a movement of inversion and eversion of the sole, some- times called, rather inaccurately, adduction and abduc- tion, or supination and pronation, and which takes place in the astragalo-calcanean joints. As already mentioned, motion of the joint. Inversion is, therefore, easier and more complete. The shape of the articular facet on the head of the astragalus is also different, its greatest di- ameter being less oblique than in adults. In the impres- sion of the infant's foot shown in Fig. 1284 the faint markings B, B, B, B indicate motion at this joint. In the ape's foot inversion of the sole is necessary for climb- ing, and among Australian savages it is similarly used. This movement is undoubtedly very useful in correcting slight disturbances of equilibrium when standing erect. The direction of the facets in the adult is such that when the posterior part of the calcaneum slips forward and downward the anterior facet moves backward and up- ward, carrying the distal end of the bone slightly inward. For this reason inversion is always accompanied by a turning in of the toes, and eversion by turning them out. A further degree of this movement of the toes is found in the astragalo-scaphoid, a shallow ball-and-socket joint, the round head of the astragalus being received into the posterior hollow facet on the scaphoid. It is this joint that gives to the foot the great freedom of movement that is enjoyed by dancers. A comparison of these joints with those of the wrist will show at once that there is no real homology possible between them. Dislocation may occur 212 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. Foot. here, the interosseous ligament being torn and the mal- leoli usually fractured at the same time. The peculiar condition of the foetal foot, with reference to this joint, is probably the primary cause of the differ- ent varieties of club-foot. The most common form, or varus, is the persistence of the foetal condition of inver- sion of the sole. (See article on Club-foot, vol. ii., p. 196.) The articular surfaces between the calcaneum and the cuboid are saddle-shaped, and have a triangular out- line. The movements allowed here are like those of the astragalo-scaphoid joint, but less in extent. The whole articular line between the astragalus and calcaneum behind, and the scaphoid and cuboid in front, is known as the medio-tarsal joint, sometimes called Chopart's joint by surgeons because of the operation frequently performed there. The movements of the other joints of the foot are similar to the corresponding ones of the hand. The great toe is the only one that lies perfectly extended, the others being more or less flexed. Together they give elasticity to the last act of walking, when the weight is thrown forward upon the other foot. In considering the surgical anatomy of the articula- tions of the foot, it is necessary to note that the bones fall naturally into three grand divisions of tarsus, metatarsus, and phalanges, and that the tarsal bones are divisible into an anterior group, composed of the three cuneiform bones, the cuboid, and the scaphoid, and a posterior group, the calcaneum and the astragalus. The astragalus may itself be considered separately, as it lies more superiorly and with a horizontally directed joint-surface. There are, therefore, the following lines in which disarticulation can be effected : First, between the different phalangeal and metatarso-phalangeal joints ; second, the tarso-metatarsal line ; third, the medio-tarsal line; fourth, the subastrag- aloid line ; and, lastly, the cruro-tarsal line, by which the entire foot may be removed. The phalangeal joints are easily found by remembering that it is always the proxi- mal phalanx that forms the prominence in flexion, and that the opening must therefore be somewhat forward from that. The same may be said for the metacarpo- phalangeal joints, the general line of which lies about three-fourths of an inch behind the skin-fold connecting the toes. The exposed condition of this part of the foot, as well as its distance from the heart, renders it liable to some injuries, such as chilblains and senile gangrene. The tarso-metatarsal line is used for the operations of Hey and Lisfranc, neither of which is frequently performed, as disease is very rarely confined to the metatarsal bones. Hyrtl's1 rule for finding the joint on the inner side is that it lies exactly at the half length of the sole. It is also about an inch and a half in front of the tubercle of the scaphoid, which may be easily felt on the inner side of the foot in front of the point of the internal malleolus. A slight eminence may usually be felt on the posterior extremity of the first metatarsal by holding the foot steady, pressing firmly on the skin, and thus following back the smooth internal surface of the shaft of the bone. On the outer side the line cannot be missed, as it lies directly behind the prominent tubercle at the base of the fifth metatarsal. The base of the second metatarsal bone is received between the inner and outer cuneiform bones, the middle cuneiform being correspondingly les- sened in length. This adds considerable firmness to the arches, but makes the line quite irregular, and is an obstacle to the speedy performance of the operation. Disarticulation is now usually practised ; but Hey sawed through the metatarsal, leaving the base in place. Til- laux 8 remarks that although the irregularity of the line varies, the joint of the second cuneiform is always at a definite interval behind that of the first-about a centi- metre. The interosseous ligaments are strong, and are the principal obstacle to the knife. In the medio-tarsal line the operation known as Cho- part's is performed. The line is not very difficult to find, as it lies on the inner side just behind the tubercle of the scaphoid, and externally just in front of the prominent edge of the head of the calcaneum. This latter is mid- way between the external malleolus and the tubercle on the metatarsal bone of the little toe. There is no irregu- larity in the line, it being composed of two curves, one between the scaphoid and astragalus, convex forward, the other between the calcaneum and cuboid, convex backward. The principle obstacle to the knife is the cal- caneo-cuboid or Y ligament, which is strong and thick, radiating, as mentioned before, from the calcaneum to be inserted by two slips into the cuboid and the scaphoid. The calcaneo-scaphoid ligament, which, it will be remem- bered, ties the vertex of the arch, is also divided in this operation. In old subjects it is occasionally found to be ossified. Disarticulation under the as- tragalus is not often resorted to. As there are no muscles attached to that bone, it can be of little service even if left in place. The muscles of the foot are divided by their position into in- trinsic and extrinsic; those which have their Fig. 1294.-View of the Muscles and Tendons on the Inner Side of the Right Foot, a, a, Annular ligaments; IS, abductor pollicis; 7Z, ten- don of flexor longus digitorum ; 8', tendon of flexor longus hallucis; 9\ tendon of tibialis posticus ; 11', tendons of extensor longus digitorum ; 12', tendon of extensor longus hallucis ; 14', tendon of tibialis anticus; 22, tendo Achillis. (Marshall.) origin above belonging to the latter class. The division is topographical rather than scientific, for there is no doubt that many of the muscles now found in the foot primarily had an origin higher up, and have become displaced in the course of phylogenetic development.9 The extrinsic mus- cles are the most active agents, the intrinsic mostly aiding and supplementing them. They fall quite naturally into four groups-an anterior, supplied by the anterior tibial nerve and composed of the tibialis anticus, extensor pro- prius hallucis, extensor longus digitorum, and peroneus tertius ; a lateral, supplied by the peroneal nerve and composed of the peroneus longus and brevis ; and two posterior, the superficial supplied by the internal popli- B. v. tibialis antici. B. v. ext. longi hallucis .. B. v. ext. longi digitorum Annular ligaments. B. subtendinea tibialis antici. B. subtendinea peronei tertii. B. v. anterior ext. long, hallucis. teal nerve and composed of the muscles inserted into the tendo Achillis (gastrocnemius, soleus, plantaris), and the deep, supplied by the posterior tibial nerve and composed of the tibialis posticus, flexor longus digitorum, and flexor longus pollicis. All of these pass over two joints, the ankle-joint or astragalo-crural and the astragalo-calcaneal, and therefore occasion motion at both, but in very vary- ing degrees. The tendons of the anterior group may be seen in Figs. Fig. 1295.-Synovial Sheaths on Back of Ankle and Foot. 213 Foot. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 1294, 1295, and 1308, and passing down over the ankle, where they are held in position by thickened bands of fascia known as the annular ligaments. There are two of these, an upper one (ligamen- tum transversum cruris), not shown in the figures, extending across the low'er part of the leg from fibula to tibia, and a lower one (ligamentum cruciatum), in the form of a ■<, placed thus on its side (the shape best shown in Fig. 1295), the main stem being a strong loop-like band which lies on the outer portion of the ankle, springing from the fore part of the calcaneum in the deep fossa between that bone and the astra- galus known as the sinus tarsi. It completely surrounds the ten- dons of the peroneus tertius and extensor longus digitorum (see Fig. 1299, a). This band was first described by Retzius, who gave it the name of ligamentum fundiforme tarsi. It is of con- siderable strength, and gives a new direction to the tendons, so that they pull more exactly in the line of the toes (see Fig. 1308), thus forming a sort of trochlea like that which the superior oblique muscle of the eye has. According to Hyrtl it usually be- comes cartilaginous in old people. By a sprain the tendons may be torn from this connection, and will then be seen to take a much more direct line to the toes. From this band the two branches of the ligamentum cruciatum diverge, passing over the tendons of the extensor proprius hallucis and the tibialis anticus. The tendons which pass down over the dorsum are provided with certain synovial sheaths which are shown in Fig. 1295. The tendon of the tibialis anticus (14' in Fig. 1294) is the largest and strongest, and may be easily made out whenever the foot is flexed and the sole at the same time bent inward. As it is in- serted into the internal cuneiform and base of the first metatarsal, it necessarily flexes the foot and inverts the sole. Fig. 1296 shows an im- pression of the sole when the tendon is strongly drawn upon. It will be seen that the attitude is much like that of varus, and in fact this mus- cle is one of the most active agents in that deformity. In dividing the tendon care must be taken not to open the astragalo-calcaneal joint. The tendon of the extensor pro- prius hallucis comes next (see Fig. 1308). It is also very large and strong and is the most prominent cord in front during flexion of the foot. On this account it is the first to suffer from any tightness of the covering about the ankle. It is in- serted into the last phalanx of the great toe, which it strongly extends in the last act of walking just as the foot is about to leave the ground. Continuing its action, it flexes the foot on the leg and assists the tibi- alis anticus to invert the sole. Fig. 1297 shows the deformation of the sole occasioned by pulling upon its tendon. It is more firmly enclosed by the cruciate ligament than the tibialis anticus, and its pull upon that band raises the arch slightly so that its impression is fainter. The extensor longus digitorum sends tendons to the four outer toes which unite with those of the extensor brevis and are inserted into the second and third pha- langes. Closely associated with this muscle is the pero- neus tertius, a thin muscular slip which sends a tendon to the metatarsal bone of the little toe. It hardly deserves a separate name. The action of the extensors upon the toes is reinforced by the lumbricales from the sole of the foot. These muscles arise from the flexor tendons and pass around the phalanges to be inserted into a triangular aponeurosis, which is common to the extensor mus- cles. In walking, therefore, as the flexors assist in raising the foot they give a firm basis for the pull of the lumbricales, so that in the final act of rolling the weight forward upon the toes they can assist the extensors. It should be remembered that the division of the muscles into flexors and ex- tensors is not, in so far as it im- plies an antagonistic condition, entirely correct.10 Those muscles which extend the toes also flex the foot, and rice versa. There is no loss of muscular force, as there would be did one set pull directly against the other. The action of the extensors upon the sole of the foot will be seen by an examination of Fig. 1298, which shows an impression taken when both the extensor pollicis and the communis were in action. The extensor brevis (see 10, Fig. 1299), though an in- trinsic muscle, should be mentioned here, as it belongs morphologically to the same group. It was originally a leg muscle, and has gradually slipped down, all stages of its descent being seen in different animals.9 It arises from the forepart of the upper and outer surfaces of the calca- neum, and presents, on the outer side of the foot, a considerable muscular belly, which contributes to the modelling of that part of the foot, and is soft and pulpy to the touch. This should be remem- bered in examining the ankle for suspected joint-disease, or after a sprain. When struck lightly it will quiver, and this movement has Fig. 1298.-Outline of an Impression of the Sole af- ter Traction upon the Ex- tensor Communis and the Extensor Proprius Hallu- cis. Same foot as Fig. 1287. (Rohmer.) Fig. 1296.-Outline of an Im- pression of the Sole after Traction upon the Tendon of the Tibialis Anticus. Compare with Fig. 1287, which shows the same foot in a passive state. (Roh- mer.) Fig. 1299.-View of the Muscles and Tendons on the Outer Side of the Right Foot. «, Ligamentum fundiforme : la, abductor minimi digiti; 7', insertion of the tendons of the flexor longus digitorum; 10, exten- sor brevis digitorum ; 11', tendons of the extensor longus digitorum ; 12', tendon of the extensor longus hallucis; 15, tendon of the pero- neus tertius; 16', tendon of the peroneus brevis ; 17', tendon of the peroneus longus; 22, tendon Achillis. (Marshall.) Fig. 1297.-Outline of an Impression of the Sole after Traction upon the Extensor Proprius Hal- lucis. Same foot as Fig. 1287. (Rohmer.) been mistaken for fluctuation, and the muscle has been incised in mistake for an abscess. The tendon which goes to the great toe is usually somewhat separated from the others, and that part of the muscle has been described separately as an extensor brevis hallucis. The extensor brevis varies considerably, especially with regard to the amount of division of the various muscular bellies of which it is composed, and there is occasionally 214 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. Foot. seen a tendency for it to become merged with the dorsal interossei, elements of an entirely different origin. The peroneus longus and brevis (16' and 17', Fig. 1299) were primitively upon the front of the fibula, but their tendons have been shifted behind the outer malleolus for adaptation to climbing. They are here held by a strong sheet of fascia (retinacu- lum superius), and are similarly sheathed (retinaculum inferius) where they lie in a groove on the outer side of the calcaneum. Notwithstanding this secure attachment the tendons are more frequently dis- placed than any others in the body. Leaving the groove they diverge from each other, the brevis being inserted into the tubercle of the fifth metatarsal, and continued by a thin tendon as far as the toe, the longus passing across under the arch of the foot in the groove on the in- ferior surface of the cuboid, and being inserted into the tubercle of the first metatarsal bone (see Fig. 1292). They strongly evert the sole, producing a con- dition like that of valgus. The effect on the sole is seen in Fig. 1300, which will answer for both muscles, the variation between the effect of each separately be- ing but slight. The peroneus tertius, the extensor lon- gus digitorum, and the extensor brevis digitorum, were originally parts of the same muscle-sheet which belonged to the back of the foot and front of the leg. The twisting over of the foot into its po- sition with the plantar surface downward has caused them to appear in their pres- ent situation. Extra peroneal muscles are not infrequent, and in one dissection performed by the author a set of five were found. The main body of the flexor tendons passes down on the inner side of the ankle. Fig. 1302 shows, in a diagrammatic form, how they are arranged, and their tendons are seen in Fig. 1294. Besides these there should be men- tioned those muscles (the soleus and gastrocnemius) which are in- serted through the tendo Achillis upon the calcaneum. Duchenne's experiments3 in the faradization of muscles led him to the conclusion that these latter act as extensors and adduc- tors of the foot, while the peroneus lon- gus is an extensor and abductor. In or- der to get a powerful and equal exten- sion of the foot both of these act to- gether, and this may be increased by a simultaneous contraction of the flexor longus digitorum and flexor longus pol- licis. He supposes that the reason for the peculiar action of the tendo Achillis, in causing adduction, is occasioned by the arrangement of the plantar ligaments. The strongest bands lie on the outer side of the foot, and this determines a devia- tion of the line of action in that direction. An impression of the sole, taken after traction on the tendon, is shown in Fig. 1301. It will be seen that the middle portion is decreased in breadth, and that the region of the first metatarsal is but faintly marked. It was formerly supposed that the sev- ering of the tendo Achillis was a neces- sarily fatal injury. Hippocrates was firmly of this opinion, and one of the names given to the tendon is chorda mag- na Hippocratis. It was undoubtedly a serious matter when the wound was an open one and proper drainage not secured ; but with the modern resources of surgery it is often safely divided for the relief of club-foot. For about an inch and a half above its lower end it is free from muscle fibres, and nar- rows slightly, and it may be cut there, care being taken to avoid the vessels and nerves at its inner side, and the bursa which exists just above its insertion (see Fig. 1302). Rupture of the tendon has occurred from violent muscular action in jumping. The tendons of the tibialis posticus, the flexor longus digitorum, and the flexor longus hallucis pass down be- hind the internal malleolus in a special compartment, confined by a strong band of fascia known as the internal annular ligament, which passes from the malleolus to the calcane- um, enclosing not only the tendons, but the vessels and nerves which accompany them. They have spe- cial synovial sheaths (Fig. 1302), and are so arranged that the ten- don of the flexor longus hallucis is nearest the tendo Achillis, that of the flexor longus digitorum next, and that of the tibialis anticus nearest the malleolus, the tendon of the digital flexor twisting around it from without inward, and then passing downward, forward, and outward under the sole. Were it not for this the tendon of the tibialis posticus would be likely to slip from under the malleolus or the sus- tentaculum tali as it passes forward to be inserted into the tubercle of the sca- phoid, and by a tendinous expansion into all the bones at the upper part of the vault except the as- tragalus. Its effect on the sole is shown in Fig. 1303. It will be seen that it strongly inverts it and raises the head of the first meta- tarsal. Spigelius called it musculus nauticus, because it was necessarily used by sailors in climbing masts. The flexor longus digitorum and the flexor longus hallucis are ar- ranged somewhat like the flexor pro- fundus digitorum and the flexor longus pollicis of the hand, as they have an arrangement of tendons which pass in a similar way through those of the flexores breves to be in- serted into the terminal phalanges of the toes. But they are very differ- ently related in the sole, for they not only decussate and unite there, but the flexor longus digitorum receives a reinforcement from an accessory head, the flexor accessorius, or caro quadrati Sylvii, arising from the tuberosity of the calcaneum, and inserted at the decus- sation. The crossing in the sole is such that in the greater number of cases the tendon of the flexor hallucis sends to the decussation a lateral twig, which again di- Tibia. B. v. flex. long, digitoruni' B. v. tibialis postici Internal annular lig't. Fig. 1302.-Synovial Sheaths of Inner Side of Foot. B. v. flex. long. hall. B. postcalcanea profunda. Fig. 1300.-Outline of an Impression of the Sole after Traction upon the Peroneus Longus. Same foot as Fig. 1287. (Rohmer.) Fig. 1303.-Outline of an Impression of the Sole after Traction on the Tibialis Posticus. Same foot as Fig. 1287. (Rohmer.) Fig. 1301.-Outline of an Impression of the Sole after Traction upon the Tendo Achillis. Same foot as Fig. 1287. Not bent by pressure against the ground. (Roh- mer.) Fig. 1304.-Outline of an Impression of the Sole after Traction upon the Flexor Communis and Flexor Longus Hallucis. Same foot as Fig. 1287. (Rohmer.) 215 Foot. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vides into slips for the second and third toes, uniting with the tendons of the flexor digitorum. The slip to the third toe may be wanting, but sometimes one is sent to the fourth. This arrangement recalls the musculature of the ape's foot, where the hallucis tendon supplies the third and fourth toes, and sometimes the second, while the digital tendon is mainly confined to the second and fifth, or to the second only, the great toe receiving only a slender tendon which quite fails in the orang. .Flexor longus digitorum. Extensor longus digitorum. Flexor longus pollicis. Fig. 1305.-Diagram Showing the Manner in which the Flexor and Ex- tensor Tendons are Reflected around the Ankle. (Langer.13) Third Layer. Fourth Layer. The unusual development of the hallucis in man appears to be connected with the use of the great toe for preserv- ing the equilibrium in the erect position. The plantar head mainly reinforces the tendons for the third and fourth toes.11 The whole apparatus appears to indicate that the original plan was for a flexor fibularis (flexor longus hallucis) and a flexor tibialis (flexor digi- torum), that the flexor accessorius originally belonged to the latter muscle, and has lost its insertion upon the fibula. Variations are found which tend to confirm this. Fig. 1307.-The Deep Muscles of the Sole. 4, 4, Flexor brevis minimi digiti; 5, 5, flexor brevis hallucis : 26, adductor pollicis, with its de- tached heads ; 3, 3, 3, also called the transversus pedis ; 1, 1, 1, dorsal interossei; 2, 2, 2, plantar interossei. Ant. tib. artery. Ligamentuni cuniatum. Peroneal nerve. Ligamentum fundiforme. Tib. anticus. Dors, pedis art. with ext. commun. digit, to outer side. Tarsal artery 'Ant. tib. nerve. Peroneus tertius. Ext. prop, hallucis. External saphenous. Metatarsal artery. Outer tendon of extensor brevis polli- cis. ' Tendons of I ext. brevis I and ext. ^prop.hallucis. Fig. 1306.-The Muscles of the Sole of the Foot, la. Abductor minimi digiti; 16. abductor hallucis ; 6, flexor brevis digitorum : 7', tendon of flexor longus digitorum ; 7a, its plantar head, or flexor accessorius ; 76, 76, lumbricales; S', tendon of flexor longus hallucis ; 17, tendon of peroneus longus ; 9', insertion of tibialis posticus. First Layer. Second Layer. It will be noticed that the most direct pull appears to be toward the second and third toes ; the tendons there are supplied, not only from the common flexor, but also from the tendon of the hallucis. This would appear to show that the original axis of the foot, or line on which it rolls, is not through the great toe, as usually stated, but Fig. 1308.-A Dissection Showing the Deeper Structures on the Dorsum of the Foot. 216 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. F oot. through the second and third toes, and would bear out the experiments of Beely,12 who found that in a cast taken from the impression made by his foot while stand- ing upon a layer of soft plaster, the heads of the sec- ond and third metatarsals made a deeper impression than any other portion of the anterior part of the foot. The action of the flexor is to bend the toes and con- tribute to the stability of the foot in standing. After bending the toes they also flex the medio-tarsal joint, as may be seen by an impression of the sole (Fig. 1304). So it follows that these muscles all co-operate in lift- ing the heel from the ground and flexing the foot, and that, as this is done, the toes are strongly flexed and pressed against the ground like elastic springs. (See Fig. 1305.) They are often divided in orthopaedic operations, usu- ally at the malleolus, as it should be re- membered that the posterior tibial artery lies near the flexor longus digitbrum, be- ing exactly in the middle of the space between the posterior margin of the in- ternal malleolus and the internal border of the tendo Achillis. The nerve is in the same sheath with the artery and behind it. The intrinsic muscles of the sole, which are quite numerous, are shown on Figs. 1306 and 1307. They are arranged in three groups, separated fro m each other by ap- propriate layers of fascia, as shown in Fig. 1286. The external group is composed of mus- cles relating to the little toe, the flexor brevis and abduc- tor minimi digiti; the inner is a simi- lar group relating to the great toe, the flexor brevis and abductor hallucis ; while the middle set is related to the muscles which come down from the calf, flexor ac- cessorius and lumbricales, together with the flexor brevis digitorum and adductor pollicis. Deep under all these lie the interossei. The muscle sometimes described as transversus pedis is not entitled to a separate de- scription, as it is clearly shown by the evidence of embryology to be a por- tion of the adductor pollicis. These muscles are of special use in supplementing the action of the liga- ments in supporting the arches, giving an elastic support variable according to the nature and direction of the strain. The interossei are in two groups, the plantar and the dorsal, the latter not being prominent on the sole. All originally de- veloped upon the sole, the dorsal gradually passing up between the metatarsal bones during foetal life. Cun- ningham 14 thinks that the primitive typical arrangement of the intrinsic plantar muscles is the same as that of the hand, viz.: that there is a plantar layer of adductors of the toes represented by the adductor hallucis and its de- tached head, the transversus pedis, and the three plantar interossei; an intermediate layer of flexores breves, com- posed of the flexor brevis minimi digiti and the flexor brevis hallucis; and a dorsal layer of abductors of the toes represented by the abductor hallucis, the abductor minimi digiti, and the dorsal interossei. The layers have lost their relative planes in the foot partly because of the arched condition, and partly by suppression of the flex- ores breves for the second, third, and fourth toes. The nerves of the foot give us important evidence with regard to the value and previous history of the muscles. Those derived from the lumbar plexus do not have any motor functions, but supply sensation to the integument of the inner side (long saphenous nerve). The sacral plexus gives sensations to the remaining portions, viz., by the external saphenous on the inner side, the musculo- cutaneous over the dorsum, and the plantar nerves on the sole, the internal plantar supplying the three first toes and half of the fourth, the external supplying the other half of the fourth and the fifth. The nerves of the dor- sum are shown in Figs. 1308 and 1310 ; those of the sole in Fig. 1309. The vessels of the foot (see the same figures) are not very numerous or large. Upon the dorsum we have the continuation of the anterior tibial artery, which, as it passes under the annular ligament, changes its name to dorsalis pedis. It is ac- companied by two veins, and passes forward to anasto- mose, at the space between the first and second toes, with the external fdantar. It is be- ieved to corre- spond to the radial artery of the hand, and it will be seen that the twisting over of the dorsal surface has given it a less devious course. It is easily secured in the up- per part of its course, where it lies quite super- ficially and just external to the ten- don of the extensor longus hallucis. Aneurism has oc- curred in it as a sequel to a sprain. The posterior tib- ial artery, coming down behind the ankle, divides, just before entering the sole, into external and internal plantar, the latter being the smaller. The external runs outwardly across the foot, deep under the muscles, and then turns again to the inner border and anastomoses with the dorsalis pedis. It is not practicable to reach these for ligature in the sole, except by resection of the metatarsal bones. The superficial veins are found mainly upon the dorsum. A refer- ence to Fig. 1310 will show that the internal and external saphenous veins coming down from above anastomose with each other across the metatarsal bones, forming an arch with the convexity toward the toes. Tight boot- lacings may so compress these veins as to produce a stasis, with pain and swelling. Veins of any considerable size are wanting upon the sole. The integument of the sole of the foot is intimately united with the layer of subcutaneous fat, which is here not loose and movable, but shut into distinct compartments by septa of connective tissue. This forms a very compact and elastic cushion for supporting the weight of the body. The hygiene of the foot will form the subject of a sep- arate article. Origin flexor brevis digi- torum. Posterior tibial artery. Abductor minimi digiti, cut.. Internal plantar artery. External plantar artery. .Internal plantar nerve. External plantar nerve. Flexor accessorius, cut ten- don flexor longus digi- torum. Tendon peroneous longus in opened sheath. Muscular branches of external plantar nerve. Abductor hallucis : cut tendon of flexor longus hallucis is on inner side. Adductor hallucis, cut. Plantar arch . .Plantar arch. Digital artery. Abductor hallucis. cut. Digital artery. Tendon abductor minimi digiti. . Trans versus pedis. Collateral digital artery. Fig. 1309.-A Dissection showing the Deeper Struct- ures on the Sole of the Foot. 217 Foot. Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Smallness of these members has been during all mod- ern times considered a mark of beauty. There seems to deformed, can still be used for walking. If they are wealthy, the deformity is carried further by so bandaging the foot that the great toe approaches the heel as nearly as possible. As to the motive for this strange custom, it seems probable that it originated in an attempt to in- crease the value of the female as an object of sexual appe- tite. As the woman can move about but little, a greater deposit of fat is found on the mons veneris, and the nymphae are thickened. Besides this, it is said these de- formed feet are kept carefully covered, because they re- semble in appearance the vulva. Only prostitutes dis- play their feet, and for the purpose of enticing customers. (Stricker15). Fig. 1312 shows the skeleton of such a mal- formation. Frank Baker. 1 Huxley (T. H.): Evidence as to Man's Place in Nature. 2 Leboucq (H.): Le ddveloppement du premier metatarsien et de son ar- ticulation tarsienne chez 1'homme. Ann. Soc. de med. de Gand, 1882, iii., 335. 3 Duchenne ; Physiologic des mouvements. 4 Bradley (S. M.): The Secondary Arches of the Foot. J. Anat, and Physiol., London, 1875-7(5, x., 430. 5 Clark (Ann Elizabeth): The Ankle-joint of Man. Berne, 1877. "Aeby (Chr.): Beitriige zur Osteologie des Gorilla. Morph. Jahrb., Leipzig, 1878, iv., 288. 7 Hyrtl, Joseph : Handbuch der topographischen Anatomie, seventh edition. Wien, 1882. 9 Tillaux (P.): Traits d'Anatomie topographique, third edition. Paris, 1882. " Ruge (G.): Entwicklungsvorgiinge an der Muskulatur des mensch- lichen Fusses. Morph. Jahrb., Leipzig, 1878, iv., Supp. 117. Ibid : Un- tersuchung uber die Extensorengruppe am Unterschenkel und Fusse der Saugethiere. Ibid, iv., 592. Ibid: Zur vergleichenden Anatomie der tiefen Muskeln in der Fusssohle. Ibid, iv., 644. 10 Pettigrew (J. B.): Animal Locomotion. New York, 1874. 11 Gegenbaur (C. von): Lehrbuch der Anatomie des Menschen. Leip- zig. 1883. 12Beely (F.): Zur Mechanik des Stehens. Arch. f. Klin. Chir., Ber- lin, 1881-82, xxvii., 457. 13 Langer (C. von): Anatomie der Aeusseren Formen des menschlichen Korpers. Wien, 1884. 14 Cunningham (D. J.): The Intrinsic Muscles of the Mammalian Foot. J. Anat, and Physiol., London, 1878-79, xiii,, 1. 16 Stricker (W.): Der Fuss der Chinesinnen. Archiv fur Anthropo- logie, 1870, iv., 241. Int. saphenous vein.. Peroneal nerve. Int. saphenous nerve. Junction of saphen- i ous with deep veins. 1 Junction of saphen- ous veins with deep. .Ext. saphenous vein. Ext. saphenous nerve. Anastomosis of pe- roneal and ext. sa- phenous. Int. branches pero- neal nerve. Digital branches. Ext. branch. Anterior tibial nerve. Junction int. and] ext. saphenous. J Fig. 1310.-The Superficial Veins and Nerves of the Dorsum of the Foot. be no good reason for this, except that it indicates a gen- eral delicacy of construction of the body and can hardly be associated with hab- its of labor. Structu- rally a small foot would seem to be an ineffec- tive organ. The Chinese women of rank are, as is well known, so treated in infancy that the foot has no oppor- tunity to grow, and soon becomes misshap- en, as shown in Fig. 1311, reduced from a photograph by Weick- er. The operation com- mences usually in the second year of the child's life, and consists in turning the toes uu- FOOT AND MOUTH DISEASE. Synonyms.-Lat., Aphtha epizootics; Ger., Aphthenseuche, Bldschenkrank- heit, Maul-Klauenseuche, Maulfaule, Maulweh; French, Fievre aphtheuse, Stomatite aphtheuse, Cocotte; Itai., Feb- bre aftosa. The foot and mouth disease is most commonly met with in cattle, sheep, goats, and pigs, less frequently in horses, fowl, and man. It is an acute, infectious disease, eminently contagious, and characterized by the appear- ance of vesicles and ulcers in the mucous membrane of the mouth, on the crown and in the split of the hoof, and on the mamma and teats of cows. In some cases, and in some species of animals, only the mouth is affected ; in other cases the chief stress of the disease is borne by the feet. The disease has only excited much attention in com- paratively recent years, and is much more frequent now than it formerly was, its greater frequency being due to the better means of communication that exist now, the shipping of cattle by railroad, the great yards where cat- tle from a number of distant points are brought together, kept for a time, and then often carried into the country again and mixed with other herds. The disease is not a new one, but has existed for centuries, although, from the imperfect state of veterinary medicine one hundred years ago, it is only in comparatively recent times that we have any clear and exact accounts of epidemics. Numbers of different diseases were mixed up under the names of plague, pest, pestilence, etc. Hierocles, the Greek veter- inarian, appears to have known the disease. Roman histo- rians, especially Livy, give accounts of pests which agreed exactly with our foot and mouth disease. In 1223 there was a widespread epidemic of the disease in Hungary and other European countries. Fracastorus mentions an epi- demic which appeared in the upper portion of Italy and in France in 1513-14, in which vesicles appeared in the mouth and in the hoof-split. From some descriptions it is evident that anthrax of the tongue and actino-mycosis were often confounded with this disease. The earlier epidemics seem to have assumed a much more malignant character than the disease does now, which is to be ac- Fig. 1311.-Deformed Foot of a Chinese Lady of Rank. (Langer.) der the sole and confining them there by bandaging. The procedure is said to be quite painful, and sometimes fatal to delicate children. If the parents be- Fig. 1312.-Section of Natural Foot with the Bones, and a Corresponding Section of a Chinese Deformed Foot. The outline of the latter is dotted, and the bones shaded. (Flower.) long to a class in which labor will be required of the child, nothing further is done, and the foot, though 218 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. Foot. counted for, in great part, by the treatment to which the affected animals were then subjected. One means of treatment then recommended was scraping the ulcers in the mouth with a gold coin, the edges of which were ser- rated.' Should a gold coin not be obtainable, silver was to be used. It was even recommended that the district authorities should keep such surgical instruments always on hand, and ready for use in case the disease should break out. As most probably the same instrument was used from cow to cow, and the disease was often con- founded with tongue anthrax and actino-mycosis, it can be easily seen why some epidemics should have been so fatal. Such treatment is only to be compared with the practice which prevails in most rural districts in the United States, of splitting the cow's tail and boring holes in the horns for any trifling complaint, a practice happily not attended with the same danger as the gold treatment, but which is not entirely harmless. In this century great epidemics have swept over Europe every two or three years, and it is but seldom that any European country is entirely free from the disease. The epidemic of 1872 was very severe and far-reaching. In some epidemics the mouth affection has been most severe, in others the affection of the feet. Although the disease, in the rule, takes a benign course, and the mortality is very slight, still it has great importance from an economical standpoint, in consequence of the losses it entails on a state. These losses are occasioned by the great and rapid emaciation which the infected an- imals undergo, their temporary incapacity for labor, and the great diminution in dairy products. To these must be added the inconvenience and loss from the necessary inter-state quarantines. It is doubtful if any other dis- ease, not excepting anthrax or rinderpest, causes such great loss to the farmer. The yearly loss in Switzer- land from this disease is reckoned at 10,000,000 francs, and the loss in France, in 1871, at 30,000,000 francs ; in England the loss from each infected cow is reckoned at £2 sterling. The percentage of deaths yaries from one to three per cent, in ordinary epidemics, while in the very severe epi- demics it may reach as high as ten per cent, of all cases. The disease is spread from one infected herd to another, and never arises spontaneously. Formerly it was believed that sometimes there was a spontaneous development of the disease brought about by severe changes in the weather, especially unseasonable cold, damp spells, feeding with Spoiled food covered with mould, the use of drinking- water from swamps, and long drives over hard, stony roads. A careful inquiry in all recent epidemics has failed to give any support to this theory. The disease usually has spread over Europe from the East to the West, and it has been supposed that the original home of the disease was in India and the steppes of Russia. Like many other dis- eases, the home of this is extremely hypothetical. The fact of its spreading toward the westward is explained by the fact that the course of trade in cattle is always in this direction, the large pastures in Russia and Hungary fur- nishing the cattle for a large proportion of the beef of Europe. The fact that it follows the rivers is also ex- plained by the circumstance that these are the highways of trade. The infectious material is found in the contents of the vesicles, in the saliva which flows freely from the mouth, and in nearly all of the other excretions and secretions. The blood and the milk are also infectious. Nursing calves whose mothers are affected have the mouth affection, and often a severe intestinal inflammation. In one district in France seven hundred calves died of intestinal inflam- mation in the course of a single epidemic. This fatal course in calves is only seen when they nurse infected cows, or are fed with their milk. It is totally prevented by feeding them on milk from healthy cows, or milk that has been boiled. The infecting material is a living virus, and capable of increase in the animal body. It has con- siderable tenacity of life, but cannot be compared in this regard with the virus of anthrax. Stables that have once contained animals affected with foot and mouth disease remain infected for months, and capable of giving the disease to any fresh cattle. The same holds good of rail- road cars ; bedding which has been used in infected sta- bles, and then thrown out in the yard, retains for months its infecting power. It is not known definitely whether the virus has also the power of growing outside of the animal body. Infection takes place most often from contact of well with infected animals, in drove-yards, in stalls, pastures, watering-places, etc., and by passing over roads over which infected herds have passed. The disease spreads to distant points by means of the large driven herds of swine, or by their transportation on railroads ; or the other an- imals, and even man, may act as intermediate conveyers of the contagium. In great epidemics the disease even affects the wild animals-deer, chamois, etc.-and can oc- casion great loss among these. It has also been seen in camels. The use of the flesh of animals which die of the disease, or are affected at the time they are killed, seems to be without danger as far as man is concerned. The outbreak of the disease usually begins with a slight fever, which is often overlooked ; von Niederhausen observed in infected animals a temperature of 101° to 102°, and in a few cases 103° to 104° F. The fever is shown by a roughening of the coat, tremor of the whole body or of the limbs, diminution of appetite, and increased heat of the skin. The animal seems weak and tired, the eyes water, the pulse is small, and the mucous membrane of the mouth reddened and covered with a tenacious mucus which hangs in long strings from the mouth ; rumination is stopped, eating as well as swallowing seems to give the animal pain. The bowels are constipated, and the secre- tion of milk diminished. In the course of tw'enty-four to forty-eight hours from the beginning of the disease the characteristic vesicles begin to appear, and the mucous membrane around these is intensely reddened and some- what swollen. The vesicles appear in greatest abundance on the mucous membrane of the upper lip, then on the inside of the cheek, along the tongue, and on the soft palate and pharynx. When they first appear they are whitish or yellowish white, and as large as a grain of wheat, gradually increasing in size until they become as large as a filbert, or when two or three vessicles become fused together they may attain a much larger size. At first they arc filled with a clear, watery fluid of a slightly yellow color; this fluid soon becomes purulent, and after one or two days the vesicles burst and form dirty super- ficial ulcers and erosions on the reddened and inflamed mucous membrane. The erosions of the mucous mem- brane become covered again with epithelium in from five to seven days, but the ulcers need a much longer time for their healing, which does not take place until a clean, granulating surface is formed. The vesicles may also appear on various portions of the body-at the base of the horns, on the mucous membrane of the eyelids, on the cornea, and on such parts of the body where the skin is thin. After the outbreak of the vesicles the febrile phe- nomena diminish, the animal slobbers a great deal, and on account of the pain in the mouth and throat can eat no food at all, or no dry food. The thirst is great, and when the animal drinks the mouth is held for a long time in the cool water. The emaciation is rapid and ex- treme. These symptoms gradually diminish as the ulcers heal, and the convalescence is rapid. Along with the other symptoms there are often those of an intense intes- tinal and gastric catarrh, and an inflammation of the air- passages. The affection of the feet comes on either at the same time with the mouth affection or wuthout this. It is pre- ceded by a similar rise of temperature ; the animal shows great sensitiveness, and a desire to protect the feet by ly- ing down a great deal. There is much redness and pain on pressure at the crown of the hoof and in the cleft. In the course of one or two days vesicles develop, which are small at first, but gradually reach the size of a hazel-nut, and are filled with a fluid at first thin and clear, but which soon becomes cloudy and viscid. They soon burst; their contents dry and form a thick brownish crust over the surface, and beneath this the process of healing rapidly advances. When the affected animal is kept in 219 Foot. Forceps. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dirty stables, or when the feet are exposed to constant irritation, as by pasturing on a stiff, hard stubble, or by being driven over a rough, stony road, the course is not so favorable; the inflammation extends greatly, and abscesses form within the hoof, which is some- times cast off. There may even be caries of the ankle- bones, and the animal may die in consequence. All these ill consequences are a result of improper care of the ani- mals. They do much better in clean stables with plenty of straw, than when tlipy are in the pastures. The dis- ease is apt to run a very severe course in the mountain cattle-those driven up in the Alps to pasture during the summer. The Alpine grasses are dry and harsh, the cat- tle are compelled often to wander considerable distances over rough, stony ground in search of pasture, and the care taken of them in the rough stables is miserable, the stables being often built on a steep incline, which throws most of the animal's weight on the fore or hind feet. To all these evils must be added the frequent sharp changes in the weather. In these cattle marked changes in the skin are often seen. There is a nodular eruption of the skin which becomes hard and dry, and is often perma- nently thickened. This eruption is not contagious ; it seems really not to belong to the disease, but to be the ef- fect of a chronic inflammation continued from the inflam- mation which accompanies the vesicular eruption. Irregu- lar bald places appear on the neck, ribs, and flanks, over which the skin is scaly, and when the scales are removed a red, soft, velvety surface is exposed. These places seem to itch violently, and the animals rub themselves against any rough surface they can find, thus adding to the inflammation. In other parts of the body the hair loses its lustre, the skin is hard and dry, and clings closely to the body; the elasticity is lost, and the folds in the skin made when the animal is lying down remain for a considerable time. In spite of the fact that the ves- icles in the mouth and on the feet have disappeared, and the appetite of the animal is good, the nutrition remains impaired and the milk dries up. Often this condition of the skin does not disappear for several months. In many animals there is also inflammation, with the formation of vesicles, in the skin around the horns ; these become loose, and are often thrown off. There is often extensive inflammation of the vagina; vesicles are formed in this, and if the animal is pregnant contractions of the uterus are set up and the foetus is expelled. The vesicles may produce extensive ulcerations, which heal, forming firm adhesions and false membranes in the vagina which prevent future coitus. Even without this mechani- cal impediment in the vagina the sexual desire is often entirely lost, and the animal remains barren. In some epidemics the course of the disease is not so favorable ; cases appear which from the first show a very malignant character. These appear with a severe fever from the first, accompanied by an intense intestinal catarrh, and the vesicles in the mouth and feet may be absent. These cases present a great similarity to intes- tinal anthrax, and usually terminate fatally. Bollinger supposes that in such cases the general infec- tion of the animal is so severe that the local phenomena are subordinate. These cases appear especially in calves, or in animals which are weak and in bad condition from some preceding disease. The chief stress of the disease may fall on the respiratory organs ; the trachea and the bronchi are injected, vesicles and surface ulcerations form in the mucous membrane, and the animal shows the symptoms of a profound bronchial catarrh. There is great dyspnoea, with cough and profuse discharge from the nose. Animals seem never to completely recover from this condition, but remain weak and asthmatic for the rest of their lives. Next to the affection of the mouth and feet the lesions of the mamma and teats are most important. Vesicles appear here accompanied by swelling and inflammation of the udder, which makes milking extremely painful or impossible. The vesicles are ruptured, fissures are formed, and the whole udder presents a raw and ulcerated sur- face. Sometimes the inflammation extends inside the udder, along the principal milk-ducts, and the openings become covered with crusts, which makes milking even more difficult. The milk which remains in the bag turns sour, decomposes, and from the inflammation thus pro- duced abscesses are formed in the bag. The inflamma- tion may go on to gangrene with large losses of substance, or destruction of the entire gland maybe caused. The milk in such cases is yellow ; it has an unpleasant smell and taste, and an acid reaction. On settling it deposits a yellowish sediment, which is often lumpy and streaked with blood. Its specific gravity is higher (1.026 to 1.034), and the fat and sugar are diminished. Chemical analysis shows that all the solids in the milk are very much di- minished. The following chemical analysis by Professor Vaughn (H. W.) shows the condition : Milk from- Diseased cattle. Healthy cattle, reaction acid. reaction alkaline. Water 91.038 84 71 Solids 8.962 15.29 Casein 5.430 5.29 Fats 2.30 4.96 Sugar 542 4.23 Salts 69 .81 When the bag is affected by the vesicles the milk is altered still more, and is often streaked with blood. Mi- croscopic examination in nearly all cases shows numer- ous red corpuscles and pus-cells with epithelial detritus. Opinion has been divided on the subject whether the disease could be communicated to man from the use of the milk. It does not prove injurious in all cases, but there is enough positive testimony on the subject to forbid the use of the milk in all stages of the disease. There seems to be no doubt at all that pigs and other animals can acquire the disease by drinking the milk. Children are more apt to be infected in this way than adults, regu- lar epidemics of aphthous eruptions having been observed in Basle, when the surrounding country was infested with the disease. Possibly, in view of the frequency of stoma- titis in children, too much stress has been laid on the in- fluence of such milk in producing it. Anecker thinks that the infectiousness of the milk depends upon the af- fection of the mamma and teats, and it is only infectious when the contents of the ruptured vesicles are mixed with the milk. Boiling the milk takes away its infectiousness. The disease may also be acquired by man by the con- tents of the vesicles coming in contact with an abraded surface ; such mode of infection is often seen in milk.- maids. The disease in man gives rise to the following symp- toms : Slight fever for one or two days, with headache, malaise, sleeplessness, and loss of appetite ; the mouth is hot and dry, and the tonsils and submaxillary glands swollen. Often there are also severe pains in the joints. The fever subsides with the appearance of the vesicles, which form in the mouth and over the face. The vesicles soon burst and give rise to superficial ulcers. In milk- maids these ulcers are apt to form around the nails, which may be lost from suppuration. The use of the milk in some cases has seemed to produce symptoms of general disturbance, slight fever, malaise, nausea, and vomiting, without any eruption of vesicles. The disease appears relatively seldom in sheep and goats, and its course in these does not vary essentially from that in cattle. The vesicles appear much oftener on the feet than in the mouth. The mucous membrane of the eye and of the genitalia may be affected. In sheep the disease is often confounded with the ordinary foot-rot and the malignant Spanish rot. The skin on the crown of the hoof and in the split is red and swollen, and the surface secretes a fluid which soon dries and forms a brown crust. Suppuration inside of the hoof leading to its loss is more frequent than in cattle, and in some cases the hoof glands are severely affected, and deep ulcers are formed which run around the hoof. In pigs the vesicles appear in the mouth and around the tail. The affection of the hoofs takes a relatively un- favorable course, owing to the worse conditions to which the feet of pigs are subjected. The affection prevails 220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foot. Forceps. most often in the large herds which are driven long dis- tances to market; under these circumstances the feet are intensely irritated by the long march and the stony, muddy roads. The disease is very often spread over large sections of the country by such herds. Sometimes the disease prevails extensively among horses. The hoof affections are absent and the affection of the mouth takes about the same course as in cattle. The ves- icles appear first on the inside of the lips. Cats and dogs are seldom affected, and when they are, it is from the use of the milk of infected cows. They have only the mouth affection, ulcers on the gums, etc. One case is reported where a cat was apparently infected from being fed on the raw flesh of an animal which had died of the disease. In autopsies made on animals which have died of the disease, or which were killed when there was no proba- bility of recovery, besides the lesions in the mucous mem- brane of the mouth, there are often found severe stomach and intestinal inflammation, erosion and ulceration in the stomach and intestine, and cloudy swelling in the paren- chymatous organs. The treatment of the disease should consist in taking good care of the animals, and placing them in as good hygienic condition as possible. Coarse dry fodder should not be given them, but the diet should consist entirely of meal or fine cut hay, fed wet. They should be kept from stubble pastures, and be driven as little as possible. Should the weather be cold or damp, they must be care- fully housed, and the stables kept well ventilated. This is especially necessary when symptoms of inflammation of the respiratory tracts appear. Any trouble of the lungs or bronchi, may prove fatal in crowded, unventilated sta- bles, where the supply of oxygen is not sufficient. The mouth should be kept clean by washing out with water, to which some honey and carbolic acid are added. In most cases all irritating applications to the affected parts should be avoided, though when the ulcers are extensive and the surface is foul, their healing can often be has- tened by touching them up with a ten per cent, solution of nitrate of silver. It is often advisable, after the vesicles about the hoofs have burst, to clean off the crusts, and after washing with carbolized water to paint the erosions with collodion, in order to prevent irritating substances from coming in contact with them. In case the constipation is obstinate it will be well to give a few doses of Glauber salts to cor- rect this. It has been recommended, with apparent rea- son, to inoculate all the cattle of a herd when the disease first appears. The advantages claimed for this procedure are : that the disease takes a milder course and the pecu- niary loss is less when all animals are affected, and the disease in a comparatively short time disappears from the herd. Inoculation is easily effected by putting the hand into the mouth of an infected cow, and then into the mouth of a healthy one. Inoculation has never been car- ried out on a large scale, so that it is difficult to determine just how much advantage it possesses. Immunity lasting for one to two years is conferred by one attack, and a second attack pursues a milder course than the first. No especial treatment can be advised when the disease appears in man ; it takes so mild a course, and recovery is so rapid, that the less it is treated the better. There should be but little difficulty in making the diag- nosis. The characteristic vesicles in the mouth and hoofs, the appearance of the disease only in an epidemic form, its mild course, the appearance of the milk, its acid reaction, its diminution-these are all points which go to establish the diagnosis. When anthrax prevails extensively there is some danger of mistaking the severe forms, accompa- nied by great intestinal irritation, for intestinal anthrax. The examination of the blood, and the presence or ab- sence of the characteristic anthrax bacilli will settle this point. From the simple ulcer of the tongue the diagnosis is easy. In this there is no evidence of general constitu- tional trouble. Foot and mouth disease has never prevailed to any ex- tent in this country. A few cases have appeared now and then in cattle imported from England, and in the fall of 1870 a rather severe epidemic spread through New York and some of the New England States. The fact of the epidemic appearing in the fall most probably pre- vented the disease from becoming general all over the country. The cattle were housed in the stables, and there was little or no communication between the different herds, so that when the disease appeared in one herd it ran out and spread no further. The disease took its origin in two short-horn cows which were imported from Liverpool to Canada. Klein has recently described a micrococcus which is constantly associated with the disease, and which must be regarded as the pathogenic factor in its production. He has succeeded in isolating the organism, cultivating it in pure cultures through several generations, and then producing the characteristic disease by inoculating ani- mals with the pure culture. He was not able to produce the disease by subcutaneous injections, but he found that when animals had been so injected they were ren- dered incapable of taking the disease in the ordinary manner. Should this become a well-established fact the value of this discovery of Klein's cannnot be overesti- mated. The writer is indebted to Professor Low, of Cornell University, for valuable information concerning the dis- ease in the United States. W. T. Councilman. FORBACH. A village on the left bank of the romantic little river, La Mourg, near Stuttgart, of interest on ac- count of its mineral springs, the water of which resem- bles to a considerable degree the composition of sea-water. Trousseau has especially recommended a resort to this spring for the relief of dyspepsia accompanied with flatu- lence. J. M. F. FORCEPS, OBSTETRICAL. The forceps obstetricius, known, because of its great value, as simply the forceps- asserted by Baudelocque to be the most useful of all sur- gical instruments-made possible the rule given by Hip- pocrates, that in certain difficult labors the hands should be applied to the child's head, and delivery thus effected. The forceps offered artificial hands to be applied without injury to the foetal head, and rendered practicable the ac- complishment of that which the unaided, unarmed human hands could not do. Yet how many centuries Medicine waited for the realization of this important idea, and how meagre was obstetric science, how imperfect obstetric art, until the idea was made actual! The word forceps, plural forcipes, is not derived, as some obstetric authorities have stated, from fortiter and capiens, or capio, that is seizing strongly, but from formas, warm, and capio, as the use of the word by Virgil and Ovid, in describing the work of the Cyclops, plainly proves, and as also shown by the employment by other writers of the term formuccdes, which Scaliger has said should be formucapes, as a synonym for forcipes. Whatever the derivation, all understand by the forceps an instrument which can, with safety to both mother and child, be ap- plied to the head of the latter, substituting a vis a f route, for a deficient or absent cis a tergo, and thus effecting de- livery. History of the Invention of the Forceps.-In the year 1569 William Chamberlen, who, it is believed, was a medical practitioner, his wife Genevieve, and their fam- ily were living in Paris ; they were Huguenots, and, flee- ing from religious persecution, took refuge in England. Peter Chamberlen, the son of William and Genevieve, born in Paris, was, at the time of the removal from France, probably about ten years old; he became cele- brated in the profession, but his great distinction came long after death, for he was the inventor of the obstetric forceps, a fact which the researches of Dr. Aveling have clearly established, for previous to these researches the most conflicting statements were made as to which of the Chamberlens-a family which through two or three gen- erations was represented in the profession, and no less than three of whose representatives bore the same name -the honor belonged. 221 Forceps. Forceps. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The date of the invention is not known, but it prob- ably was sometime in the first quarter of the seventeenth century. The following is a representation of what Aveling as- serts is doubtless the first forceps constructed by Chamber- len. The branches cross, a characteristic of most obstetric forceps made to this day, and they are united by a screw. The Chamberlens had at least three other forceps, simi- larly made, but somewhat improved upon this model. The invention was kept carefully concealed in the family, and used exclusively for their benefit, instead of being made known to the profession. In 1670 Hugh Chamberlen, a descendant of the brother of the inventor, went to Paris, hoping to sell the forceps for "10,000 ecus," about six thousand dollars. After spending some six months, his negotiations came to an abrupt close by his failing to deliver a woman who had such pelvic deform- ity that Mauriceau, then in the height of his fame as an obstetrician, declared could only be delivered by the Cae- sarean operation. The latter, who we may be sure would tell the worst in regard to the conduct of this would-be rival, states that Chamberlen asserted he could deliver the poor woman in half of a quarter of an hour, but that he tried for three hours without stopping except to take breath, uselessly exhausting his strength as well as his industry, and then abandoned his efforts when he saw that the patient was likely to die on his hands. The post-mortem examination of the woman, who lived until twenty-four hours after Chamberlen's attempt, showed that the uterus had been greatly injured by the instrument. In a few days Chamberlen re- turned to England. In 1693 he went to Amsterdam, and was more successful in his efforts to dispose of his secret than he had been in Paris, for the famous Roonhuysen became its purchaser. The latter associated with him Ruysch and Boelkman, and the firm, with their successors, seem to have carried on for several years a successful trade in the for- ceps ; this traffic was greatly in- creased by the original purchasers having a law passed forbidding any to practise obstetrics unless first ex- amined by them, and then purchas- ing the secret. The baseness of those' who thus trafficked in the for- ceps sank, as Klein wachter says, still lower ; for in some cases only part of the secret was sold, one blade of the forceps being given. Roonhuysen had a student named Van der Swam, who had been with him several years, and whom he had promised to teach the art of deliv- ery, but had failed to make his promise good. One day this student had, by a fortunate accident, an opportunity to see the forceps without the knowledge of his preceptor. He made drawings of it, and let a friend have them ; that friend communicated them to Peter Rathlaw, who, com- ing to Amsterdam to practise obstetrics, had been rejected by the Amsterdam examiners because he refused to buy the secret. Rathlaw made good use of the knowledge acquired after his rejection, for, actuated possibly by re- venge, he published a description of the forceps in 1747. In 1716 Jean Palfyn, of Gand, who was a celebrated surgeon, presented to the Paris Academy an instrument devised by him, consisting of two parallel blades, which were to be applied, one on each side, to the foetal head, and by which extraction was to be then made ; they were known as the Palfynian hands, Manus Palfyniana. Dif- ferent devices were used for fastening the hands together after their introduction-Heister among others attempted thus to make the instrument useful, but failed-neverthe- less the instrument was not successful. Still it repre- sented an idea in the construction of the obstetric forceps which a hundred years after was made practical, and which an obstetrician of the present day, Chassaignay, has sought to realize, regarding it as of great importance that the branches of the instrument shall be parallel in- stead of crossing. The celebrated obstetrician La Motte saw Palfyn's in- strument at Paris, and declared that it was as impossible to use it successfully as it would be to pass a cable through the eye of a needle. In 1734 Mr. Alexander Butter, surgeon in Edinburgh, published an account "of a forceps used by Mr. Duse, who practised midwifery in Paris," stating that it was " scarce known in this country, though Mr. Chapman tells us it was long made use of by Dr. Chamberlane, who kept the form of it a secret, as Mr. Chapman also does." Nevertheless " Chapman, in 1733, published a description and plate of the instrument which he had used from the year 1726, stating it to be the instrument used by the Chamberlens, but without stating whence he had pro- cured it " (Churchill). It also appears that Drinkwater, of Brentford, "surgeon and man-midwife," who began practice in 1668, and died in 1728, had similar forceps. From the time of the publication by Chapman, the Cham- berlen forceps became the property of the profession. The conduct of the Chamberlens in keeping the forceps a family secret has met with general professional condemnation. Recent- ly, however, some voices have been lifted up, if not in defence, at least in palliation of their conduct, Avel- ing, for example, saying that it is not fair to judge members of the profession who lived two hundred years ago by the code of ethics which medical men now accept; and Poullet promptly responds that those who condemn the Chamber- lens commit an anachronism. Right must have some firmer foundation than the shifting sands of public opinion ; " ought is an ethical atom," not merely in the fact that it is an ultimate defying analysis, but that it remains always the same ; human standards of right and wrong may vary with knowl- edge, with conventionalities, and the prevailing sentiment of the times ; nevertheless, none nor all of these can make that right which is es- sentially wrong. The ethical rule which governed the conduct of the Chamberlens was not found in the teaching of Hippocrates, and no one for a moment can suppose that, if Sydenham or Harvey had invented the forceps and learned its great value for the saving of human life, and the relief of human suffering, either would have kept it secret, but rather would have hastened to proclaim the instrument and its importance to the profession. The general verdict of the profession upon the conduct of the Chamberlens probably had better remain undisturbed. Varieties of Forceps.-Kleinwachter states that at the beginning of the present century every professor thought it important that he should devise a new forceps, which, of course, when made received his name. This ambition has not been limited to obstetric teachers, nor is it yet extinct. Where inventive genius failed to produce a new instrument, it was usually equal to making some modification of an old one, so that the author, if he could not say " my forceps," could atleast say " my modification," and such words with some carry great authority and con- sequence. The profession has thus had forceps almost innumerable-some long, some short, some with narrow blades for introduction in the only partially dilated os ; others with asymmetrical blades for sacro-pubic applica- tion ; some of " gigantic volume," dangerous alike to the mother aud to the foetus ; some physicians have invented Fig. 1313.-Chamberlen's Forceps. Fig. 1314.-Palfyn's For- ceps. 222 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Forceps. Forceps. what Delore has called microscopic, or pocket forceps- mere toys, or at least capable of meeting only the most trivial needs. Many of the forceps invented show modifi- cations of modifications immoderately made, alterations of alterations, additions to additions, originalities that are not priorities, until one finds it far more difficult to re- member half of them than to recall, at the bedside of a woman in labor, the many foetal presentations and posi- tions given by Baudelocque. Undoubtedly hundreds of obstetric forceps have been devised, but, in regard to each one of the majority of these hundreds, only a single instrument has been made, and that for the inventor. In some instances the new forceps which gave fame to the inventor never existed, probably, save in the form of a drawing,* nevertheless drawing and description have been published of ' ' the author's instru- ment." Velpeau wisely remarked that very many of the alleged improvements in the forceps have been made by young men, who have not yet learned that in all surgical opera- tions much less depends upon the form of the instrument than upon the skill and ability of the man. The most important improvement in the Chamberlen instrument was that made by Levret, the addition of the pelvic curve ; he presented his " new curved forceps " to the Royal Academy of Surgery, Paris, in January, 1747. It was not until after 1751 that the great British ob- stetrician, Smellie, speaks of using the pelvic curve in his instrument. Pugh, a contemporary of Smellie, a prac- titioner at Chelmsford, England, published in 1754 the statement that he had invented the pelvic curve in 1740. But professional opinion cheerfully concedes priority in the invention to Levret, because of priority of publica- tion. Obstetricians universally accept the advantages of the pelvic curve. Not so, however, with the next great im- provement in the instrument, that of Tarnier (1877), by which traction is made in the axis of the birth canal, some regarding the axis-traction forceps -chief among these being Pajot-as no advance upon the old instrument. Some obstetricians, especially those of Lyons, have insisted upon the importance of the plan shown in the forceps of Palfyn, that is, the branches instead of being crossed are parallel. Description of the Forceps.-The short, straight forceps, which never was much used in this country, and which has fewer advocates abroad, in Great Britain or Ireland, than it had even twenty years ago, will not be considered in this description, the ordinary long for- ceps only being referred to. This consists of two halves, known as branches or arms, these branches being distinguished as right and left. A fundamental law gov- erning their application gives rise to these names; thus the left branch is held in the obstetrician's left hand, and introduced in the left side of the mother's pelvis, while the right branch is held in the right hand, and introduced into the right side of the pelvis-this being the only un- changeable law in the application of the forceps. The instrument is made of steel, and the blade should have some elasticity, but not the least flexibility; the surface should be smooth and pol- ished, so as to be readily and thoroughly cleaned ; the gutta-percha covered instruments ought to be rejected, for in spite of all care the covering will be broken, and the roughened surfaces thus left will be a most inviting lurking-place for septic poison. Each branch is divided into a handle, an articulating portion or joint, and a blade. The handle must be shorter than the blade, lest too much power of compression be given the instrument. In many forceps the handle ends externally in a blunt hook, which, in rare emergencies, may be of value, but often proves an incon- venience, and may very well be omitted. They may be covered upon their exter- nal side with ivory or ebony, this being grooved or notched so that they can be more firmly grasped. In some instru- ments, Simpson's, for example, each handle has near the lock a transverse projection, or shoulder, so that two fingers may be placed over these when traction is made ; a similar addition can be usefully made to the Davis for- ceps. Not only is a convenient method for traction thus secured, but avoidance of too great compression of the head, which might occur, at least with some forceps, when the handles are firmly grasped. In Bedford's forceps rings take the place of shoulders in Simp- son's. The lock may be a fixed button or tenon upon one branch, which ac- curately fits into a mortise or depres- sion in the other branch ; or there may be a screw which, after locking, may by a few turns be made to more firmly fasten the branches together ; or that which is known as the English lock, as seen in the illustration of Simpson's instrument, the one branch notched just beyond the shoulder, and into this notch a narrowed part of the other branch fits. The blade is fenestrated, thus mak- ing it lighter and securing better adap- tation to the foetal head ; the fenestra has somewhat the form of an elongated oval, and both the external and in- ternal margins of the blade are bevelled. Looking at the branches when locked, it will be seen that each blade pre- sents above a concavity, below a convexity; this curve was called by Levret the new curve, but is generally known as the pelvic curve ; it adds greatly to the readiness of application of the instrument when the head is in the pelvic cavity, or at the inlet, and to the efficiency of the instrument. Another curve which all forceps have in com- mon with that originally invented, is called the cephalic curve ; each blade is concave internally, while convex exter- nally ; the blades thus fit closely upon the foetal head, and at the same time oc- cupy the least space. In no forceps is this curve better adapted to the sides of the foetal head than in the Davis instru- ment. When the branches of the for- ceps are united the points of the blades should not touch, but be at least half an inch apart; the distance between the blades themselves varies in different in- struments ; thus, it is three inches in Simpson's, two inches and a half in Hodge's, and two and a fourth in Davis's. It should be remembered that this measurement is made between the two op- posite most distant points of the margins of the blades. Forceps vary in length, and even the same forceps varies as fur- nished by different makers. In illustra- tion of the latter point, I have three of the so-called Davis forceps, procured from three different dealers ; one of the instruments is less than eleven inches in length, while the second is thirteen, and the fourth is fourteen inches long ; the first instrument, though procured from a leading Newr York house, is Fig. 1316.-Simpson's Forceps. Fig. 1315.-French Forceps. Fig. 1317. - The Davis Forceps with Shoulders on Han- dles. * The writer happens to know of a treatise on obstetrics in which the author gives a representation of his forceps, and yet the instrument never advanced beyond this primary condition ; it exists only as a draw- ing. 223 Forceps. Forceps. REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES. coarse, heavy, and does great injustice to one of the best of obstetric forceps, while the second is modelled in all essentials after the forceps used by the late Professor Meigs, weighs but ten ounces and a half, and is adequate to almost every case in which forceps delivery is advisable. The Hodge forceps is sixteen inches long, that of the late Dr. Wallace, fifteen inches ; Braun's Simpson, fourteen inches ; Elliot's, fifteen inches ; Robertson's, thirteen inches and a half ; Barnes's, fifteen inches ; Pajot's for- ceps is forty-five centimetres, and Stoltz's forty-two, the same length as Levret's. Powers of the Forceps.-1. A dynamic action has been claimed for this instrument. It sometimes hap- pens that even after the introduction of a single blade of the instrument languishing uterine contractions are quick- ened, or absent ones recalled, and so much importance was attached to this occasional occurrence that Kilian devised a galvanic forceps, hoping thus to increase the dynamic power of the instrument, but the experiment, of course, failed. The obstetrician, so far from seeing any quickening effect upon uterine and abdominal action re- sulting from the application of the forceps, may find such action entirely ceasing, and hence no trust can be put in a dynamic action of the instrument. 2. The forceps may be used to compress the foetal head. Experiments have proved that the diameter compressed can be reduced a little more than one-third of an inch, but that compression carried beyond this is liable to cause fractures. Moreover, when the blades are applied, as they ought always to be, if possible, to the sides of the child's head, there is no gain in compressing any of the trans-, verse diameters, as there is no hinderance arising from any of these being too great. Still more, if the biparietal diameter be lessened by compression, the suboccipito- bregmatic is increased, so that there is no absolute, or only slight, diminution of the head-circumference. Fur- ther, such compression hinders the moulding of the head, by which nature seeks to adapt it to the canal it must pass through ; it hinders, too, the movements of the head occurring in normal, labor. That a particular forceps is a powerful compressor is not a commendation, but a con- demnation. In traction more or less pressure is made upon the head ; according to Delore's experiments the pressure perpendicular to the axis of the head is about one-half the traction. There is a relation between the force of traction and the degree of compression, which will be referred to hereafter. Enough now to state that in the opinion of most obstetricians any compression be- yond that which is required to prevent the instrument from slipping is unnecessary, and may be injurious. 3. The forceps as a lever. Notwithstanding able the- oretical arguments by some, especially by Dr. Ma- thews Duncan and by the late Dr. Albert H. Smith, against the pendulum, lateral, or oscillatory movements of the forceps, most obstetricians use them in certain conditions, and this practice is confirmed by the experi- ments of Delore and of Berne. The former states, as the result of his experiments made with the dynamom- eter, that by slight oscillatory movements great differ- ences are obtained, which may vary from twenty-five to sixty-five kilograms when strong tractions are used. In using the forceps as a lever the fulcrum is on one, and then on the other side of the birth-canal-or one of the hands of the operator may be placed externally upon one, then upon the other, side of the vulval margin, and thus be made the fulcrum, while the other grasps the handles-the power is at the handles, and the resist- ance the head, firmly held by the blades. As Spiegel- berg especially enjoins, traction should always be asso- ciated with this to-and-fro movement, a movement which should be gradual, not abrupt, and not great, and should only be regarded as a supplement to the former when that is insufficient to effect delivery; if traction be not made the head simply seesaws with the lateral move- ments, the fulcrum on each side not advancing, but con- stantly remaining the same, and thus no progress is made to delivery. 4. The forceps used to effect rotation. It not unsel- dom happens that in occipito-anterior positions the in- troduction of the posterior blade of the forceps causes the occiput to rotate in tlie pubic arch. In persistent occip- ito-posterior positions many obstetricians advocate at least the attempt to produce anterior rotation by the for- ceps. Kristeller describes rotation movements as " suc- cessive cyclic, horizontal, and vertical movements, with the transition movements that occur between them " (Spie- gel berg). While in the pendulum movements the fulcrum moves down in a straight line, in the rotation movements it moves spirally. Spiegelberg further states that a ring so tight upon the finger that it cannot be removed by pull- ing in a straight line, but can be by twisting movements, or partial rotations, is an imperfect illustration of the pendulum and rotation movements. He regards ro- tation movements as less efficient, and decidedly more dangerous, than pendulum movements, but that they may be useful when the position of the head is not known, as indicating the right direction for traction, and that of least resistance. This doctrine should be accepted not without hesitation, and yet, coming from such eminent authority, not rejected without just consideration. But in general the use of the forceps as a rotator is but ex- ceptionally advisable, and frequently then the attempt is only an attempt-only an experiment. 5. The forceps as a tractor. Having thus considered the doubtful or occasional powers of the forceps, or powers that are only exceptionally required, we come finally to the essential power of the instrument, that of traction. The pulling power made by means of the for- ceps is to be considered in reference to the force exerted, the line of direction of the pull, and as to whether this traction should be intermittent or continuous. In easy labors the force exerted is probably, as stated by Mathews Duncan, little more than equivalent to the weight of the child ; in difficult labors it is very much greater, possibly amounting to fifty pounds, and in for- ceps delivery it is in some cases very much greater than even the latter. Here is Delore's statement as to the force that may be used with the forceps. A man without sup- port, that is, not bracing himself, exerts a force equal to 88 pounds ; with support, twice as much, or 176 pounds, the same as two men, but the two with support, 286 pounds. According to Tarnier, and this opinion is in- dorsed by Delore, it is scarcely ever necessary to use a force exceeding 132 pounds ; a force exceeding this is dan- gerous. It is very rarely that the obstetrician finds it necessary to even approximate this figure ; according to Spiegelberg the pulling should be done with the forearms, while the arms rest by the sides ; there is usually no neces- sity for extending the arms, still less for bracing the body by placing the feet against the bed. It is universally agreed that the direction of the pull should correspond with the axis of the birth-canal. But what is that axis ? Obstetricians for a time held that it was represented by the curve of Carns, and then a para- bolic curve was substituted, as better showing this axis; but as the investigations, first of Fabbri, afterward of Sabatier, of Pinard, and more recently of Boissard, show the obstetric pelvis, the dynamic as distinguished from the static pelvis-the soft parts being appended to the bony pelvis, and those which make the pelvic floor, thus forming the entire pelvis-presents a cavity which is not in any respect a curved canal, but rather a cavity chiefly cylindrical, having two walls, anterior and posterior, almost vertical, and at'the fundus forming a plane nearly perpendicular to these two walls. The cylinder has its fundus at the coccyx, and an opening upon the anterior wall. Now, laying aside confusing curves, pelvic inclined planes, and speculative synclitisms, the head descends to the pelvic floor in a straight line, then turns at almost a right angle to make its exit at the vulva ; in other words, the axis of the birth-canal is at first a line directed back- ward and downward, and then a line almost perpendic- ular to it. Hence, until the head reaches the pelvic floor, the fundus of the pelvic cylinder, the traction with the forceps must be downward and backward, and then up- ward and forward. When the head is high in the pelvic cavity, or is just entering the inlet, pulling downward 224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Forceps. Forceps. and backward, that is, in the axis of the obstetric pelvis, is not an easy task ; and yet, if it be not done, there is a great loss of power. Now, to effect such traction, many obstetricians, since Osiander, have resorted to pressure downward at or be- yond the forceps lock with one hand, while the other grasps the handles near their end, not so much for mak- pull was, theoretically at least, in the axis of the pelvis. Hermann, in 1840, applied traction-rods to the forceps blades, but this invention seemed to attract no attention until after 1877, the year in which Tarnier first exhibited his own forceps with traction-rods. The following is an illustration of Tarnier's instrument, not as originally de- vised, but as subsequently modified (see Fig. 1320). Many modifications of Tarnier's instrument have been made, among the best of which are that of Simpson and that of Lusk; other axis-traction forceps have been de- vised, and among those worthy of note are the instruments of McFerran, of Philadelphia, and that of Breus. While many distinguished obstetricians have hailed the forceps of Tarnier as marking a new era in obstetrics, and as being the only important change since Levret gave the forceps the pelvic curve, others, chief among whom may be mentioned Pajot, prefer the old instrument, " the classic forceps." Tarnier's is a much more ex- pensive instrument, and more complicated, and prob- ably never will supersede the old forceps, while it pre- sents great advantages in special cases-cases, how- ever, which rarely occur to the general practitioner. The general rule, as to traction with the forceps, is that it should be intermittent-a pull, and a pause- our art thus an imitation of nature, which in normal labor expels the child by intermittent, not by continu- ous contractions. Nevertheless, Pinard regards slowness of traction as more important than in- termittence. Indications for the Use of the Forceps. -The forceps is alike the mother's and the child's instrument, and the indications for its use may be summed up as, whenever the life of either re- quires immediate delivery. Thus, on the part of the mother, convulsions, haemorrhage, rupture of the uterus, excessive feebleness, ' ' threatened asphyxia from cardiac or pulmonary disease," arrest of the progress of the labor from perineal resistance ; on the part of the foetus, prolapse of the cord, com- plicated presentation, sud- den death of the mother, feebleness of the cardiac pulsations, either associ- ated with great slowness or frequency, showing in- terference with the utero- placental circulation, or compression of the cord, may be present, and demand instru- mental delivery. May the obste- trician use the forceps solely for the purpose of shortening the mother's suffering ? Spiegelberg admits this indication, but wisely adds that he who undertakes such " luxus-opera- tion " must understand how to con- trol his hands intellectually and mechanically ; but this is not al- ways the case, a.id the intended as- sistance is often the reverse. Conditions Necessary for the Use of the Forceps.-1. The for- ceps is to be applied to the head of the child ; the head may be first or last, the presentation may be cranial or facial, but the rule is to apply the forceps blades only to the head. The application of the forceps in pelvic presentation was probably first suggested by Levret, and in recent years Pajot has given this use of the instrument a quali- fied approval, if the child be dead. But for several years some obstetricians have used the forceps in pelvic presen- tation when the child was living, and in some instances the child has thus been safely delivered, after the means usually resorted to in delayed pelvic deliveries had been vainly tried. Among those who have in recent years rec- ing traction as to resist the downward pressure of the other hand, and thus the handles become a lever rather than means by which pulling is done. The preceding fig- ure (Fig. 1318) is copied from an illustration published in connection with a paper by the late Dr. Albert H. Smith. Pajot's method is the following: "We apply the left hand as near as possible to the vulva, the right hand near the end of the handles; then we use sometimes these two hands in order to make the forceps, at times a lever of the first order, sometimes of the third, sometimes a lever and a tractor at the same time, sometimes a direct tractor. Fig. 1318. Fig. 1320. Fig. 1319.-Pajot's Manoeuvre. according to the resistances and the height of the pelvis at which they are found." Other methods of securing axis-traction have been by certain modifications of the forceps itself, or by attaching to it, at or near the blades, traction-rods. Hubert had arms projecting from the under surface of each handle of his forceps. Morales gave the handles of his instrument a perineal curve, so that pulling on the lower portion the 225 Forceps. Forceps. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ommended pelvic application of the forceps, may be mentioned Frari, Tarnier, Miles, Pinard, Behizzi, and Lusk. Frari, of Pavia, in 1847, devised a forceps for this purpose, and so have Miles, of Cincinnati, and Beluzzi, of Bologna, each constructed an instrument for like purpose. The practice is growing in favor, and will probably ul- timately meet with general professional acceptance. The subjoined illustration shows the forceps applied to the thighs in a case of pelvic presentation in which the lower limbs are extended upon the trunk. Tarnier's forceps has, in the unvarying compression exerted, an advantage over other instruments for this use. 2. The mouth of the womb must be completely di- lated, or so far dilated and so dilatable that the blades can be readily introduced and applied, and then extrac- tion of the head made without injury to the lower seg- ment of the uterus; if this rule be neglected, there is danger of the forceps blades tearing the neck of the womb as they are introduced, or else, when traction is made, "the lower uterine segment will be dragged down," or The advocates of forceps with parallel, instead of crossed, branches, claim as an advantage of such instru- ment, that it is peculiarly adapted to large heads, grasp- ing these with such firmness-and yet without injury- that extraction can be more readily accomplished. We present one form of the forceps with parallel blades, the forceps of Valette. 4. The birth-canal must present no serious hinderance, either from pelvic deformity or from neoplasms, to the passage of the child. The hinderance most frequently arises from narrowing of the pelvic inlet, and the question as to whether podalic version, or the application of the forceps, be indicated, is one in regard to which eminent obstetric authorities differ. Certainly, if prema- ture labor be induced, the results obtained by version give it the preference over forceps. Barnes makes the limit in the pelvic narrowing as three inches and a fourth, which will admit of the useful application of the forceps, at the same time stating that a head slightly below the normal size, and less firmly ossified than usual, may be brought through a conjugate diameter of only three inches. Pi- nard holds that if the pelvis measure less than eight cen- timetres, the infant being at term and presenting normal ossification of the bones of the head, the forceps is not to be applied but with the greatest prudence ; traction should be made gently and slowly, for the cases of exceptional success reported by dif- ferent authors have naturally caused excessive tractions which could not but mutilate the foetus, and, further, killed both mother and child. 5. Spiegelberg makes the condition positive that the head has passed the in- let by its greatest periphery, while Pajot regards it as favorable for the applica- tion of the forceps. When obstetricians speak of the head being at the superior strait or inlet, they do not mean that it is just at its entrance, but that it has so far descended that the parietal protuber- ances are as low as the ilio-pectineal line. The application of the forceps when the head is movable above the inlet is re- jected by most obstetric authorities, po- dalic version being preferred, unless, as stated by Charpentier, the uterus, in consequence of the flow of the amniotic liquor, is strongly contracted upon the foetus, rendering version impossible, and one then rightfully tries the application of the forceps. Those who are partial to Tarnier's axis-traction forceps regard it as peculiarly favorable for use when the head is high up, not having entered the pelvic inlet; Spiegelberg observes that such application when the head is high, or, perhaps, to the movable head, is not a matter of indifference for mother or for child, and must not be made to the extent that many claim. Hodge regarded " fixation of the head, and its partial pro- jection through the superior strait," as " essential prere- quisites for the operation of the forceps." Preparations for Using the Forceps.-Few women suffering the agony of childbirth who do not gladly ac- cept means which will shorten the duration of that agony ; few women, when their unborn child is in peril, who have not the maternal instinct so strong that they will cheerfully consent to the use of the forceps to ward off that peril. It is unnecessary, as some obstetric authorities have recommended, to show the patient the instrument; if foolish and timorous, she will not be thereby reassured, but rather have her fear increased; while the wise and cour- ageous are willing to trust the word of their physician when they have confidence in him. Delore very well sug- gests that, if it happen that the obstetrician has not his forceps with him, it is better to send rather than go for the instrument, lest the labor end in his absence. the tissues about the mouth of the womb be torn or seri- ously bruised. Dubois devised forceps with narrow blades for intro- duction into the partially dilated os, but, according to Tarnier, the results were bad. Dr. Taylor, of New York, also has narrow-bladed forceps for like use in certain cases. The late Dr. Al- bert H. Smith advocated in some cases-in which the first stage of labor was delayed after the evacuation of the liquor amnii, the uterine contractions being feeble- seizing the head within the uterus by the Davis forceps, but then using the instrument, not for extraction, but simply to bring the presenting part down to the os, so that by the pressure of the former upon the latter more vigorous uterine action might be evoked. A few years ago some distinguished members of the Dublin school urged the early application of the forceps ; one of them, Johnston, thus applied the instrument once in ten cases, but Spiegelberg has remarked that the results he obtained were decidedly more unfavorable than those which can be had by waiting. It is only when the condition of mother or of child is one of great and immediate peril that the rule given may be departed from, and these cases are quite exceptional. 3. The head must be of normal size and consistence. A small or macerated head readily slips out of the forceps blades, and these cannot be sufficiently approximated if the head be very large, as, for example, in hydrocephalus. Fig. 1322.-Forceps of Valette, of Ly- ons. Each branch has a bayonet ar- ticulation. The branches are paral- lel instead of crossed. Fig. 1321.-Tarnier's Forceps Applied in Pelvic Presenta- tion. 226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Forceps. Forceps. If the foetal head be low, only the resistance of the vulvo-vaginal outlet to be overcome, the patient may be brought to the foot of the bed, the lower limbs being flexed ; but if the head be in the pelvic cavity, or at the inlet, she should be placed across the bed, her hips at its edge, and each foot resting on a chair, while each knee is held by an assistant. The bladder should be artificially evacuated, if necessary, for the use of the forceps with a distended bladder may have the most deplorable results so far as the integrity of the vesico-vaginal wall is con- cerned. The use of an anaesthetic will be advisable in most cases ; however, this may be left usually to the decision of the patient, it being always remembered that the anaes- thesia is obstetric, not surgical. It is advisable, especial- ly if the labor has been protracted, to thoroughly cleanse the vagina by a warm antiseptic injection, as, for example, a two per cent, solution of carbolic acid, or a solution of corrosive chloride, one part to five thousand of water. The obstetrician should have at hand hot water, and other means that may be necessary if the child happen to be partially asphyxiated, and he also has ready his hypo- dermic syringe, sulphuric ether, and a liquid preparation of ergot, in case the condition of the mother after delivery should require either of the two latter to be given. He auscults the foetal heart, and thus knows the condition of the child ; he repeats very carefully digital vaginal exami- nation, so as to be fully assured as to the presenting part and its position ; and if any doubt remains, let him intro- duce the hand into the vagina, when, for example, he can by feeling the car of the foetus, and observing the direction of its convex border, at once know both pres- entation and position. He will require at least two as- sistants, as, for example, the nurse and the husband of the patient; but more may be needed, according to the difficulty of the operation, or the indocility of the pa- tient. Operation.-This includes three acts : (1) the introduc- tion of the blades of the forceps ; (2) locking the branches ; and (3) extraction. The instrument having been first made aseptic and warmed by dipping each branch into a warm solution of carbolic acid, he applies to the ex- ternal surface of each blade carbolized cosmoline, vase- line, or oil, and similarly annoints the fingers of his right hand. As the locking is effected when the right branch rests upon the left, the general rule is to introduce the left blade first-" left blade, held in the left hand, and always passed in the left side of the mother's pelvis "- and accordingly this is taken in the left hand, the thumb being placed upon the inner, the fingers upon the outer surface near the lock ; the grasp should be firm, secure, but gentle. The obstetrician takes a convenient position, for example, either sitting or standing between the pa- tient's knees, if she be lying across the bed ; introduces two, or if the head be high up four, fingers of the right hand into the vagina, and if possible brings their tips in contact with the margin of the mouth of the womb, and thus the fingers are made a guide to the course of the forceps blade, and a guard to the maternal parts, saving them from injury. The point of the blade is now made to enter the vulval orifice, the handle pointing upward and to the right, the blade " sinks by its own weight into the peri- neo-sacral gutter," its convexity presses against the inner surface of the introduced fingers, its concavity adapts itself to the foetal head ; with the ascent of the blade, which should be assisted by gentle pressure with the left hand, and its concave surface kept in contact with the foetal head by the fingers of the right hand, the handle moves downward and to the left, so that it becomes nearly horizontal, and in the median line. Here the question arises, should the forceps be applied simply transversely with reference to the mother's pelvis, or to the sides of the child's head ? Many British and German obstetricians hold to the former, while the general teach- ing of French and American is in favor of the latter. Of course, when the head is low and internal rotation has occurred, the mode of application necessarily meets both requirements ; but the difference of methods comes when the head is high. The arguments in favor of placing the blades upon the sides of the child's head are, that the sides are the only parts that are symmetrical-the only parts, if labor has been in progress for some time, that lie in the same plane, and to them only are the con- cavities of the blades accurately adapted. The last re- mark applies especially to the Davis forceps, and if one prefers applying the forceps transversely in the mother's pelvis, without reference to the position of the foetal head, he will select an instrument having a wide interval between the blades, such as that of Simpson. Whichever method is adopted, it should be borne in mind that the blade must be introduced gently, not forcibly-gliding, feeling its way to the proper place ; decided resistance to its progress proves that the direction is wrong, and therefore must be changed ; the words arte non ri, which Blundell suggested should be engraved on one of the forceps blades, should not be forgotten in their introduction. After the first blade is placed in position, its handle is given in charge of an assistant, while the obstetrician in- troduces the second blade. The latter takes the right branch in his right hand-right blade, held in the right hand, and introduced into the right side of the mother's pelvis-and, using the fingers of the left hand in a simi- lar manner and for the same purpose that those of the right were used when the first blade was introduced, the second is placed on the opposite side of the child's head. When the operation is completed, the right handle rests upon the left, and they are usually locked without diffi- culty. Such difficulty may occur either because one blade has been introduced farther than the other, or because the handles are not in the same plane. The difficulty in the first case is removed by pushing the one blade farther in, or slightly withdrawing the other. Where the handles are found to be in different planes, each handle is grasped by a hand, and the operator gently rotates the blades in oppo- site directions ; if this fail to make the handles parallel, the second blade is removed and reintroduced, and if failure still follow, both blades must be taken out, and the effort made to introduce them so that the proper relation shall be secured. If, with some difficulty in locking, it is after- ward found that the handles cannot be approximated, but stand widely apart, this may result from the head being irregularly grasped, or from its being of unusual size, or from the blades not having been passed far enough over the head. In the last case it may happen that, if the handles are thus left without effort to bring them to- gether-the blades of course being correspondingly sepa- rated-a few vigorous uterine contractions will force the head farther down in the embrace of the blades, and the difficulty is ended. Irregular seizure of the head-as, for example, that in which an oblique occipito-frontal diam- eter instead of the biparietal lies in the transverse diam- eter of the blades-is necessary in some cases ; the opera- tor recognizes this condition, and makes no effort to force the handles together, remembering the golden rule as to compression-let it only be sufficient to keep the insfru. Fig. 1323.-Introduction of Left Blade of Forceps. 227 Forceps. Forceps. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ment from slipping. The difficulty in approximating the handles is always great, even insuperable in case of a very large head, and it is possible that the instrument may slip after the most careful application, when this method of delivery may have to be abandoned. A mistake which I am sure is not infrequently made, is failure to introduce the blades far enough, and then, for example, they lie in the direction of the occipito-frontal instead of the occipito-mental diameter. Care must be taken in the locking that hair or folds of skin of the external genital organs are not caught in the lock. The readiness with which locking occurs, the approxi- mation of the handles, the firmness and fixed state of the forceps, the instrument and the head making for the time being a unit, indicate that the blades are in proper posi- tion. That these include nothing more than the head- no prolapsed cord, or projecting border of the uterus, and no vaginal fold-has been guarded against by the careful manner of their introduction ; but if there be any possi- bility of such an accident having occurred, the sole means of resolving the doubt is to " introduce one or two fingers to the level of the blades, as well in front as behind." The traction, as before stated, should, as a rule, be in- termittent ; full force must not be employed at first ; it may not be necessary at all, but if required it should be in- creased gradually ; pulling with the forearms, or with one of them at first, the arms being by the side, is a practice that has been advised. Usually if the force be given the right direction, it need not be great; but in rare instances the accoucheur has to exert considerable force-it must be his own, unassisted by that of another. In some in- stances the operator may find an immediate forceps de- livery carrying greater danger to the mother and to the child, or to both, than will a delay until nature's forces have moulded the foetal head, thus facilitating its trans- mission through the birth-canal, and therefore the effort at instrumental delivery must be postponed until such moulding has occurred. Should the forceps be removed before the head is deliv- ered ? Such removal has been strongly recommended in recent years by Freund, Goodell, Lusk, and others, and it has been made a rule of practice by Taylor, of New York, for a long time. It is the revival of an old prac- tice. " Among the German authors, Boer, and after him Joerg, Carns, and others have recommended removing the forceps as soon as the head is engaged in the vulva, if there is no indication for the immediate termination of the delivery " (Naegele and Grenser). Madame Lacha- pelle strongly advocated this plan. The object sought by the removal is to prevent injury to the perineum by thus taking away the addition to the head circumference caused by the blades of the forceps. The objections that have been made to this practice are, that while the accoucheur is removing the instrument, a violent con- traction may suddenly expel the head, and he being otherwise occupied, is powerless to give any protection to the perineum ; or nature's forces, on the other hand, may be unequal to the expulsion, and a reapplication of the forceps may be necessary. Moreover, we have in the forceps the best means of retarding the exit of the head until the vulval orifice is sufficiently dilated, and at the same time of guiding it in its proper direction when that exit is made ; the forceps may be so used that the peri- neum will suffer less injury than in natural labor. Having given this general consideration of the applica- tion of the forceps, there will now be presented the method in which the instrument is used in different presentations and positions. Head-first Labor.-Cranial Presentation, and (1) Occip- ito-pubic Position. In this position the head was so small that it entered the inlet with its occipito-frontal diameter in relation with the antero-posterior of the for- mer, instead of one of the obliques or the transverse ; or, and this is the more frequent case, anterior rotation, in- stead of direct descent, has placed the occiput at the sub- pubic ligament, or in the pubic arch. The blades of the forceps are necessarily placed in direct relation with the sides of the mother's pelvis, and upon the sides of the child's head. In a primipara the nearer the head is to the vulval orifice, the more difficult the introduction of the guiding fingers, but this introduction need go no far- ther than the parietal protuberances, for if the rim of the os uteri has cleared these it has retracted as far as the child's neck ; passing the blades deeply in is unnecessary, and may do serious injury. After locking, which is ea- sily done, the traction should be somewhat downward at first, if the occiput has not come in front of the subpubic ligament; but if it has, or after it has been brought thus in front, the handles are gradually raised so as to assist deflection, the occipital end of the long head diam- eter being outside the pelvis, and the normal delivery of the head taking place by a rotation upon its transverse axis through the arc of a circle, suboccipital diameters measuring the distance from the lower margin of the pubic joint to the anterior margin of the perineum. Care must be taken to observe this normal mechanism in for- ceps delivery. Where immediate extraction of the child is not imperative, let the head be held back until the parts are sufficiently dilated, and gradually lead it out, the nucha being made to hug the subpubic ligament. At the end of the extraction of the head, the handles of the forceps will be near to and almost parallel with the mother's anterior abdominal wall. Only one hand is needed for the forceps, and the other should be used to note the condition of the perineum, and to protect it from being torn. (2) Occipito-sacral Position. After the application of the forceps the pull must be upward and somewhat forward, increasing the head-flexion, until the occiput emerges over the anterior margin of the perineum, and then the head is delivered by extension, the nucha pivot- ing upon the anterior border of the perineum. Some accoucheurs, among whom Charpentier may be mentioned, always attempt anterior rotation, and it is only when this attempt fails that delivery over the perineum is accepted. (3) Left Occipito-anterior Position. Supposing the head to be in the pelvic cavity, the left blade, which is introduced first, is passed to the left side, and posteri- orly, so that it corresponds with the left sacro-iliac joint; very frequently the introduction of this blade determines anterior rotation of the occiput, and then the position is simply occipito-pubic, so that the introduction of the second blade is the same as has been described. But when this rotation does not occur, the right blade is "di- rected at first below, to the right and posteriorly, then brought by a very extensive spiral* movement to the level of the right ilio-pectineal eminence." After the blades are applied and locked, traction with anterior rotation, and delivery of the head as in occipito-pubic position ; no attempt at rotation, however, should be made until the head has reached the pelvic floor. Should the head be at the inlet, still the effort should be made to place the blades at the sides of the head. The simple rule given by Pinard applies in common to these, and to all oblique or diagonal positions which the head may occupy in the pelvis. Place the two blades at the two extremities of the empty oblique diameter ; by such di- ameter is meant that in which the transverse diameters of the head are, and especially the biparietal, because this diameter does not occupy all its extent, there being al- ways a space left between the former and the pelvis. * This is known as the method of Madame Lachapelle, and has been described by her as follows: " If the branches are to be placed diago- nally, that is, one behind on one side, the other in front upon the opposite side, it will suffice to pass directly the branch which ought to remain posteriorly over the sacro-sciatic ligament-nothing arrests it. The other can be easily managed if I commence with it. Held in the hand as a pen. and leaning it across over the opposite groin, I insinuate the point of the blade in front of the sacro-sciatic ligament, then as it enters farther I lower the handle, bringing it by degrees between the thigljs, until it inclines strongly below. By this movement I have made the end of the blade describe a spiral, which the fingers in the vagina direct and com- plete. This movement carries the blade at the same time in front and above. It is necessary to encircle the head by an oblique passage, which represents a line extending from the sacro-sciatic ligament to the hori- zontal ramus of the pubes, and traced on the interior of the basin. The movement is effected in the twinkling of an eye, without the least pain, without the least bruising." The spiral movement is not to be employed in cases where the head has not entered the inlet. 228 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Forceps. Forceps. (4) Right Occipito-posterior Position. The introduc- tion of the blades is done in the same wray as in a left oc- cipito-anterior position. The head is brought to the pelvic floor, then anterior rotation* attempted, which, if successful, requires re- moval, and then reapplication of the forceps ; but if the attempt should fail, the occiput must be delivered over the anterior margin of the perineum. (5 and 6) Left Occipito-posterior Position, and Right Occipito-anterior Position. The only difference in the in- troduction of the blades is, that in many cases it is diffi- cult to introduce the second, right or posterior, blade after the first or left blade has been placed in position ; hence, in such cases, the right blade is introduced first, but of course the handles must be crossed before they can be locked. But this difficulty may be removed by follow- ing the method of Stolz. After introducing the right blade, raise the handle and pass the left blade beneath it, and then the handles occupy their relative normal posi- tion without having to cross them after the application of the blades. Application of the Forceps in Head-last Labors.-Where it is possible manual delivery is to be preferred. If this cannot be accomplished, then the forceps must be used, and its prompt application may save the child's life. One of three conditions may be present: 1. The face has rotated into the sacral cavity. Here the body of the child is to be lifted up, back toward the mother's abdomen ; then the blades of the forceps are to be applied to the sides of the child's head, the chin being anterior and nearest the lock ; the mental end of the long head diameter passes out of the birth-canal first, and the head is delivered by flexion, the nucha pivoting on the subpubic ligament as the head is evolved. 2. The occiput has rotated posteriorly, but the head remains flexed. In order that the forceps may be used, the body must be carried backward, child's back toward mother's back ; then the blades are applied to the sides of the head, the mental end of the long diameter being de- livered first. 3. With posterior rotation of the occiput there is de- flexion, the departure of the chin from the chest is so great that the occipital end of the long diameter is the lowest, and hence must be delivered first. The child's body is held in an almost vertical position, the forceps applied to the sides of the head, and first the occiput and last the face is delivered-"the disengagement is by a series of sub-mental diameters, as in a facial presentation, the sole difference being that these diameters now appear in an inverse order." Head Movable above the Inlet.-In case the forceps is ap- plied before the head has entered the inlet, an applica- tion which should be avoided if possible, an assistant holds the head by suitable pressure upon the lower por- tion of the mother's abdomen during the application of the blades. Almost invariably one blade passes over one frontal protuberance, the other over the side of the occiput obliquely opposite, thus, first blade over right side of the frontal bone, second blade over left side of the occipital bone. If the head cannot be brought into the inlet after a few vigorous efforts, some other method of delivery must be resorted to. Head Separated from the Trunk.-It may happen, by "accident or by design," that the head has been de- tached from the trunk, and remains in the uterus after the latter is delivered. Removal by the forceps is " deli- cate and difficult," and should not be resorted to unless other means, such as the use of the hand and the assist- ance of uterine contractions, have failed. Either make the head fixed, by pressure through the abdominal wall or by seizing the head with a hand introduced into the uterus, and apply the forceps to the sides of the head. The Forceps in Facial Presentation.-In presentation of the face the chin must rotate anteriorly if the labor ends naturally ; the chin in this movement takes the place of the occiput in vertex presentations. While anterior rota- tion is the rule in the latter, yet delivery is still possible by nature's unaided efforts, even should the occiput ro- tate posteriorly. Not so, however, as to the movement of the chin in a face presentation, for anterior rotation is essential for delivery. It should therefore be remem- bered that, in the application of the forceps, the instru- ment is valueless if such rotation cannot be effected. The difficulty and the danger of the forceps application to the head above the inlet lead obstetricians to greatly prefer conversion of a facial into a cranial presentation, or podalic version. But when descent into the pelvic cavity has occurred, and the chin is right or left an- terior, either as primitive position, or as resulting from rotation from a transverse or a posterior position, the ap- plication of the forceps and extraction are no more diffi- cult than in similar positions of the occiput. The same rules are followed as to the introduction and articulation of the blades in the one case as in the other ; but in facial presentations it is especially imperative that the blades be upon the sides of the child's head ; departure from this rule, as, for example, applying one of the blades in the trachelo-bregmatic diameter, would give an insecure hold, and probably do irreparable mischief to the child's throat. After the application of the forceps in a mento-anterior position, extension and rotation of the chin into the pubic arch are the movements at first to be executed, and then the delivery of the head is accomplished by flexion ; " care must be taken in this last step to prevent too long compression of the vessels of the neck against the pubic joint." In mento-posterior positions, either right or left, the mode of application of the forceps-blades does not differ from that employed in corresponding occipito-posterior positions, and therefore need not be repeated. In trans- verse positions if the forceps be used, the rule as to the application of the blades to the sides of the head is neces- sarily departed from, and an oblique application is made in which " one blade is placed upon the cheek and the base of the jaw, while the other is upon the temporo-occipital region of the opposite side." " One ought not to apply the forceps except in case of absolute necessity, in presentation of the face ; for an ac- couchement which may end spontaneously and favorably is sometimes arrested when its march is disturbed by un timely attempts ; the operator acting rashly, if he fails in his attempt, regrets too late the resources which would have been found in prudent expectation " (Tarnier), The changing of a face into a vertex presentation by means of the forceps has been recommended. In this proposed method the chin is directed toward one of the great sciatic foramina, where by pushing before it the soft parts, it was thought that sufficient room might be obtained for the rotation of the occipito-mental diameter, so that descent of the occipital, with ascent of thd mental, end might be obtained. This could only succeed if the pelvis was large and the head small, so that any attempt to accomplish it is but a forlorn hope. * It is claimed that in natural labor anterior rotation does not occur until the head has reached the pelvic floor. This statement is too abso- lute, for the rotation may occur before there is the least pressure upon that floor. But in artificial rotation, as made by the forceps, no effort should be made to this end until the floor is reached by the descending head. Traction should be made simultaneously with the effort to produce rota- tion, and it is important, too, that the forceps should be used to keep the head well flexed. Richardson, of Boston, very ingeniously applies the forceps with the anterior and posterior pelvic curves reversed, in order to effect rotation, removing the instrument as soon as the desired change has been accomplished, and then reapplying if necessary in the normal position of the blades. Barnes holds that instrumental rotation is only exceptionally useful, more rarely necessary, and is not free from danger. The chief objection that is made to such rotation is that if the head be moved through more than one-fourth of a circle, the body being firmly held by the contracted uterus, and therefore not able to make a corre- sponding movement, injury is necessarily done to the spinal cord. The experiments of Tarnier and Ribemont have proved that this opinion is erroneous, for they have shown that the torsion of the neck is distributed upon all the extent of the cervical column, and the first six or seven dor- sal vertebrae. Tarnier states that exaggerated rotation exposes the spinal cord less to injury than does the great flexion necessary to be produced in order to deliver the occiput posteriorly. Wasseige states (Des Operations Obsti-tricales) that Van Huevel advised applying the new curvature of the forceps behind toward the occiput: as the blades only enter the excavation, it is, strictly speaking, possible, but very difficult to execute, according to Wasseige, and he rejects it. The method differs only from that of itichardson in that after rotation is effected there is no removal and reapplication. 229 Forceps. F oxglove. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. Hodge thought that it might occasionally be prac- ticable to deliver a living child, if the head were small and the perineum greatly relaxed, by applying the forceps when the chin had rotated posteriorly, as accurately as possible in the direction of the occipito-frontal diameter, and drawing the head down, then causing the occipito- mental diameter to revolve between the anterior margin of the perineum and the subpubic ligament. Some cases are on record where a living child has been delivered in direct mento-posterior position, either spontaneously or after the application of the forceps ; but they are simply rare exceptions to a general law, and the rule in such positions is craniotomy. Application of the Forceps in Presentation of the Peiris. -If the child be dead the blades may be placed simply upon the sides of its pelvis, and firm compression made without reference to possible injury to the bones; but if it be living there ought to be interposed between the han- dles of the ordinary forceps, according to Pinard, some- thing that will prevent their coming too close together, and thus avoiding injurious compression. Pinard directs the blades to be applied, so far as possible, so that the pel vis may be seized by its bisiliac, or bistrochanteric diam- eter ; nevertheless he states that he has seen Tarnier with his forceps seize the pelvis by the sacropubic diameter, the genital organs being in the fenestra of one of the blades, and extract an infant without causing any lesion. The blades ought not to pass the iliac crests lest injury be done the abdomen. The extraction must be made slowly. Accidents and Dangers in the Use of Forceps.-The blades may slip, the liability to this accident being greater if the head be high. " The most common cause is the bad application of the blades, and the wrong direction of the traction." Madame Lachapelle described two varie- ties of this accident, vertical and horizontal. The first may occur when the head is high, so that it recedes dur- ing the application of the blades, and hence is incom- pletely and thus insecurely grasped ; or it may happen that the operator, misled by a large caput succedaneum, does not introduce the blades far enough ; the handles do not readily approximate, or their points embrace one of the transverse diameters of the head. So, too, the acci- dent may happen from the head being so small, or having so little firmness that the forceps cannot hold it. Hori- zontal slipping occurs when the blades imperfectly seize the head, being too far to its anterior or to its posterior surface, and it is held only by the posterior or by the an- terior pelvic curvature of the instrument ; this condition may be recognized by the easy approximation of the han- dles. The consequences of the slipping, when vigorous tractions are made, are the sudden escape of the instru- ment from the pelvis with more or less injury to the mother's soft parts and to the child, and the operator may find himself prostrate on his back. The obstetrician guards against this accident by observing whether the part of the foetal head nearest the lock is receding, the beginning of the blades becomes visible without the han- dles taking the usual direction, and the blades appear empty, while the forceps is " getting longer." The mo- ment any indication that the blades are slipping occurs, all traction should cease, the instrument should be un- locked, and the blades passed farther in. It has sometimes happened that one of the blades is pulled straight, the head curve quite lost. Elliot de- scribes this as having occurred with him in using a Simpson forceps ; and I know of a recent case in which this accident happened with a Hodge forceps, the delivery of the child being very readily effected afterward by the use of McFerran's axis-traction forceps. It is probable that the accident occurs from a want of proper direction of the traction, or from too great effort to force a delivery before the head is sufficiently moulded. Among the dangers of the forceps to. the mother are prolapse of the uterus, or lacerations of the cervix ; if great traction is made before the dilatation of the os ; the lower uterine segment may be dragged down, torn, or seriously bruised ; the vaginal vault may be penetrated by the forceps-blade, or the vagina may be torn. Spiegelberg mentions an instance he knew, in which the anterior vag- inal wall was torn from the fornix down to the lowest portion of the urethra. ' ' Severe compression of or- gans contained in the pelvis may lead to inflammation ending in suppuration or gangrene, causing fistula?, ab- scesses, and partial paralyses ; " injuries of the external generative organs, and laceration of the perineum ; fract- ures of the pelvis, or separation of pelvic joints ; finally, a rapid forceps delivery may, if suitable care be not taken, lead to post-partum htemorrliage. So far as the child is concerned, the " forceps may pro- duce various lesions, from simple excoriation of tissues to fractures of bones." Charpentier states that he has seen, as a consequence of an application of the forceps by an inexperienced operator, one of the branches pushed with such violence that the blade had penetrated the scalp near the occiput, passingas far as the root of the nose, detach- ing in its progress the skin from the cranium ; the child died at the end of forty-eight hours. I have observed a similar case ; the operator had passed one blade on the outside of the scalp, but the other was applied beneath the scalp, when the difficulty in making it penetrate far enough led him to ask professional assistance ; fortunately the child was dead. Intracranial effusion of blood may occur, oftener, as suggested by Spiegelberg, not from the direct compression of the forceps, but indirectly from drawing the head rapidly through a narrow birth-canal. Paralysis of the facial nerve, usually on one side only, in rare cases on each side, may occur from direct pressure by the forceps-blade upon the nerve-trunk ; the compres- sion may be of one of the branches only, and then the paralysis is only of the parts supplied by it. Generally this paralysis disappears in one to twp weeks without treatment, but in some instances it lasts for years, and then may be regarded as incurable. While the obstetrician will neither resort to the for- ceps " from complaisance, nor reject it from cowardice," he must be quite sure that the interests of the mother, or of the child, or of both, demand the use of the instru- ment, and that the conditions are present rendering that use safe. Theophilus Parvin. FORGES. Three mineral springs of France bear this name. They are as follows : . 1. Forges, or La Chapellesur-Erdre, in the depart- ment of the Loire-Inferieure, or southwestern portion of France. This spring possesses but little medicinal virt- ue, containing less than .75 grain of solids in the pint, and is not much frequented. 2. Forges-les-Eaux, in the department of the Seine- Inferieure, on the railroad from Paris to Dieppe, at an al- titude of about live hundred and twenty feet above the sea. There are at this place four springs, known respec- tively as La Reinette, La Royale, La Cardinale, and La Nouvelle. The last of these was discovered in 1834, but so far as the writer is aware no proper analysis has yet been made of its water. Prominence was first given to these springs by the visits of Louis XIII. and his Court in 1632, and of Anna of Austria in the year following, after which many so-called analyses of the water appeared. In com- position the four springs are about the same. An analy- sis of La Cardinale, by Henry, shows it to contain in each pint about as follows : Grains. Calcium and magnesium carbonates 583 Sodium and magnesium chlorides 944 Calcium, sodium, and magnesium sulphates 353 Ferric oxide (crenate) 061 Cilicia and aluminium 253 Total solid constituents 2.194 Cub. in. Carbonic acid gas 6.504 Grains. Total solid constituents of La Royale 1.674 " " La Reinette 2.000 Temperature of the waters, about 42° to 44° F. Chevalier is said to have found also traces of arsenic in these springs. The oxide of iron here present readily be- comes converted into the peroxide on exposure to the at- mosphere, and falls as a flocculent precipitate. 230 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Forceps. Foxglove. The combined flow of water from the four springs amounts to nearly one thousand gallons in twenty-four hours. An institution has been erected for the adminis- tration of the water by drinking, and by hot and cold baths. With regard to the therapeutic value of the waters of Forges-les-Eaux, the French writers claim that they pos- sess decidedly tonic and mildly diuretic properties ; that they regulate digestion, increase assimilation, and reduce over-excitability of the nervous system. They are rec- ommended also for diseases of the urinary organs. Their former reputation for the cure of sterility has been pretty generally abandoned. The German writers consider them of too feeble chemical composition, however, to be of any decided medicinal value. 3. Forges-les-Bains, or Forges-sur-Briis, a station on the railroad from Paris to Orsay and Limours, in the de- partment of the Seine-et-Oise. The springs are three in number, namely, From ant, Vuitel, and Viltoz. All are poor in chemical constituents, however, containing less than one part of salts in a thousand. But they have main- tained a considerable reputation for the cure of scrofu- lous affections, and large numbers of children are sent there annually from the Paris hospitals. After an abode of several months they are returned much invigorated. The improvement is probably due rather to the change of atmosphere and good hygienic surroundings than to the action of the waters. James French. or more), and extend along the upper half of the stem, beginning to blossom in the early part of summer, and con- tinuing until autumn, the seed ripening in the lower part of the raceme as the season advances; they are alter- nate, short, peduncled, bracted, and generally turned to one side of the rachis, especially if it is inclined from the perpendicular. Calyx five-cleft, upper lobe narrow and pointed, corolla cylindrical, bell-shaped, slightly flattened, and gibbous, with an oblique five-notched, slightly two- lipped border, and an abruptly narrowed base ; paler, hairy, and spotted within. Stamens four, with diverging anthers, ovary two-celled, with numerous ovules, capsule septicidal, seeds minute. Foxglove grows abundantly in most parts of England, and in central and southern Europe, but is freaky in its distribution, and from many extensive locations is un- accountably absent. It appears to avoid limestone dis- tricts. Although extensively cultivated for ornament, the wild plants are generally selected for medicine. It has escaped from gardens in this country, and is now FORMIC ACID: HCHO2. Formic acid is a heavy, colorless fluid of a sharp, sour odor and taste, soluble in all proportions in water, alcohol, and glycerin. It is exceedingly irritating, producing, when applied to the skin, redness, blistering, and even sloughing, and, taken internally, gastro-enteritis and bloody urine. It has been occasionally used, locally, as a counter-irritant, applied diluted with an equal measure of water. Edward Curtis. FORTUNA. Baths in the province of Murcia, Spain, with odorless, warm springs (125.6° F.). Chemically the springs are of little value, and are used chiefly for bath- ing purposes. The baths have attained some reputation for the cure of sterility, and are patronized by a consider- able number of women for that purpose. J. M. F. FOXGLOVE (Digitalis, U. S. Ph.; Digitalis Folia, Br. Ph.; Folia Digitalis, Ph. G.; Digitale, Codex Med.). The leaves nt Digitalis purpurea Linn., Order Scrophulariacew, taken from the mature and blossoming plant. The flow- ers are also official in France, but are seldom employed ; the seeds, which have the same properties as the leaves, but are several times more active, are not used unless in the manufacture of the active principles. It is one of the largest and handsomest of European wild flowers, and has obtained a favored place in our flower- gardens by its dignified and stately beauty. It is a biennial, and consists in the first year of only a cluster of thick, fibrous rootlets, and a large, mullein-like rosette of dull green, pubescent, oblong or spatulate leaves. At this stage it is rejected for medicinal use by the pharmacopoeias above mentioned on account of its comparative inactiv- ity. In the second season it develops a tall, upright, or slightly inclined, wand-like, simple or nearly simple leafy stem terminating in a long, often one-sided, many-flowered raceme of long, bell-shaped, rose-pink or purple (rarely white) drooping flowers. The leaves at the base are often very large (20 to 30 ctm. = 8 to 12 inches long, and 8 to 16 ctm. = 3 to 6 inches broad), ovate, with straightish sides and blunt-pointed apices, narrowing at the base ab- ruptly to a long, flat, winged petiole; those of the stem are progressively smaller, narrower, and more nearly ses- sile. All are dull green above, and moderately hairy ; light gray-green and densely pubescent beneath. The midrib is broad and prominent. The principal veins leave it at an acute angle (less than 45 degrees) and branch and anasto- mose freely. The surface is rugose, the border crenulate or bluntly serrated ; the serrations are terminated by small, wart-like glands or rudimentary prickles. The flowers on thrifty plants are very numerous (often fifty Fig. 1324.-Digitalis Purpurea Linn., Foxglove. Plant in blossom, flower slightly reduced in size, and section of flower natural size. (Bailion.) and then found in a half wild state. No medical use of this plant appears to have been made until about the mid- dle of the sixteenth century. Its modern and more rational employment dates from the time of Withering, who wrote a monograph upon it about a hundred years ago (1785) (Pharmacographia). Description.-The size, shape, and general appear- ance of the leaves are sufficiently detailed above. When dry they have a faint, tea-like, not unpleasant odor, and an intensely and persistently bitter and disagreeable taste. They should be collected after flowering has well be- gun, and be carefully and quickly dried. The midrib, which is very broad at the base, is said to be compara- tively inactive, and is sometimes removed. Mullein and some other large leaves are sometimes found mixed with foxglove, but are easily detected. Composition.-The name digitalin has been succes- sively given to a number of substances prepared from foxglove leaves, and possessing their active properties to a greater or less extent. The older and most widely known of these are little more than purified precipi- 231 Foxglove. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tates of alcoholic or watery extracts, previously freed from the pectic and inorganic substances of the leaves, and they consist of variable mixtures of what are now thought to be the real active principles of the drug with more inert compounds. One of the most famous of these is the digitalin of Homolle (1845 and later), which marked an important advance in the chemistry of digitalis. It is prepared by a tedious process of extraction, repeated pre- cipitations with various substances, solutions, and purifi- cations, and is a neutral substance in white warts or scales, but more generally a powder, of no odor, but having a most intensely bitter taste. It requires two thousand parts of cold water and twelve hundred and fifty of cold absolute ether for its solution, but dissolves freely in alco- hol. With concentrated hydrochloric acid it forms a liquid which becomes rapidly green, and finally deposits a green powder. It is one of the best of the available " digital- ins." The so-called German or soluble digitalin, founded on the digitalin of Walz, is a yellow or light brown, amor- phous powder, of disagreeable odor and intensely bitter taste. It is freely soluble in water and in diluted alcohol, but not in ether nor much so in chloroform. Its powder is excessively irritating to the eyes and nose. This prep- aration is evidently very different from that of Homolle, and, although active, is more variable, and hardly worthy of modern employment. The digitalin of Nativelie, for which he was awarded the Orfila prize in 1872, is more nearly a chemical compound than the above. It forms a light, flocculent mass of silky, radiating, or clustered crys- tals of neutral reaction, of a slowly but intensely bitter and persistent taste, and no odor. It is insoluble in cold water, ether, and benzol, and requires about twelve parts of ordinary alcohol for solution, but dissolves readily in chloroform in all proportions ; with hydrochloric acid it gives the green color of Homolle's. The Digitaline amorphe of the Codex and the Digitalin of the previous British and United States Pharmacopoeias were essen- tially Homolle's. The Digitaline cristallisee of the Codex is essentially Nativelle's. The composition of digitalis is either very complicated, or else its constituents are of a remarkably unstable and elusive character, as scarcely any two observers have yet succeeded in giving the same names and characteristics to any of them. Besides, the term " digitalin," which, as seen above, has been applied to so many things as to be about meaningless, Homolle, Walz, Nativelie, Schmiedeberg, and others have each a complete set of names for the principles and decompo- sition products accompanying their particular " digital- ins." Homolle (and Quevenne) considers his " digitalin" to be a mixture of digitalin, digitaline, and digitalose. Nativelie obtained from foxglove three peculiar prin- ciples-his crystalline digitalin, an amorphous digitalein, soluble in water, and an inert crystalline substance (digitin ?). According to Schmiedeberg, one of the most recent in- vestigators, commercial "digitalin" (and probably fox- glove) contains the following substances: Digitonin, a white amorphous mass, easily soluble in water, slightly so in alcohol, and not in ether or chloroform ; resembles saponin in some respects. Digitalin is something like Homolle's digitaline, but little soluble in cold water and ether, freely so in alcohol. Digitalein in some respects re- sembles digitonin, but differs from that substance in being physiologically active; it is the valuable portion of the German soluble (in water) digitalins. And finally Digi- toxin, the essential part of Nativelie's digitalin ; this is insoluble in water, sparingly so in ether, more soluble in chloroform, and freely so in alcohol. Of these sub- stances, the second and especially the last are the essen- tially active ones, and constitute the important part of all previous " digitalins." Nearly all the digitalis constit- uents are glucosides (but not digitoxin), and their decom- position products are numerous and very confusing. Besides the above, foxglove-leaves contain starch, tan- nin, mucilaginous and pectic matters, several peculiar acids -antirrhinic, digitoleic, digitalic, etc.-inosite, and ash. Action and Use.-Digitalis appears to be rather slowly absorbed, however taken, and very slowly eliminated, so that its effects may not be noticeable for several hours after ingestion, and, on the other hand, they are more per- manent than those of other medicines ; if the doses are too frequently repeated, therefore, an accumulation of effects of rather alarming character is likely to follow. Twice or three times a day is usually often enough. Toxic doses produce vomiting, diarrhoea, colic, and other symptoms of acute gastro-enteritis; they are also followed by giddiness, muscular weakness, diminished reflex irritability, amaurosis, stupor, and convulsions. The pulse is usually slow, small, and irregular, but may be greatly quickened, or the heart may stop entirely, and the victim die in sudden syncope by slight exertion, such as rising in bed. Death usually occurs from such failure of the heart in digitalis poisoning. After smaller, but still large, doses, nausea, lassitude, dizziness, dilatation of the pupils, and dimness of vision, with delusions of color, are common symptoms. Pulse slow and weak ; respira- tion often retarded. Digitalis is generally regarded as directly reducing, although not entirely obliterating, muscular irritability. It also appears, in large doses, to reduce the activity of the spinal column and nerves, but this is denied by several experimenters, who claim that the apparent paralysis that it produces is due to its stimu- lating influence upon the inhibitory centre of Setsche- now ; their experiments show that at least part of its ef- fects may be so explained. The respiration, as just men- tioned, is made slower. The urine is increased by moderate doses, both in regard to its liquid and solid components ; after large doses it is diminished, and even sometimes suppressed. This fact is offered by Brunton as an ex- planation of the cumulative action which sometimes fol- lows repeated doses of foxglove. Medicinal doses of this drug exert their most appreciable and useful effects up- on the action of the heart, which is rendered decidedly slower, its systole increased in force, and its diastole pro- longed by it; both the cardiac muscles and the vagi ap- pear to be concerned in this phenomenon. The amount of work done by the heart under this foxglove stimula- tion is notably greater, the pulse-beats are fuller as well as slower, the arterial pressure is elevated, and the cir- culation accelerated. After fuller doses the weakening of the circulation, dicrotic and irregular pulse, and the other baneful symptoms described above appear. The use in medicine of this plant is confined to the cardiac and renal stimulation produced by it in small doses ; its paralyzing and depressing properties are never desired. The most frequent disorders requiring it are valvular disease of the heart, especially mitral, with dilatation or weakness, after the stage of compensatory hypertrophy has passed ; simple dilatation, in cardiac failure in pneu- monia and typhoid, and in collapse from various causes. The dropsy accompanying cardiac disease is relieved both by its action upon the heart and its diuretic power. Of the particular constituents digitonin acts like sapo- nin ; digitoxin, digitalin, and digitalein act similarly to each other, but in different degrees. Digitoxin is the most poisonous of the three, and is locally irritating. Administration.-It may be given in substance: one decigram of the powdered leaves being an average dose (| to 1^ grain, Br. Ph.; maximum dose, 0.2 Gm. ; maximum daily quantity, 1 Gm., Ph. G.). It is very disa- greeable to the taste, but can easily be concealed in a coated pill or capsule. Several preparations are officinal, all of which are good, although perhaps not necessary. The abstract (Abstracturn Digitalis, U. S. Ph.) is a new form designed to replace the extract, over which it has the advantage of a fixed relation to the crude drug. It is made by exhausting the powder with alcohol, evaporating the tincture so obtained by moderate heat (having added a little sugar of milk) to dryness, and then adding enough more sugar of milk to make the product weigh just half as much as the digitalis used. It is, therefore, theoreti- cally twice as strong, and suitable to be given in powder or pill, or mixed with other medicines. The extract (Ex- tractum Digitalis, U. S. Ph.; a percolate, made with alco- hol, two parts, and water, one part, evaporated to a pillu- lar consistence and mixed with four per cent, of glycerine) represents four or five times its weight of the powder. The fluid extract (Extracturn Digitalis Fluidum, U. S. Ph., strength }), made in the usual manner for this class 232 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Foxglove. Fractures. of preparations, is a good form, and keeps well. It may be diluted with water for subcutaneous use. Dose, two or three drops. The infusion (Infusum Digitalis, U. S. Ph., digitalis, 3 ; cinnamon, 3 ; boiling water, 185 ; alco- hol, 15 ; macerate two hours, strain anil add water enough to make 200 parts) is regarded as the most desirable where the diuretic effect of digitalis is wished for. Dose, fifteen to thirty cubic centimetres (= 3 ss. ad. § j.) from two to four times a day. It does not keep well, and should be renewed every two or three days. But of all the prepara- tions the tincture (Tinctura Digitalis, U. S. Ph., strength, tVo, menstruum, diluted alcohol, by percolation), is the most generally employed ; dose, fifteen to twenty-five drops (0.5 to 0.8 c.c. = Ft viij. to xij. Of the digitalins the German, the French amorphous -Homolle's-and the French crystallized are in the market; the two former are the most common, and dis- tinguished from each other by the solubility of the Ger- man in water. They are not very uniform, and with our present knowledge of them it is better practice to use one of the above preparations instead. The crystallized is more uniform, but difficult to get. The following are ap- proximate doses: Of the amorphous, German and Ho- molle's, one or two milligrams (0.001 or 0.002 Gm. - gr. 3*0 ad -/o); of Nativelie's or other crystalline digitalins, about one-fourth as much. Their solutions should be freshly made. Digitalis is occasionally given in suppositories or sub- cutaneously-there is generally no advantage, however, in these methods. Allied Plants.-The genus comprises eighteen bi- ennial or perennial, showy, often yellow-flowered herbs, growing in Europe and Western and Central Asia. Several of them have similar medicinal qualities to D. purpurea, but are less active. The order Scrophulariacece is a large family of about nineteen hundred species, growing in all parts of the earth. They are generally herbs with more or less labiate and irregular pentamerous flowers, and two-celled, many-ovuled ovaries. A disagreeable bitter taste and drastic, sometimes diuretic, qualities are common in it. A few of its members, like foxglove, are very poi- sonous. Many genera have very handsome flowers, and are favorite garden ornaments. The following are a few of the more familiar members : Verbascum, Mulleins. Several species contribute the Flores Verbasci of the German Pharmacopoeia ; Calceolaria., furnishes a number of beautiful garden flowers. Linaria vulgaris Mill.," butter and eggs," a pretty and common introduced weed, formerly used in dropsies, and as the basis of an ointment for haemorrhoids. Antirrhinum. Snap-dragons, beautiful flowers, for- merly official. Scrophularia. Figwort. A homely weed. Chelone glabra Linn. Snake-head ; wild in swamps in the United States, a domestic purgative for hepatic dis- orders, etc. Mimulus; several species cultivated for ornament. M. Mosch Dough, is the "musk plant" of gardens. Digitalis. Foxglove. Veronica; Speedwells, many species. Leptandra, and others of the genus have active properties. Gerardia, several species, with beautiful flowers and half-parasitic roots, are a feature of American fields and woods. Allied Drugs.-Ammonia, and its carbonate, and alcohol, are in every-day use where a quick and certain stimulation of the circulation is needed, as in syncope, col- lapse, acute diseases, loss of blood, etc. ; also where the heart-weakness is only an expression of the general de- bility of the entire body, as in chronic and wasting dis- eases. Convallaria majalis Linn., the lily of the valley, especially its active principle convallamarin, is claimed to have the cardiac-stimulating power as foxglove ; although apparently of some value, it is much inferior to the latter drug. Squill, Sparteine, Helleborein, Caffeine, Adonidin, and others have a good deal of similarity with digitalis in their cardiac action. IF. P. Bolles. FOX SPRINGS. Lovation, about ten miles from Flemingsburg, Fleming County, Ky. Access.-By Cincinnati & Southeastern Railroad. Analysis.-According to Dr. Frazer's report in "The Mineral Waters of Kentucky," this is a sulphur water, similar to the Esculapia Spring in the same region. No more particular information has been obtained. G. B. F. FRACTURES. When the continuity of a bone or car- tilage is forcibly destroyed, either in part or completely, except by the direct and limited action of a cutting instru- ment at the injured point, the injury is called a fracture. Although the lesions produced in bone and cartilage by cutting instruments resemble those of fracture very closely, they differ in some important points, especially in extent and in the accompanying laceration of the soft parts, and they are habitually classified as wounds, not as fractures. A fracture, then, is the breaking of a bone or cartilage. The injury is a common one. Between the years 1842 and 1877 there were treated at the London Hospital 243,- 636 surgical cases of all kinds, including "out-patients," of which 51,938, more than one-fifth, were fractures. Of these, 18 per cent, were of the forearm, 16 per cent, of the leg, 15.9 per cent, of the ribs, and 15 per cent, of the clavicle. During childhood the frequency in males and females is about the same ; during middle life it is ten times as great in males as in females ; between the ages of fifty and seventy years the difference is slight; and after the age of seventy years fractures are more common in females than in males, the fracture most frequently met, at that age, being fracture of the neck of the femur. Fractures are most numerous in children under ten years of age ; but in proportion to population the injury seems to be most common after the age of sixty years. Varieties.-Fractures are classified according to differ- ences in the extent, character, and position of the injury, and in the number of bones involved, as follows :1 1. Incomplete fractures. (a.) Fissure. (b.) True incomplete " green-stick fracture; " bent bone. (c.) Depressed. (d.) Separation of a splinter or of an apophysis. 2. Complete fractures, subdivided according to- (a.) Direction of the line of fracture into transverse, oblique, longitudinal, toothed or dentate, and V-shaped. (b.) Seat of the fracture-into fracture of the shaft of the bone, of the neck of the bone, of the epiphysis, inter- condyloid, separation of epiphysis ; and (c.) If communicating with a joint, intra-articular. 3. Multiple fractures, comprising fractures of two or more bones, two or more fractures of the same bone at different points, comminuted or splintered fractures, im- pacted fractures, and fractures with crushing. 4. Compound fractures. 5. Gunshot fractures. The following terms are also in use to designate condi- tions not included in this classification. Simple, in contra- distinction to compound; complicated, to indicate the ex- istence of important associated injuries to neighboring parts ; spontaneous, a fracture produced by very slight force in an abnormally fragile bone ; recent, in contradis- tinction to old or ununited. 1. Incomplete Fracture.-In an incomplete fracture tiie continuity of the bone is not entirely lost. The mott Fig. 1325.-Green-stick Fracture. common form, excluding, perhaps, fissures associated with complete fractures, is the one known as the " green- stick " fracture or infraction, which occurs especially in young children. In this the fracture usually extends 233 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. transversely partly across the bone, and then longitudi- nally for a variable distance in either or both directions, the remaining portion of the breadth of the bone being bent but not broken ; the transverse fracture is on the convex side. There is reason to believe that a bone may be sometimes bent so as to receive a permanent change of shape, but without recognizable fracture. In the rarely seen incomplete fractures of spongy bones, or of the spongy portion of long bones, the fracture is actually a crushing of the bone, and is on the concave side. Infrac- tion is observed most frequently in the clavicle and the bones of the forearm. The diagnosis is made by consideration of the deformity, localized pain, absence of abnormal mobility, age of the patient, and history of the accident. Depressions are fractures of flat bones, in which the entire thickness of the bone is not broken. The term has also been applied to those rare cases in which the side of a long bone has been crushed in by direct violence. 2. Complete Fractures.-"The term com- plete, when applied to the fracture of a long bone, indicates that the bone is divided into two or more distinct fragments by a line of fracture crossing its long axis." The terms transverse, oblique, and longitudinal refer to the general direction of the line of fracture ; dentate and V-shaped to irregularities in the line, or to a combination of two or more lines. It is exceptional, but not unknown, for the line of fracture to be exactly transverse and smooth ; and, as it is usually impossible to determine in a given case whether these conditions exist, the epithet transverse is commonly ap- plied in practice to fractures in which the deviation of the line of fracture from an exactly transverse line is not great. When distinct irregularities of some size in the edge of the fracture can be recognized, and especially if re- duction of the displacement is made difficult by the inter- locking of the points and depressions, the fracture is called dentate or toothed. Oblique fractures comprise all grada- tions between the transverse and the longitudinal. In the longitudinal fracture the line of fracture runs parallel (or nearly so) with the long axis of the bone. Very long ob- lique fractures are usually classed as longitudinal. The V-shaped fracture is a variety most frequently observed in the tibia. It is characterized clinically by a projecting point on the anterior and inner edge of the end of the upper fragment (A in Fig. 1329), which can be readily felt through the skin. Its clinical importance arises from the fact that a fissure always extends downward from the re-entrant angle in the end of the lower fragment corresponding to the projection on the upper one, and frequently enters the ankle-joint. In addition to these terms which indicate the direction and shape of the line of fracture, others are used to indicate the position of the fracture, such as fracture of the shaft or of the neck of a bone; fracture of the upper, lower, or middle third ; intercondyloid fract- ure ; separation of the epiphysis. The term intra-articular is used in two senses : when applied to a fracture of the neck of the femur or of the neck of the humerus it means that the line of fracture lies entirely within the capsule of the joint ; when applied to fract- ures involving other joints, it means that the line of fracture runs into the joint. The term articular is sometimes used as a substitute for intra-ar- ticular in the second sense, and its use is to be preferred. Of these varieties the separation of an epiphysis and intra- articular fractures present differential points of especial interest. The term separation of an epiphysis is applied only to those cases in which the line of fracture more or less ex- actly follows the line of the still existing conjugal cartilage which unites the epiphysis to the shaft, and by which the growth of the bone in length is carried on. The injury, therefore, is found only during the period of life which precedes the ossification of this cartilage. The age at which this ossification takes place varies with the differ- ent bones and with the individual ; in the female it is usually complete for all bones by the twenty-second year, and in males by the twenty-fifth, but in exceptional cases the cartilage persists for a much longer time. As a positive diagnosis can be made only in compound fractures, or when the associated injuries are such as to cause death or require amputation, the recorded cases are not numerous; but some writers think that the injury is a frequent one. Bruns collected 81 reported cases, comprising 101 fractures, in which the diagnosis was made by direct examination. In his list the lower end of the femur is the most frequent seat of the injury, 28 cases ; and the lower end of the radius next, 25 cases; followed by the lower end of the tibia and upper end of the humerus with 11 cases each. The ages were re- corded in 52 cases : 8 between one and nine years, 44 between ten and nineteen ; the greatest frequency being in the six- teenth year. In the majority of the cases the line of fracture passed in part through the chondroid tissue forming the contiguous portion of the shaft; but in one-third of the cases the injury was an exact separation of the epiphysis. It has been experimentally shown that the separation of an epiphysis can be readily effected by a moderate force that exerts a cross-strain, as in hy- per-extension or in lateral flexion at the knee or elbow. The line of fracture usually follows the cartilage throughout, and is therefore in many cases transverse ; but at the upper and lower ends of the humerus and upper end of the tibia, where the direction of the cartilage is more or less irregular, that of the fracture is corre- spondingly deviated. An important feature in the pa- thology of the injury is found in the persistence of the connection between the epiphysis and the periosteum of the shaft, and the consequent stripping up of the latter fora considerable distance if there is much displacement. The symptoms and course of the injury do not differ notably from those of other fractures, except in the prob- ably rare cases in which the growth of the bone is arrested because of unreduced transverse displacement of the epiphysis, or because the injury pro- vokes premature ossification of the car- tilage. Intra-articular fractures owe their es- pecial importance to the arthritis which is likely to accompany the process of repair, and to the diminution or de- struction of the functions of the joint by the consequences of this arthritis or by change in the relations of the artic- ular surfaces to each other. The cap- sule and periarticular tissues may be- come thickened and hard, or adhesions may form within the joint, or the broken pieces of bone may unite in new positions in which they will mechani- cally interfere with motion. These pos- sibilities are the more serious because they often cannot be prevented ; the small size of the fragments, the swell- ing of the soft parts, and the effusion within the joint may make readjustment impossible or prevent its maintenance. Accuracy of diagnosis in detail is always difficult, and sometimes impossible, even with the aid of anaesthesia. 3. Multiple, comminuted, and impacted fractures. Under multiple fractures are included two very different varie- ties : simultaneous fracture of two or more bones, and fracture of a single bone at two or more points. From the first variety are excluded fractures of parallel bones, Fig. 1326.- Toothed Fracture of the Femur. Fig. 1328.-Longitu- dinal Fracture. Fig. 1327.- Oblique Fracture. Fig. 1329.-V-shaped Fracture. 234 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Fractures. Fractu res. which, instead, are simply termed (for example) fracture of both bones of the forearm, of the leg, or of the ribs. The especial importance of this first variety lies usually in the character and extent of the violence that has pro- duced the fractures, and in their frequent association with other grave injuries. The second variety, fracture of a single bone at two or more points, is commonly the result of direct violence. When the fragments are numerous and irregular, with communicating lines of fracture, or, in other words, when a portion of the bone is splintered or broken up into several pieces, the fracture is said to be comminuted. This comminution may be the result of di- rect crushing violence, or of the splitting of one main frag- ment by the penetration into it of the adjoining end of the other; or of indirect violence, when it is great or when it continues to act for a moment after fracture has taken place, or when the bone is unusually friable. When the end of one fragment penetrates the other, with or without splintering the latter, or when each penetrates the other with crushing of their more friable portions, the fracture is said to be impacted. This form is commonly seen at the junction of the shaft and the expanded spongy end of a bone, and at the neck of the femur. The fragments vary in size and number ; they are some- times completely detached from the periosteum, and sometimes preserve their connection with it. In either case, whether completely detached or not, they will, in simple fractures and in the immense majority of cases, preserve or renew their vitality. It is probable that in every fracture some splinters are entirely detached ; but nature is abundantly able to take care of them, either by solution and absorption, or by incorporating them in the callus. In the latter case granulations make their way into the minute canals of the fragment, carrying with them vessels and nerves to take the place of those which origi- nally existed there, and thus make it again an integral, living part of the skeleton. In exceptional cases the frag- ment remains as an inert foreign body, and after a longer or shorter time, and under the influence of various causes, such as chilling, traumatism, or alteration of the general health, provokes suppuration, and then, unless either cast out spontaneously or removed by the surgeon, main- tains a fistulous opening. When the fracture is com- pound, fragments that are completely or almost com- pletely detached should be removed ; all others should be left. 4. Compound Fractures.-A compound fracture is one in which a coexisting wound of the soft parts establishes communication between the fracture and the air. The wound may be caused simultaneously with the fracture by direct violence, or from within outward by perfora- tion of the skin by one of the fragments, or at a subse- quent period by sloughing of the soft parts in consequence of primary bruising or of pressure by a displaced frag- ment of bone. The greater gravity of a compound fracture, as com- pared with a simple one, is due to this communication with the air, which makes the occurrence of suppuration at the seat of. fracture more probable, with all its dangers to life and limb. From this point of view those fractures are the most dangerous in which the wound is caused by external violence, and is accompanied by so much bruis- ing and laceration of the soft parts that primary union cannot be obtained and suppuration is inevitable. Those are less dangerous in which the wound of the soft parts is small and clean-cut, as when the point of a fragment has been forced through the skin, and those in which the opening occurs in consequence of pressure or bruising after the lapse of several days, and when the medullary cavity and vascular canals of the bone have had time to become sealed by granulations. A special variety of compound fractures, characterized usually by much laceration of the soft parts and splinter- ing of the bone, is found in those caused by firearms, when a bullet or charge of shot enters the limb and fract- ures the bone by direct impact. They owe their especial gravity not only to the extensive injury done to the bone, but also to that inflicted upon the soft parts, including the large vessels and nerves. In making the diagnosis it must be remembered that a wound of the skin and underlying soft parts may exist, and yet not extend to the seat of fracture. Such a case would be a " simple fracture complicated by a wound ; " and if exploration of the wound js thought necessary, it must be made with great care and gentleness, so as not to convert the fracture into a compound one. In cases of doubt it is better to abstain from much handling and treat the case as if it were compound, using every means to keep the wound aseptic, and to immobilize the limb. Or- dinarily the diagnosis presents no difficulty, for the broken end of the bone can be seen or felt in the wound. In doubtful cases profuse and persistent venous bleeding, mingled with drops of fat, indicates communication of the wound with the fracture. The prognosis is always serious, although modern methods of treatment have greatly availed to reduce the risks, and it is now the rule to save many limbs which a few years ago would have been sacrificed ; but whenever those methods are not carefully employed, the complica- tion of prolonged suppuration and necrosis, with all their attendant risks, which formerly made compound fractures so dreaded, which raised the rate of mortality so greatly in our hospitals, and which led to the amputation of so many limbs, must be expected. The aim of treatment is to obtain early union of the wound, at least in its deeper parts, whenever that is pos- sible, and thus transform the fracture into a comparatively harmless simple one, and to keep it surgically clean and well drained. The details of the treatment are essentially those of the treatment of other surgical wounds, and will be considered elsewhere. In brief, they are as follows : Fragments that are completely or almost completely de- tached must be removed, bleeding points secured, the wound (unless very small and clean-cut) thoroughly irri- gated with a five per cent, solution of carbolic acid in water, or a 1 to 1,000 solution of corrosive sublimate in water, the fracture reduced and supported by appropriate splints, and the wound dressed antiseptic-ally. When the wound is large and bruised, or lacerated, a drainage-tube should be used, and perhaps a dependent opening made. The tube may be passed directly between the fragments, if desirable, but in any case it should be removed at the earliest moment, as soon as the tissues have consolidated about it. Usually a tube is useful only to remove the blood and the serous discharge poured out during the first two or three days ; its longer retention only favors suppuration and delays the final closing of the wound. In the less severe cases the tube may be omitted. If the sharp end of a bone projects through the skin and cannot be reduced, it is usually better to enlarge the open- ing in the skin rather than to cut off the end of the bone ; the wound may be closed with sutures or with adhesive plaster, but if oozing persists the wound must not be closed too accurately, space must be left through which the blood can escape. The dressings should be thick, soft, and snugly applied, so as to make firm, uniform pressure. Amputation may be made necessary by extensive shat- tering of the bone or laceration of the soft parts, especial- ly if combined with division of the main artery or nerve. In doubtful cases rigid employment of the antiseptic method of treatment may enable the surgeon safely to postpone his decision for a few days, until the full extent of the damage and of nature's ability to repair it has been revealed. Splints should be so applied, whenever possible, that the wound can be dressed without removing them. Usu- ally the best method is to apply a moulded posterior splint (in fracture of the leg, for example) next the skin, then the dressings of the wound, and then an anterior plaster- splint which can be readily and safely removed whenever the wound needs to be dressed, since the posterior splint secures immobility. In short, the essentials of treatment are immobilization of the fragments, primary union of the wound whenever possible, and absolute surgical cleanliness. Displacements.-When a bone is broken across, its two principal fragments are commonly displaced, as regards each other, in one or more of the following ways : Trans- 235 Fraetu res. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. versely-the broken surfaces are displaced upon each other in the direction of the transverse axis to an extent that varies from a fraction of the diameter of the bone to the entire diameter, or even more. Longitudinally-the fragments are approximated so that the broken ends over- ride each other (Figs. 1330 and 1331), or one fragment may penetrate the other. Angularly-the long axis of the fragments form an angle with each other, in- stead of remaining parallel (Fig. 1332). By rotation of one fragment about its long axis. By direct longitudinal separation, as in fracture of the pa- tella. It is quite common to find two or more of these displacements associ- ated in a case. They are produced either by the fracturing force at the time the injury is received, or by mus- cular action, voluntary or involuntary, or by the weight of the limb as the pa- tient lies in bed, or by the ill-regulated pressure of splints and bandages. Etiology.-The causes of fracture are predisposing and determining. The main predisposing cause, excluding form, position, ami function, is abnormal fragility of the bone, either in- herited, congenital, or acquired, as the result of general or local disease, or of age. In a few cases families have shown through three or four generations a remark- able fragility of the bones ; in others, one or more of the children of healthy parents have shown the same peculiarity during childhood and adolescence, but have out- grown it, and have not transmitted it to their children. In all the fractures united within the usual time, and so firmly that in no case did the bone again break at the same place. The pathology of this inherited and con- genital fragility is not known, but it seems reasonable to assume that it was probably similar to the osteoporosis found so com- monly as a senile change and in the numer- ous other cases of acquired fragility due to general or local disease. The senile change which makes the bones of old people weaker is an increase in the size of the medullary spaces and canals, and a consequent diminu- tion of the thickness of the cortical layer and of the trabeculae. This changed condition, osteopo- rosis, has been found also in many cases of acquired fra- gility, and in some the change was so great that the bones could be broken by the pressure of the fingers. It has been observed as a consequence of disease of the nerve- centres, as in locomotor ataxia, in rachitis, accompanying cancer of a distant part, and after injury to the bone, or in connection with caries and necrosis. In a very con- siderable number of cases fracture by a slight cause has been preceded, sometimes for months, by constant dull pain in the bone. In some few cases the pain has been thought to be due to syphilis. The immediate causes of fracture are external violence and muscular action. Fract- ures by external violence, by a blow or fall, for example, are divided into two groups ; fractures by direct violence; fractures by indirect vio- lence. Fractures by direct violence are those in which the fracturing force is received upon the surface of the body at a point corresponding to the fracture, as when the wheel of a wagon passes across the leg and breaks it in the line of its passage ; fractures by indirect violence are those in which the violence is received at a point more or less distant from the fracture, as when the humerus is broken by a fall upon the hand, or the femur broken by a fall upon the feet. An important clinical difference between the two groups depends upon the greater extent of the injury to the bone and soft parts usually present in fractures by direct violence, and the greater probability that they, if at first simple, will become compound by sloughing and suppuration of the bruised skin and muscles. Fractures by muscular action are those in which a bone is broken by the contraction of muscles attached to it or to adjoining ones. The bone most frequently broken in this manner is the humerus, then the femur, bones of the leg, and bones of the forearm. Occasional fractures of other bones by the same mechanism have been reported, as of the scapula, clavicle, sternum, and even the verte- brae. As examples of the means by which these fractures have been produced may be mentioned epileptic or tetanic convulsions, the throwing of a stone (fracture of the humerus), kicking and missing the object kicked at (fracture of the femur), wringing clothes (fracture of the forearm), striking with the fist (fracture of the olecranon), fracture of the ribs by coughing, and fracture of the sternum by expulsive efforts in parturition. The term "spontaneous'' is sometimes applied to fract- ures caused by a very slight muscular effort, as turning in bed. Symptoms and Diagnosis.-The objectice symptoms of fracture, those which can be recognized by the surgeon himself, are deformity, abnormal mobility, and crepita- tion. Under deformity are included changes in the form, length, and posture of a limb, and in the relations of recognizable bony parts to each other. Swelling of a part may be due to contusion or to extravasated blood ; other changes are due to displacement of the fragments, and, of course, vary with its character and extent. In examining for deformity, the injured limb and its fellow should be stripped of clothing and compared ; and in doubtful cases the question should always be asked whether the limb has ever before been injured, in order that an old deformity may not be mistaken for a recent one. When a deformity is found, its character must be determined by tracing the outline and direction of the bone so far as that is possible, and by comparing the length of the limb and the relations of the different bony points with those of the other limb, or, in some cases of fracture about joints, with known standards. In com- paring the length of limbs care must be taken to place them in symmetrical positions, and to measure accurately between corresponding points ; and in basing a diagnosis upon the results of measurement it must be remembered that in a small percentage of cases differences varying in amount from one-fourth to one and a half inch in the lower extremity exist normally. By abnormal mobility is meant the possibility of com- municating independent movements to a portion of a bone ; and when this is found to have been produced by an injury it is pathognomonic of fracture. It can be recognized by manipulations which vary with the seat of fracture. For example, when the shaft of a long bone is broken, traction upon the lower segment will lengthen the limb, and pressure toward the trunk will shorten it; if the upper portion is firmly grasped the lower portion can be moved laterally, so that the limb will form an an- gle at the seat of fracture, and a similar angle may be produced by passing the hand under the limb at the fracture and raising it gently ; or, if the upper portion is held firmly, the lower one can be gently rotated without communicating the motion to the other. When an apoph- ysis or a portion of the expanded articular end of a bone is broken off, as a condyle of the humerus, its mo- bility may be recognized by grasping it firmly between the thumb and finger, and moving it in a direction par- allel to the surface of the fracture. Mobility is sometimes absent, as in partial or in im- pacted fracture, and sometimes cannot be recognized, as when the fragments are small and deeply seated. When the broken fragments are thus moved upon each other a sound is sometimes produced, or a sensation of gritting communicated to the hand of the surgeon, and this is called crepitation. The conditions of its occur- Fig. 1330. Fig. 1331. Fig. 1332. 236 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. reuce are contact of bare surfaces of bone with each other, and their mobility upon each other with some friction; consequently in impacted fractures and in fractures with much displacement it is frequently lack- ing, and it often happens that the manipulation which produces it in a given case at one time will not produce it at another. It is sometimes loud enough to be heard by a bystander, but it is best perceived through the hand of the surgeon, either when he grasps the end of the bone and moves it, or when he lays his hand over the fracture and gently presses. It must not be confounded with the sounds produced in roughened and inflamed joints by moving them, or in inflamed tendinous sheaths or bursae, or with the crackling of emphysema or coagulated blood. The subjective or rational symptoms of fracture are loss of function, pain, and the history of the case. None of them is absolutely pathognomonic, and their diagnostic value, therefore, is less than that of the objective signs ; but they are often sufficient, even when taken alone, to justify the surgeon in considering the case as one of fracture. Loss of function may be due to the breaking of the lever through which the action of the muscles is exerted, or to the loss of support at one of the attachments of a muscle, or to pain or the fear of causing it if the limb be moved. It is not pathognomonic, because it is also ob- served after a simple contusion, and, similarly, its absence is not proof that there is no fracture. Many cases have been reported in which men have walked longer or shorter distances after fracture of the lower extremity, or have used their arms quite freely after fracture of the radius or ulna. Pain is uniformly present when the limb is moved, or when pressure is made over the seat of fracture. Its di- agnostic value depends upon its close limitation to one point, and upon the absence of other injuries which might equally well give rise to it. It is, therefore, a more posi- tive sign in fractures by indirect violence or muscular action than in fractures by direct violence. When the bone that is thought to be broken is deeply seated, the best method of detecting the pain and determining its character is to communicate slight and varied movements to the lower portion of the limb ; if under such manipu- lation pain is always felt at one point, the existence of fracture at that point (other possible causes of the pain being eliminated) is probable. When the bone is more nearly superficial, the best method of examination is to draw the finger slowly along the line of the bone, with gentle, steady pressure. The pain thus excited, if there is a fracture, is sharp and limited to a narrow area. The possibility of confounding it with the pain of a sprain, if near a joint, or with that of a bruise of the periosteum must be borne in mind. The history of the case includes the fact of a muscular effort, or of the receipt of external violence, the pain felt at the time, the loss or diminution of function, and some- times a snap heard by the patient or the bystanders at the moment the injury was received. An audible snap has been reported often enough, when taken in connec- tion with the known conditions, to make it probable that it is always produced, and that it fails to be heard only because the attention of the patient is absorbed by other circumstances. In a compound fracture the bone can usually be seen or felt in the wound, the bleeding is venous, and usually profuse and long continued, with the admixture of a few drops of oil coming from the crushed marrow. The examination of a case should be systematic, thor- ough, and gentle. It should first be directed to the his- tory of the patient and the injury ; then to pain and loss of function; and finally to the objective signs. Anaes- thesia should be used in doubtful cases when pain or muscular rigidity interferes with the examination, and especially in suspected fractures near a joint. Repair. - Shortly after a limb has been broken it swells and feels sore, and after the lapse of a few hours, or a day or two, ecchymoses appear at points on its sur- face more or less distant from the seat of fracture. Usu- ally, too, a few blebs form. The patient at first suffers somewhat from the shock and excitement of the injury- and his temperature commonly rises from one to three degrees during the first two or three days ; but as a rule he eats and sleeps well, and complains at most of some pain or uneasiness in the limb, and of his confinement. After the inflammatory swelling and oedema have sub- sided, a firm ovoid mass can be felt about the bone at the seat of fracture, which gradually becomes smaller and harder, until finally nothing is left of it but the callus which unites the fragments. The ecchymoses give place to a yellowish discoloration of the skin, which is often very widespread and may last for weeks, and after union is complete and the splints have been removed, the limb is found to be shrunken, and its surface dry and rough. The joints have become stiffened by disuse, and the limb readily swells and becomes congested when allowed to be dependent. Months may pass before it fully regains its original condition, and in old and rheumatic patients some stiffness of the joints may persist indefinitely. Occasionally, but rarely, a simple fracture suppurates, and the occurrence of this, as of any other serious com- plication, is marked by a return of the fever. In compound fractures the coutse is more varied, and the chance of serious complications greater. If the wound heals promptly and without suppuration, the fract- ure becomes simple, and its course is then the same as that of a fracture that has been simple from the begin- ning, and the same is measurably true of those cases also in which only the deep part of the wound heals without suppuration. The capital point is that the seat of fract- ure should be shut off from communication with the ex- terior, and should escape suppuration ; the presence of a superficial, non-communicating wound is relatively unim- portant. Even when the communicating wound remains open, and heals slowly by granulation, repair may take place without fever and without complications if the wound is kept aseptic. If, however, suppuration occurs, the patient is exposed to all the accidents which formerly made a compound fracture so redoubtable an injury. The broken bone shares in the inflammation and suppuration, and osteo- myelitis is, set up which may become putrid and infect- ing ; pus forms and burrows among the tissues, fever is constant, and death may ensue in consequence of septi- caemia, pyaemia, or tetanus. The ends of the bone, de- nuded of their periosteum, lie bare and white in the wound, and may become in part necrotic and carious, and the smaller fragments remain as foreign bodies to keep up suppuration, until cast out by nature or removed by the surgeon. Consolidation is delayed, the callus large and irregular, and the cicatrix adherent. The anatomical details of the process of repair, taking a fracture of the shaft of a long bone as an example, is as follows: When the fracture takes place the marrow of the bone is crushed, the periosteum torn through in part, and the adjoining musclesand connective tissue lacerated to an extent that varies with the degree Of displacement. Blood is poured out from the torn vessels, and coagulates between the fragments and in the muscular spaces. The continuity of the periosteum covering the two fragments is probably preserved in part; but this membrane is loosened, and stripped off the bone for some distance on one side or the other. All the elements of the bone, the periosteum, and the adjoining connective tissue share in the process of repair, and they do so by forming granulations which fill the gap between the fragments and become structurally united with them. Of these granulations those furnished by the soft parts and the marrow are the first to appear ; those springing from the broken edge of the cylindrical shaft can only appear after rarefaction of the bone by enlargement of its Haversian canals has opened a way for them. The first effect of the traumatism is to cause irritation and induration of the soft parts adjoining the fracture, and this is the explanation of the large ovoid swelling which can be distinctly felt after the first day or two. After the displacement has been reduced and the limb im- mobilized, the irritation, and with it the swelling, dimin ishes ; the periosteum thickens and pours out a viscid, 237 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gelatinous substance between itself and the bone for a short distance beyond the edge of the fracture, or beyond the point to which it has been stripped up. The untorn, stripped-up periosteum-the "periosteal bridge"-forms granulations on its under surface, which unite with those springing from the marrow and other torn surfaces, and fill the cavity as the blood is slowly absorbed. The ends of the bone thus become embedded in a mass of soft tissue, which subsequently is to constitute the permanent bond of union. The granulations arising from the periosteum pass through a cartilaginous stage before they become bone ; those arising from the bone and marrow are trans- formed directly into bone, the process of transformation beginning on the inner surface of the cylindrical shell. The new bone the callus, at first is large and spongy, but it gradually grows smaller by absorption on its outer sur- face, and denser by thickening of its lamellae, so that finally, after the lapse of months, it is as firm and com- pact as normal bone, but differs from it in the irregularity of the arrangement of its vascular canals. The original bone adjoining the callus shows also a similar and perma- nent change in the arrangement of its canals, in conse- quence of the rarefying and condensing processes through which it has successively passed. The plug formed ■within the medullary canal by ossification of the granu- lations may also disappear, in time, by absorption, and thus, in favorable cases without permanent displacement repair may be so perfect that the seat of the fracture can only be detected by sawing the bone longitudinally and re- cognizing the remaining variation in the thickness of the cylindrical shell. Ordinarily, however, some irregulari- ties of the surface remain and make recognition easy. Fragments of bone, even if entirely detached, may con- tract new adhesions and regain their vitality by the spreading into them of new vessels from the granulations by which they are surrounded, or they may become em- bedded in the callus and remain as inert and harmless foreign bodies. Sometimes, perhaps after the lapse of years, and by the agency of various causes, they cause irritation and suppuration, and require to be removed. In a relatively small number of cases union fails be- cause of an arrest of the process of repair at the fibrous stage. This is favored by displacement and by failure to keep the fragments motionless upon each other. The pieces may be closely bound together by an intermediate fibrous bond springing from and uniting their broken surfaces, or the union may be constituted by an external sheath or capside, within which the ends of the bone lie bare and smooth, and sometimes covered even with a layer of cartilage, and bathed in a synovial liquid. The term pseudarthrosis includes both kinds of union. In a few cases not only has the bond of union failed to ossify, but a large portion of the bone itself has disap- peared by absorption, giving place to a simple cord of fibrous tissue. In compound fractures the process differs by the ab- sence of the cartilaginous stage wherever the periosteal granulations have suppurated. In short, flat, and spongy bones the only differences arise from the absence of a medullary canal and from the greater ease with which granulations are produced by the bone itself. As a consequence, final permanent union is rather more promptly obtained. In articular fractures the modifying factors are the absence of periosteum and soft parts along the intra- articular portion of the line of fracture, and the presence of the synovial fluid which bathes the granulations and dilutes the lymph. In consequence, repair is effected more slowly, and the bond of union more frequently re- mains fibrous. There is no external callus along the por- tion covered by the articular cartilage, and the break in the latter is permanent, the gap being usually occupied by fibrous tissue. Displacement of a fragment, or over- growth of the callus, often intervenes to limit the range of motion of the joint by interposing a mechauical ob- stacle. When parallel and adjoining bones are broken, the callus of one may unite with that of the other, so that the two form a single mass of bone (Fig. 1333). This result, which is unimportant in the leg or between the ribs, has serious consequences in the forearm, where it necessarily abolishes the movements of pronation and supination. In other cases the process of ossification may extend far beyond the seat of fracture, and by involving adjoin- ing ligaments cause complete ankylosis of the corre- sponding joint; or the callus may envelop or incor- porate adjoining muscles or tendons, and destroy their usefulness. Occasionally, also, it envelops or presses upon nerves and blood-vessels. When the line of fracture passes through or near the conjugal cartilage, which during youth unites the epiphy- sis to the shaft, the irritation of the traumatism may lead to premature ossification of this cartilage and consequent arrest of the growth of the bone. The same, arrest of growth, of course, follows unreduced transverse displace- ment of the epiphysis. In addition to the accidents and complications already mentioned, there are three others which are dangerous, but fortunately rare-embolus, fat embolism, and injury to a large blood-vessel. As in other surgical injuries, the blood coagulates in the small veins about the fracture, and occasionally this coagulation extends into the larger vessels, where a por- tion of the clot may then become detached, swept away by the current, and lodged in the pulmonary artery or one of its branches. The symptoms are the same as those of pulmonary embolism having any other origin, and usually end in almost immediate death. Fat embolism-the plugging of the capillaries of the lungs with free fat- has only been recognized as a cause of death after fracture within the last twenty years. The mechanism ap- pears to be liquefaction of the fat of the marrow, its passage into the small veins of the bone which remain patent because of the attachment of their wqlls to the bony canals in which they lie, and its arrest by friction in the capillaries of the lungs. It acts inju- riously by obstructing the circulation. It seems probable that fat embolism, to a moderate extent, takes place after every fracture of a large bone, and it is fatal only when the amount taken up is sufficient to close a Large number of the pulmonary capillaries, or when, as in the case of other emboli, extravasation of blood takes place about them and an inflammatory process is set up. When death does not occur until after the lapse of several days, similar fat emboli are found in the capillaries of the systemic circulation, especially in the brain and kidneys. The symptoms are not very constant or well defined ; they point to a disturbance of the pulmonary circulation, usually dyspnoea, hurried respirations, cyanosis ; the per- cussion note clear, the respiration harsh. In the rapidly fatal forms the symptoms resemble those of shock, and Czerny says the differential diagnosis is then to be based upon the intercurrence between the receipt of the injury and the appearance of the symptoms of a period during which the patient seems to be doing well. Under injuries to the large vessels are here included their laceration, bruising, and compression. The conse- quences which may ensue are haemorrhage, traumatic aneurism, and gangrene. In every compound fracture venous bleeding is usually free and lasts for several hours, but it seldom requires other treatment than pressure over the wound by a band- age, snugly applied, with elevation of the limb. In ex- ceptional cases it is necessary to make pressure upon the main artery of a limb until a clot shall have formed in the wounded vein. The same treatment may be suffi- cient to arrest arterial haemorrhage; but if not, the wound must be enlarged when necessary, and the bleed- ing point secured. If the wounded artery is a very im- portant one-as the femoral or popliteal-and especially if the fracture is accompanied by much comminution of the Fig. 1333.-Union of Bones of Forearm by Callus. 238 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. bone and laceration of the soft parts, amputation is to be preferred. In simple fractures large extravasations may take place between the skin and the fascia in consequence of rupture of the large subcutaneous veins, or beneath the fascia in consequence of laceration of the muscles or of rupture of an artery or large vein. In the former the bleeding soon ceases spontaneously, or under moderate, uniform press- ure, and rarely requires subsequent attention ; but occa- sionally, when the collection is large and circumscribed, it may be desirable to remove the serum of its clot by means of the aspirator, or it may provoke suppuration and the formation of an abscess which will require to be opened. The source of a deep extravasation cannot often be recognized with certainty; the absence of pulsation in the distal arterial branches indicates injury to the main trunk. This, however, is rare, except when the fracture is. at a point where the artery lies very close to the bone. The swelling, at first diffuse, soon becomes distinctly limited and fluctuating, and after a time bruit or pulsa- tion, or both, may appear as the result of the formation of a wall or sac about the collection. Arteries wounded subcutaneously will usually heal with the aid only of elevation of the limb and moderate uniform pressure. If an aneurism forms it should be treated by ligature or compression of the main trunk above ; or, if consolidation has taken place, by laying open the sac and tying the ar- tery above and below the opening in it. Gangrene due to injury of, or pressure upon, a vessel may be moist or dry, according as the venous or the ar- terial flow is principally obstructed. As the same result may be caused by too tight bandaging, the surgeon should always note the condition of the distal circulation both before and after the limb has been placed in splints, and if he has reason to think that the vessels have been injured or are compressed by irreducible fragments, he should apply only such dressings as are certain not to make any injurious compression, for the sake of both the patient and himself, since the occurrence of the gangrene may be charged to the pressure of the bandages. It must be remembered, also, that in fracture by direct vio- lence, as by the passage of a wheel across the arm, the artery may be so bruised that a thrombus will form in it after a few hours and lead to gangrene of the distal por- tion of the limb. In the common form of gangrene the foot or hand be- comes swollen, dark, insensitive, and cold, and this change spreads up the limb until the point where the line of demarcation forms is reached. The occurrence may be without marked effect upon the patient's general con- dition, or it may give rise to fatal septicaemia. Preventive treatment lies in the removal of the obstacle to the circulation, if that is possible, and in favoring the venous flow. After the condition is fully established amputation is the only resource. The period and the point at which it should be done vary in the different cases ; if it is evident that all below the injury is lost, or that the possible difference is not worth saving, or if gen- eral infection threatens, the surgeon should amputate without delay above the fracture, and as near to it as is safe ; if, on the other hand, there is reason to think that the process will limit itself to a portion of the distal seg- ment, amputation may be deferred until after the line of demarcation has fully formed. Treatment.-If the fracture is such as to require the confinement of the patient to the bed, he should be placed upon mattresses that will not yield under his weight so as to form inconvenient hollows. If the underlying springs are too soft, they should be reinforced by planks placed lengthwise under them. Specially constructed fracture-beds are seldom needed ; a bed-pan can be used without causing pain or disturbing the fragments, and the sheets can be changed by folding half of one longitudin- ally, passing the fold under the patient, and unfolding it on the other side, aiding the act by rolling or shifting him slightly, first to one side and then to the other. Or the sheet, folded transversely, may be passed in like manner from above downward, while his shoulders first, and then his hips, are raised. The objects of treatment are to restore the misplaced fragments to their original positions and to keep them there. These objects may be attained more or less per- fectly, according to circumstances. Reduction of a fracture is usually made by extension, counter-extension, and coaptation. After fracture of a long bone the tonicity of the muscles, aided by the spasm provoked by the traumatism or the fear of pain, usually shortens the limb by drawing the lower fragment upward past the other, or by inclining them to each other at an angle. This displacement is overcome by drawing the lower segment downward (extension), while the upper one is kept stationary by counter-extension upon it or upon the trunk. The traction must be gentle, but firm and steady, sometimes long continued, and sometimes aided by anaes- thesia. Lateral pressure, coaptation, is made at the point of fracture to overcome lateral displacement ; rotatory displacement is corrected during extension by rotating the lowTer fragment until its position corresponds with that of the upper one. The rule is to reduce the displacement at once, and as completely as is possible under the circumstances, and without the employment of a dangerous amount of force. These two limitations arise from conditions of the bone and of the limb. In some fractures the fragments are so firmly wedged together that they cannot be separated without the use of great force ; in others (fractures of spongy bones and of the spongy ends of long bones) the bone is so crushed and compressed that if the fragments were replaced in their original positions a gap would be left between them, and it is therefore better to leave them in contact, since union with displacement is a less disa- bility than failure of union. Or the inflammation may be so far advanced that the muscles have lost some of their extensibility, or the bulk of the limb may be so in- creased by exudation that the tension under the envelop- ing fascia, if this were stretched to its full length, would be dangerously great. The "guiding principles are: (1) That reduction, to any extent, diminishes pro tanto the irritation and reaction due to the fracture ; (2) that excessive force employed to accomplish reduction may cause additional lesions, the consequences of which are worse than those of displacement; and (3) that more or less complete reduction is still possible one, two, or three weeks after the receipt of the injury, that is, at a time when two important obstacles to reduction, spasm and inflammation, have ceased." Other obstacles to reduction are found in interlocking of the fragments, the interposition of a small fragment or of a bundle of muscle between the principal ones, or in the perforation of the soft parts by the sharp end of one of the fragments, or when a fragment is too small or too deeply placed to be acted upon by the surgeon. Perfora- tion of the soft parts by a sharp fragment may be over- come by extension, and by pressing the skin downward over the point with the palm of the hand. If this fails, and if great disability, or deformity, or failure of union threatens to result if the displacement remains uncor- rected, the knife must be used and the fracture changed into a compound one. If the skin is perforated, there is no reason for hesitation; the opening should be suffi- ciently enlarged to allow the reduction to be made com- pletely, and with full recognition of the character and extent of the obstacle. Retentive dressings are required to secure immobility of the fragments, and prevent displacement by the action of the muscles or of gravity. The limitations of space forbid a detailed description of such dressings, which are numerous and often complicated, and for which the reader is referred to other sources. The problem is a mechanical one, with simple, well-known elements, and when success is possible it can be obtained by accurate recognition of the causes of displacement existing, or to be expected, in the case, and by intelligent use of suitable means to oppose them. These means are found in splints, fixed dressings, and continuous extension. As a rule, the dressing should be applied directly to the hare limb. It may be desirable to bandage the distal por- tion of the limb to prevent swelling, but a bandage should 239 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. never be circularly applied at or above the seat of frac- ture, unless temporarily needed to arrest haemorrhage or reduce swelling, and then it should be elastic, and care- fully watched. Splints may be made of any material firm enough to give the necessary solidity, and capable of readily receiv- ing any needed shaping. All, except those which can be accurately moulded to the shape of the limb, need to be fitted with interposed cushions, or covered with muslin and stuffed on one side with cotton or wool, so as to fit the inequalities of the surface. After being fitted, they are bound on with adhesive plaster, straps, or a roller- bandage. The bivalve cushion (Fig. 1334) is a simple dressing that can be readily made of materials that are always at hand, and is w'ell suited for use during the first few days, while waiting for an opportunity to apply a more stable dressing. It is prepared for the leg in the following manner : " A rectan- gular sac of stout cotton cloth, of a length and breadth suited to the size of the limb, is divided into two parts by a seam which, beginning at the centre of its lower border, passes di- rectly upward for one-third its length, and then bifurcates so as to leave a central, V-shaped portion, the base of which is at the upper border of the sac, and is about three inches wide. The two lateral pouches thus formed are stuffed, and the openings closed. The limb is then placed along the centre, the two sides raised and supported by lateral splints, and the whole se- cured by straps. If used in fracture of the leg, it is well to have the lower end of the sac project sufficiently be- yond the sole of the foot to allow it to be turned in and fixed so as to support it." (Stimson, on Fractures, p. 161.) Fracture boxes (Fig. 1335) are useful temporary dress- ings for fracture of Ihe leg, and consist essentially of a board upon which the limb lies, hinged sides, and a mov- able hinged foot-piece. The padding is done with oakum, bran, or cushions, and the sides fixed with straps. The foot should be swung in them by means of a broad piece of adhesive plaster, passing from the middle of the calf under the heel, and along the sole to the top of the foot-piece, where it is tacked fast. Gutters made of galvanized iron wire, padded, and roughly shaped to fit the limb, are convenient substitutes for the more cum- bersome fract- ure boxes, and can also be used for the upper extremity. In fracture of the leg or arm the comfort of the patient can be increased by suspending the limb. Suspension is also used, in fracture of the thigh, as a means of making extension, as in Hod- gen's splint (Fig. 1337). This is made of two stout iron rods, connected by three or four half hoops which pass over the front of the limb, and several stout cotton bands which pass under and support the limb, and can be length- ened or shortened so as to share the weight evenly. The limb rests upon these supporting bands with the knee slightly Hexed, and is attached to the lower end of the rods by adhesive plaster, as in " Buck's extension " (Fig. 1340). The limb is suspended above the bed by cords passing from the rods to a pulley made fast at some fixed point above, and the amount of extension is regulated by the angle of inclination of these cords. It is a useful splint for fractures of the thigh, especially for those of the lower third. Moulded splints are constructed of any material that can be temporarily made soft enough to take the shape of a surface to which it is fitted, and that will retain this shape after hardening. The materials most commonly used are stout pasteboard, leather, felt, gutta-percha, and plaster- of-Paris ; the former are softened by wetting or by im- mersion in hot water, and are bound upon the limb until they have hardened. Plaster-of-Paris splints are made by soaking strips of old blankets, flan- nel, or folded cheese-cloth, or even muslin, in thin plaster cream. The strips should first be cut in the proper shape, then wet and thorough- ly wrung out, and then passed through the cream. The excess of plaster is allowed t o drip off, and then the splint is applied either directly to the well-oiled limb, or with the interposition of a layer of cotton cloth or batting. When the splint is to have the form of a gutter with sharp angles, as at the elbow or shoulder, it should be cut partly through from the edges in the lines that would be taken by the folds if it was not cut, and the edges of the cuts interlaced. While the splint is hard- ening, it should be bound on snugly with a roller-bandage, and measures should be taken to prevent displacement in the meantime. If the splint is to be used for a compound fracture, it should be protected with oil-silk at points where it is liable to come into contact with the discharges from the wound, or should be var- nished with shellac or coated with melted paraffine. Plaster splints are in very general use, because they are strong, readily made, and fit accurately. Anterior ones can be Fig. 1336.-Nathan R. Smith's Anterior Splint. Fig. 1334.-Bivalve Cushion. Fig. 1337.-Hodgen's Suspended Splint for Fractures of the Thigh. arranged for suspension by imbedding rings or loops of wire in them. The Bavarian plaster splint (Fig 1338) is designed to surround the limb entirely, and at the same time to allow it to be inspected readily. "It is made of two pieces of coarse flannel that has been shrunk and cut of the proper length, and of a width somewhat greater than the circumference of the limb. The pieces are then fastened together by two rows of stitching, about half an inch apart along the centre, which, in the case of the leg, is to occupy the posterior median line, and placed in posi- Fig. 1335.-Petit's Fracture Box. Fig. 1338.-The Bavarian Splint. tion under the limb. The one that is next to the leg is then folded around it, and its free edges stitched together in front and along the dorsum and sole of the foot; plas- ter cream is spread smoothly over it and well rubbed in, and the outer layer of flannel then drawn over and stitched, or pinned fast in like manner. After the plas- 240 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. ter has set the stitches are cut, the excess of flannel cut away, and the edges bound by stitching those of each side together, or by binding on strips of leather provided with eyelets. The bandage is kept in place by a roller-bandage, or by a cord passed through the eyelets, and can be readily removed, or one side can be lowered by turning A piece of stout adhesive plaster, four or five inches wide, and long enough to reach from a point three or four inches above the knee, loosely around the sole, and back on the other side to a point opposite the beginning, is prepared by splitting its ends for a few inches, and by turning in the sides of the central portion so as to cover in a piece of thin wood measuring about five by three inches, and perforated in the centre. A roller-bandage is then applied to the foot, ankle, and lower third of the leg, the plaster placed on the sides of the limb above it, so that the loop containing the piece of wood will hang about two inches below the sole, and secured by carrying the bandage up over it; the upper ends of the plaster, if long enough, may be turned down and covered by addi- tional turns of the roller. Short "co-aptation splints" are strapped upon the front, back, and sides of the thigh, a cord attached to the foot-piece by passing it through the hole and knotting it, carried over a pulley fastened to the foot of the bed, and made fast to the weights. Counter- extension is made by raising the foot of the bed six or eight inches. The patient's comfort will be increased by the use of Volkmann's sliding-rest. " Volkmann's sliding-rest (Fig. 1342) is a wooden frame the side-bars of which are triangular, with an upper edge Fig. 1339.-Esmarch's Double-inclined 1'lane. it on the hinge which is formed by the narrow' strip left between the two rows of stitching behind." Complete encasement of a limb in plaster-of-Paris ban- dages is done as follows : The limb is first enveloped in a layer of cotton batting, or a sheet of blanketing cut to fit it; and then roller-bandages, prepared by unrolling them, rubbing dry plaster into them, rolling them again, and then placing them on end in water deep enough to cover them, are applied in the usual manner from below up- ward until a sufficient thickness, usually three or four layers, is obtained. The limb is sup- ported and extension maintained by assistants during the application, and until the plaster has hardened. In default of roller-bandages, longitudi- nal and short circular strips of coarse, thicker material, soaked in plaster cream, may be used. For use in compound fractures, fenestrae must be cut, after the plaster has hardened, at points corresponding to the wounds ; and if these openings are so large as to weaken the dress- ing, strips of iron must be interposed between the layers, so as to give the needed strength. Instead of plaster, starch, dextrine, and silicate of soda are sometimes used. They are lighter and cleaner, but harden more slowly. After a plaster dressing has been applied, the circula- tion in the limb must be carefully watched for a day or two, and if the dressing is too tight, it must be cut lon- gitudinally, or removed, and a new one applied. If it becomes too loose by subsidence of the sw'elling, it may be made tighter by cutting out a longitudinal strip, about an inch wide, and drawing the edges together by straps or a few turns of a roller-bandage, but it is better to make a new dressing. The contra-indications to its use are present or threat- ening gangrene, extensive extravasation of blood, great swelling, injury of a large ar- tery, and acute phlegmonous inflammation. The double-inclined plane is sometimes used in the treat- ment of fracture of the femur. It consists of posterior splints for the back of the leg and thigh, hinged at the knee, and resting upon a board to the up- per end of which the upper end of the femoral splint is attached by a hinge. The femoral splint should be short, so that the buttocks rest directly upon the mattress. The principle of continuous extension by weight and pulley, " Buck's extension," or by india- rubber, is to tire out the mus- cles which cause displacement by a moderate but continuous strain upon them. Its principal use is in the treatment of fractures of the femur, to wdiich it is applied as follows : Fig. 1341.-Buck's Extension Apparatus. upon which two cross-bars rest. To these cross-bars are fixed a posterior splint and an upright foot-piece, the former cut away centrally in its lower quarter to accom- modate the heel. The foot and leg are fastened to the splint by a roller-bandage, after the dressing by which extension is to be made has been applied, and can thus be moved freely up and down the bed, the cross-bars which support them sliding without much friction upon the tri- angular side-pieces. This apparatus adds /k much to the comfort of the patient, and, moreover, prevents rotation of the leg. It takes the place of the long side-splint and cross-bar " (Fig. 1343). Instead of the cord and weight, a stout piece of india-rubber tubing may be used, together with a long side-splint to the lower end of which the tubing is attached, while counter-extension is provided for by a perineal band. Passive motion of the larger joints should be made whenever it is convenient and can be done without danger of preventing union of the fract- ure. Early passive motion diminishes the amount and duration of the stiffness that follows fracture, but it is not essential to the full recovery of the motions of the joint. In fact, if the joint is involved in the fracture, or Fig. 1342.-Volkmann's Sliding-rest. Fig. 1340.-Strip of Adhesive Plaster, Shaped for Use in Extension Apparatus. 241 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. if it is inflamed so that passive motion causes pain, it should be kept at rest, for its use increases the inflamma- tion and therefore does harm. In the smaller joints of the hand, when the fracture is of the arm or forearm, passive motion should be diligently employed from the beginning. Treatment of Compound Fractures.-The essential prin- ciple of treatment is to secure the earliest possible union of the wound, and to treat it while it is open in accord- ance with the principles of the antiseptic method. At present the details of the antiseptic treatment of wounds vary greatly, and many different antiseptics are em- ance with general principles. The treatment of other complications has been referred to under special titles. In compound fractures involving joints, the same prin- ciples of treatment apply : absolute surgical cleanliness, and perfect drainage. Excision of the joint, partial or complete, is to be preferred after fracture at the elbow or shoulder with much shattering. After fracture at the knee or ankle firm ankylosis is usually better than a mov- able joint obtained by excision ; consequently operative interference at these points should be limited to the re- moval of detached fragments, regularization of the sur- faces, and provision for drainage. Vicious Union.-Vicious union of the shaft of a long bone is union ■with displacement to an extent which causes notable deformity or disability. It is more com- mon in the lower than in the upper extremity. The methods of treatment present four varieties : (1) reducing the displacement abruptly or gradually while the callus is still soft; (2) forcible rupture of the solid callus ; (3) di- vision of the callus ; (4) resection of a projecting por- tion of bone. The first method mainly differs from the setting of a recent fracture in the greater resistance opposed by the induration of the soft parts, and by adhesions or portions of callus that have formed between the fragments. These obstacles are very efficient to oppose the correction of over-riding, but an angular displacement can usually be corrected. Pressure should be made at the apex of the angle, and counter-pressure upon the limb above and be- low. Gradual correction is done by permanent exten- sion in the direction of the long axis of the limb, or by a lateral splint and an elastic roller-bandage. Forcible rupture of a callus is done by lateral pressure on the limb, either by the hands or knee, or by pressure over the end of the table, or by one of the so-called osteo- clasts, instruments constructed for this purpose. The result is a simple fracture produced with the minimum of injury to the adjoining soft parts. The displacement is then reduced as far as possible, and the case treated as a simple recent fracture. The third method, division of the callus, differs from the preceding one as a compound fracture differs from a simple one. It is of use especially in old cases of angu- lar displacement, in which the tissues on the concave side of the angle have become permanently shortened, and it is then also necessary to combine it with excision of a wedge of bone so as to make the length of the limb, when it is made straight, correspond to that of the short- ened muscles. The incision of the soft parts should be longitudinal, and should pass, when practicable, between, rather than through, overlying muscles. The bone may be divided with a saw, or preferably with a chisel. When the deformity is simply due to the projection of the end of one of the fragments, with or without ulcera- tion of the skin covering it, it can be readily and safely overcome by cutting down upon and removing the pro- jecting portion with the chisel or bone-pliers. Pseudarthrosis and Delayed Union after Fract- ure.-The term pseudarthrosis, which etymologically signifies a false joint false; SpOov, a joint), is applied to the condition produced by failure of bony union after fracture of a bone, whether there be fibrous union with limited mobility, or whether an actual joint have formed between the fragments. When only a few weeks have elapsed since the receipt of the injury, and there is still reason to hope that bony union may be obtained by simply prolonging the usual treatment of a fracture, the condi- tion is called delayed union. The resulting disability may be very slight or may be complete. Excluding cases of fibrous union or failure of union after fracture of the patella, olecranon, apophyses to which powerful muscles are attached, and of the neck of the femur, or, in other words, limiting the term only to failure of bony union after fracture of the shaft of a long bone, the condition is of relatively infrequent occurrence. The statistics and estimates of its frequency differ widely, but it may be fairly claimed that the cases are very few ployed. The ones that are in most favor are carbolic acid, corrosive sublimate, and iodoform. Carbolic acid is used as a wash in solutions of two and a half per cent, and five per cent., and in prepared gauze dressings ; cor- rosive sublimate is used as a wash in solutions of one per one thousand, and one per two thousand ; iodoform is used as a powder applied directly to the purified wound, and in gauze dressings. If the ■wound is small, clean-cut, and recent, it should be gently washed with the carbolic acid or corrosive sub- limate solution, as should also the adjoining surface, and then the gauze dressings should be applied as usual, or over a small occludent dressing made of strips of adhe- sive plaster, or of some impervious tissue fastened over the wound with collodion. If the wound is large and contused, it should be thor- oughly cleaned by deep irrigation with the antiseptic solution, and a drainage-tube should be inserted ; and if there is much laceration, and the wound is badly placed for drainage, a counter-opening should be made for the tube at the most suitable place. Loose splinters should be removed, but those that are broadly attached to the periosteum should be retained. Splints must, of course, be used as in simple fracture, and they must be so arranged as to allow the dressings to be changed whenever necessary without disturbing the fragments. Absolute immobility of the fragments, even Fig. 1343-Long Side-splint and Cross-bar. Fig 1344.-Cripp's Splint. in a defective position, is a most valuable adjunct in pre- venting suppuration, and it must be remembered that a faulty position can often be corrected even after the lapse of two or three weeks. In cases complicated by much laceration of the soft parts, Professor Markoe's method of "thorough drain- age," with frequent irrigation with a weak carbolic solu- tion, has given excellent results. He passes a drainage-tube through the wound and a counter-opening made in the opposite side, the tube being long enough to project through the dressings. A two or two-and-a-half per cent, solution of carbolic acid is syringed through the tube several times daily. A simple dressing, kept wet with the carbolic acid solution, is placed over the wounds, and the limb supported by splints. Intercurrent inflammatory processes, burrowing of pus, formation of abscesses, etc., must be treated in accord- 242 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. in which a sufficient cause cannot be found in faulty treatment, in loss of substance after compound fracture, or in great unreduced displacement. Tabulated cases show failure of union to be most frequent in the humerus, thirty-four per cent, of all ; next in the leg, twenty-eight per cent.; then the femur, twenty-four per cent., and then the forearm, twelve per cent.; more common in males than in females, and most frequent between the ages of twenty and thirty years. Anatomically the cases may be divided into two princi- pal groups : Those in which the fragments are united by a fibrous band ; and those in which an actual joint is formed, with a capsule, synovial liquid, and perhaps even a cartilage of incrustation. The former is much the more common ; the latter very rare. The former presents many differences of degree ; the band may be long or short, broad or narrow ; the ends of the bone may be en- larged by partial ossification of the granulations, or di- minished by absorption. In a remarkable case reported in the Boston Medical and Surgical Journal, July 11, 1838, the entire shaft of the humerus disappeared by absorp- tion after fracture. A few other cases of similar but less extensive absorption have been reported, and also a few in which a partly-formed callus has been absorbed. The causes are general and local. Among the former are included general conditions and diseases which give rise to notable deterioration of the health, such as severe acute diseases, anaemia, pregnancy, and syphilis. Cases have been reported in which these affections have ap- peared to be the efficient causes, but they are so few that it must be admitted that the influence upon the healing of a fracture is in general very slight. Local causes are classified as follows :2 1. Unfavorable relations or conditions of the fract- ured parts. 2. Interposition of a foreign body. 3. Defective innervation. 4. Defective blood-supply. 5. Disease of the bone. 6. Inflammation on the surface. 7. Defective treatment. Of these, the first and last are the more common causes, including, as they do, the one that is admitted to be by far the most frequent cause of all, failure to immobilize the fragments during treatment. Not only will mobility prevent or delay consolidation during the earlier stages of repair, but it may intervene at a later stage to arrest the process, or even to provoke absorption of the partly- formed callus. Callender has said that movements com- municated to the limb in order to prevent stiffness of its joints are a frequent cause of failure of union, especially movements of the elbow after fracture of the humerus ; and premature use of a limb that has been broken has frequently been followed by the reappearance of mobility at the point of fracture, and by increase of deformity. Softening and absorption of a firm callus, sometimes after the lapse of weeks or months, has been observed in a few cases, usually under the influence of some acute disease, such as typhoid fever, small-pox, or even scurvy, or of local injury or inflammation. Treatment must be directed to the removal of the cause, and must be combined with measures to quicken or renew the reparative process, or, when necessary, to restore the parts to the condition of a recent fracture. Prolonged immobilization in an accurately fitting apparatus, aided by good hygienic conditions, food, air, exercise, and tonics, should always be tried in recent cases, when there is reason to think that the failure is due simply to defective immo- bilization. Internal remedies have not proved valuable. Local measures designed to provoke irritation at or near the seat of fracture have been employed in many forms. The least violent is the slight but frequently repeated ir- ritation excited by the use of the limb. A considerable number of successes after fracture of the thigh and leg have been obtained in this manner, by the use of the splints devised by the late Professor H. II. Smith, of Philadelphia, which are strong enough to prevent mobil- ity or angular displacement from being caused by this use of the limb. Another method, frequently employed before resorting to operation, is to rupture the uniting bond and irritate the broken surfaces by rubbing them forcibly against each other. If it be desired to do this thoroughly, anaes- thesia should be used, and the distal segment of the limb should be forcibly bent until the tissues are felt to tear, and it is brought nearly or quite to a right angle with the upper segment. It is then bent to the same distance in the opposite direction and moved freely about, and then treated as a recent fracture. The limb should not be bent in a direction that would endanger the main artery. The seton, passed between or beside the fragments, was frequently employed during the first half of the present century, but has now fallen into complete disuse. Perforation of the ends of the bone, combined or not with the insertion of metal, ivory, or bone-pegs, is a favor- ite and efficient method of treatment which originated with Dieffenbach in 1841, and was popularized and sys- tematized by Brainard of Chicago. If the drill alone be used, it may be forced through the soft parts, without a preliminary incision, and made to perforate the bone at several adjoining points and in different directions. If pegs are used an incision is made down to the bone, a hole drilled in it, and the peg (which should not fit tightly) inserted. The peg should traverse the bone com- pletely ; it may be cut short and the wound closed over it, or left long and withdrawn after a few days. It may also be used in suitable cases to pin the fragments to- gether. Antiseptic precautions must be taken. Resection of the fragments is a radical and effective, but more dangerous, method. It places the parts in the condition of a fresh compound fracture, by dividing the fibrous band, freshening the ends of the fragments, and fitting them together. The bone should be exposed on the side that permits the easiest approach without dan- ger of injury to the main vessels or nerves, and with the least injury to the muscles. The fibrous band is stripped off or divided, the periosteum raised as far as necessary, the ends exposed or turned out through the wound, and freshened and fitted to each other by trim- ming them with the saw, chisel, or bone-pliers. If one of the fragments is so small that it cannot be properly immobilized by a splint, it may be fastened to the other by pegging or wiring. A drainage-tube should be in- serted, the wound treated antiseptically, and the limb im- mobilized, preferably in a plaster dressing. Clavicle, Fractures of.-With the possible excep- tion of the radius, the clavicle is the bone most frequently broken, and in nearly half the cases the patients are less than five years old. The fracture may be partial or com- plete, single or multiple, simple or compound. Com- pound fractures are rare ; partial fractures are thought to be very common, an opinion which finds support in the youth of the patient and the usual production by indirect violence. The fractures are conveniently classified according to their position in the inner, middle, and outer thirds of the bone, and these apparently arbitrary divisions coincide with important anatomical and clinical differences. The outer third is attached by ligaments at either end to the acromion and coracoid processes, respectively, and the displacement after its fracture is, therefore, not so great as after fracture of the middle third ; when the middle third is broken the inner fragment is drawn upward by the sterno-cleido-mastoid muscle and the outer fragment is pressed inward toward the median line by the weight of the shoulder. Fractures of the middle third are by far the most fre- quent, and the point of fracture is commonly near the junction with the outer third of the bone. When the fracture is oblique, as is commonly the case, its line runs inward and downward, or backward ; multiple or com- minuted fractures are rare. Displacement is caused by the falling downward, for- ward, and inward of the shoulder in consequence of the loss of its anterior support; this presses the outer frag- ment toward the sternum, and as its inner end usually passes under the inner fragment, the outer end of the latter is displaced upward by the pressure, and also by 243 Fractures. F ractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the traction of the sterno-cleido-mastoid muscle. This displacement may be very marked ; in a case of old, un- united fracture recently under my observation, the inner fragment lay midway between its normal position and the line of the sterno-cleido-mastoid muscle. When overriding is prevented, as in most transverse fractures, the adjoining ends may be together displaced upward- angular displacement, with the apex of the angle in jhe neck. Fractures of the outer third are next in order of fre- quency, the line of fracture being usually transverse. The displacement is usually angular, the apex of the angle being directed backward ; and when the fracture is in the outer half of this third, the inner fragment is dis- placed upward, and may notably override the outer one, or the fragments may remain on the same level, and the angular displacement may be nearly equal to a right angle, the broken surface of the outer fragment lying against the front of the inner one. Fractures of the inner third. Since the classification of these by Malgaigne as a separate class, 31 cases have been reported, which show that the line of fracture may be transverse or oblique, and that the common form of dis- placement is downward and forward of the inner end of the outer fragment, accompanied or not by the adjoining end of the inner one-a displacement due, in part, at least, to the action of the deltoid and pectoralis major muscles. In two cases the outer fragment was over- lapped by the inner, and both were directed upward and backward. Multiple fractures are very rare ; when the intermedi- ate piece has been formed by the middle third of the bone its displacement has been great and irreducible. Complications, due to the displacement of the bone and not to an associated cause, as in gunshot fractures, are rare, and consist in injury to nerves, blood-vessels, or the lung. There is no well-authenticated instance of injury to the subclavian artery, but there are a few of wound of subclavian or internal jugular vein. In five cases of sup- posed injury to the brachial plexus, paralysis of the arm was the symptom on which the diagnosis was based : in two it was permanent, in the remaining three it disap- peared wholly or in part. Injury to the lung, shown by emphysema without associated wound of the skin or fracture of a rib, has been observed in five cases ; in two of them the emphysema was very extensive, occupying the entire trunk in one, and the head, neck, breast, and arm in the other ; greater or less dyspnoea was associated with it. The causes of fracture of the clavicle, in the order of frequency, are indirect violence, muscular action, direct violence. The common agents of the former are falls upon the hand or shoulder ; those of the second, efforts to lift a heavy weight, or to strike a blow ; in one case it was part of a general muscular effort made by a lad to raise himself while hanging by his feet from a bar and holding nothing in his hand. In a few cases the bone has been broken, apparently, by being bent across the first rib in a sudden and forcible depression of the shoulder. Both clavicles are sometimes simultaneously broken by a force that presses the shoulders toward each other ; in three such cases mentioned by Malgaigne union failed in both bones. The only symptom peculiar to such cases is the marked dyspnoea observed in some while the fracture was still recent, and attributed to the weight of the shoul- ders resting on the thorax, and to the temporary abolition of the function of aid to respiration belonging to some of the muscles attached to the clavicle. The dyspnoea was relieved by dorsal decubitus. Symptoms, Diagnosis, and Course.-The symptoms of complete fracture are pain, deformity, a false point of motion, and diminution or loss of function. Pain is found on pressure at the seat of fracture, and is the symptom on which the diagnosis in cases of partial fract- ure mainly rests. Deformity consists in change in the relations of the fragments to each other, and in the fall- ing inward, forward, and downward of the shoulder be- cause of the loss of its anterior support. The former is recognized by examination with the eye or fingers of the course of the bone ; the latter, which is practically lim- ited to fractures of the middle third, is best seen from be- hind, and is accompanied by marked prominence of the inferior angle and posterior border of the scapula. The shoulder is suspended by the trapezius muscle, and is held out from the thorax by the clavicle in front, resting against the sternum and the scapula behind, held in place by the underlying serratus magnus muscle, which is attached to its posterior border. When the clavicle, the anterior support, is broken, the shoulder falls forward, inward, and downward, anil the scapula rotates upon the curve of the thorax, its anterior portion approaching the median line in front, and its posterior portion correspond- ingly leaving it behind. The patient usually sits with the head and body inclined toward the injured side, and supports the elbow with his other hand. A false point of motion is recognized by manipulation of the bone ; and crepitation is obtained at the same time if the broken surfaces have not been too far separated by displacement, or if the displacement has been reduced by drawing the shoulder backward and outward. The patient can usu- ally swing the arm freely backward and forward, but cannot raise it without pain. Hurel found that circum- duction of the arm is the last movement to be regained, and that the delay was considerably increased by perman- ent shortening that amounted to half an inch or more. Union, which rarely fails, is usually complete by the end of the fourth week ; shortening and displacement, to some extent, are common in adults. Besides the rare complication of primary injury to un- derlying vessels or nerves that has been mentioned, par- tial disability, due to pressure upon these vessels or nerves by an exuberant callus, has been observed in two or three cases, and has been relieved by operation. Treatment.-The displacement is reduced by drawing the shoulder upward, outward, and backward to its orig- inal position, combined, when necessary, with manipula- tion of the fragments or with pressure on the projecting angle formed by them. The object of the subsequent treatment is to retain the shoulder in the position thus given to it, and thereby prevent recurrence of the dis- placement. The methods employed to accomplish this are very numerous, varying from a simple sling to elab- orate dressings or splints. Success is easily obtained in some cases, especially those of transverse fracture in chil- dren where the periosteum is not much torn ; but in most cases any retentive dressing that the patient will submit to falls more or less short of accomplishing its object. When a perfect result is earnestly desired, and the tendency to displacement is marked, the patient should be kept upon the back in bed for two or three weeks, with the arm properly immobilized by one of the dress- ings described below. A simple dressing, one which is often quite efficient, is a modification of Mayor's scarf. It is made of a square of muslin, the diagonal of which is long enough to reach easily around the body ; it is folded diagonally, the fore- arm placed between the folds and laid horizontally across the chest; the ends of the diagonal are tied together at the back, and the other two ends drawn snugly up in front so as to support the weight of the arm, and tied to- gether around the neck, or fastened by bands passing over the shoulders to the diagonal behind. Velpeau's dressing is made with a long roller-bandage. The hand of the injured side is placed upon the opposite shoulder, " and the limb is drawn snugly up toward the neck by successive turns of the roller, which, beginning at the opposite axilla, pass obliquely across the back, over the shoulder, in front of the arm, under the elbow, and back to the axilla; after three or four such turns have been placed the bandage is carried circularly around the body, covering in the arm from below upward. The turns should be secured by stitching or by soaking in plaster." Sayre's dressing is a very simple one, made of "two strips of adhesive plaster, each about three inches wide, and long enough to go once and a half around the body ; one end of the first strap is stitched loosely about the arm just below the axilla, and the other end carried around 244 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. the back and the opposite side to the chest in front. The second strap is then carried from the top of the shoulder on the uninjured side across the back, under the elbow, and along the forearm to the shoulder again. The elbow should be drawn back while the first strap is applied, and yell forward while the second is." It is well to leave the hand uncovered. Other dressings aim to hold the shoulder back by pos- terior splints or cushions, to which the shoulders are fastened by bands passing over them and back through the axilla, or by an anterior splint or brace moulded to the front of the chest. An axillary pad designed to furnish a fulcrum over which the shoulder can be forced outward by pressing the elbow inward has not proved of sufficient value to justify the risk incurred in its use. A plaster-of Paris roller applied about the shoulders in the form of a figure-of-8, crossing on the back and secured by additional turns about the chest, so as to keep the shoulder elevated, aided by a plaster-of-Paris breast- plate, moulded upon the front of the chest and shoulders, has given me good results in two cases of marked dis- placement that could not be prevented by other dress- ings. The comfort of the patient will be increased by a small pad of absorbent cotton placed in the axilla, and a com- press between the arm and body, wherever they would otherwise be in contact. In fractures near the acromial end, with elevation of the inner fragment, reduction can be maintained by a long strip of adhesive plaster, the centre of which passes under the elbow, and the ends are carried up, one in front and the other behind the arm, and crossed tightly on the fracture. Scapula, Fractures of.-Fractures of the scapula are classified as : 1, fractures of the body ; 2, of the in- ferior angle ; 3, of the upper angle and supra-spinous fossa ; 4, of the spine ; 5, of the acromion ; 6, of the coracoid process ; 7, through the surgical neck ; 8, of the glenoid cavity. Fractures of the Body, Inferior Angle, and Upper Angle. -These are commonly the result of direct violence, a blow or fall, but in one recorded case the inferior angle appears to have broken by the contraction of the teres major. In fractures of the body the line of fracture is usually transverse or oblique, and the displacement, if any, consists in overriding of - the fragments. After fracture of the inferior angle the lower fragment is drawn forward and upward. The treatment consists in immobilization of the arm and scapula, the latter by broad bands of adhesive plaster encircling the chest. Fracture of the spine of the scapula is produced by direct violence. Independent mobility and crepitation can be recognized by manipulation. The tendency to displace- ment appears to be very slight, and the only treatment re- quired is to immobilize the arm. Fracture of the acromion may be caused by violence acting directly upon it or through the humerus, or (rarely) by muscular action. The line of fracture is transverse or oblique, and commonly situated either at the root of the process or at a point about an'inch from its tip ; in the latter case the displacement is slight, in the former the distal fragment is drawn downward and inward by the weight of the arm. The displacement can be recog- nized by drawing the finger firmly along the crest of the spine toward the tip of the acromion. Crepitation can sometimes be got by raising or abducting the arm, or manipulating the fragments. Usually the patient is un- able to raise the elbow. Union by a fibrous band is the rule. The treatment consists in immobilizing and supporting the elbow in such a position that the head of the humerus raises and holds the fragment in its place. Fracture of the coracoid process is rarely seen unaccom- panied by other fractures of the scapula or of the ribs. It has been caused by muscular action. The displace- ment is seldom great; the objective signs are recognized only with difficulty, because of the thickness and tense- ness of the overlying soft parts. Bony union is excep- tional. The treatment is to immobilize the arm in an easy position in which the muscles attached to the process are relaxed. Fracture of the Surgical Neck of the Scapula.-In this class are included fractures which pass from the border of the scapula below the attachment of the triceps, up to the super-scapular notch, or to a point in front of the base of the coracoid process, perhaps within the glenoid cav- ity ; the essential feature of the fracture is the detach- ment of the portion of the bone to which the triceps is made fast. The symptoms are those produced by the sinking of the humerus through lack of support by the triceps: the shoulder is flattened, the acromion prominent, and the normal form of the part can be readily restored by press- ing up the shoulder, but the deformity immediately re- turns when the support is removed. The treatment is to support the elbow firmly and keep the head of the humerus pressed outward. Fracture of the rim of the glenoid cavity probably occurs only in connection with dislocation of the shoulder. Humerus, Fracture of.-Fractures of the humerus occur in the proportion of nearly eight per cent, of all fractures. They are clinically classified as fractures of the upper end, fractures of the shaft, and fractures of the lower end. Fractures of the Upper End of the Humerus.-These fractures present several anatomical varieties, differing in importance, and not always to be distinguished clinically. Simple fissure, or partial fracture of the head alone, is very rare. Pure fracture of the anatomical neck, the line of fracture lying entirely within the capsule, is also very rare. Fractures in which the line passes partly along the ana- tomical neck and partly through one or both, tuberosities, are less rare, and are usually accompanied by more or less splintering of the adjoining end of the shaft. The frag- ments are commonly held together by the untorn perios- teum and capsule, and by impaction, but may undergo a gradual change of position by which the shaft is drawn upward and the upper fragment pressed downward or inward, so as to resemble after a time an unre- duced dislocation. An exact diagnosis is difficult. Re- pair is accompanied by an exuberant callus, and sometimes by partial ossification of the capsule. When the upper fragment is small and completely detached, as in pure fracture of the anatomical neck, it may remain indefi- nitely, without causing suppuration, either loose within the capsule or fixed by the surrounding callus, or may become partly absorbed. Eburnation of a similar com- pletely detached fragment has been observed in the elbow. Fracture of the greater tuberosity is rare, except in con- nection with dislocation. It has been caused by direct violence and by muscular action, the contraction of the at- tached external rotators. The size of the fragment varies, but the line of fracture seems usually in part to adjoin the anatomical neck and the bicipital groove. When the periosteal attachments remain in part untorn and the sepa- ration is not great, bony union follows. In other cases the fragment may be withdrawn to a considerable dis- tance, and then union fails. The symptoms are loss of the power of external rota- tion, pain, swelling, and crepitation, combined wfith evi- dence of the continuity of the head and shaft. Flattening of the deltoid and prominence of the acromion, which have been observed in some cases, were doubtless due to associated dislocation. Fracture of the lesser tuberosity has been observed in connection with dislocation of the shoulder upward. Separation of the epiphysis is caused only by external violence, as in a fall or in drawing upon the arm of the child during delivery. Displacement, if present, is trans- verse and angular, the lower fragment being drawn for- ward, and the under surface of the upper fragment in- clined forward, when the transverse displacement is not complete ; and the lower fragment being drawn inward toward the coracoid process when the displacement is complete. In the former case there is a distinct promi- nence on the front of the arm a little below the acromion, 245 Fractures, Fractures, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which moves with the shaft ; in the latter the prominence is found near the coracoid process. Union without loss of function is the rule ; suppura- tion has occurred ; as has also arrest of growth by pre- mature ossification of the cartilage, or in consequence of an unreduced complete transverse displacement. Dr. Moore, of Rochester, has reduced the displacement easily by carrying the elbow forward and upward while making traction. Fracture of the surgical neck is the most common va- riety. The direction of the line of fracture and the dis- placements vary greatly. The tendency of the muscles is to turn the broken surface of the upper fragment for- ward and outward, and to draw the lower fragment up- ward and inward ; but this tendency is often overcome by the direction of the line of fracture, the original fractur- ing force, or the existence of impaction. Usually the upper end of the lower fragment projects on the inner side, and the elbow is directed outward. The sharp end of either fragment may perforate the skin, especially if the bone has been broken by a fall upon the elbow. The diagnosis can be readily made by attention to the common signs of fracture. Union is the rule, in from five to eight weeks. Dislocation of the upper fragment after fracture within or without the capsule has been observed. In some cases it appears to have been produced simultaneously with the fracture ; in others to have followed it; and in others the bone has been broken in the attempt to reduce the dislo- cation. In the first class the dislocation can sometimes be reduced by manipulation with the aid of anaesthesia ; in several of the others the fracture has failed to unite, and the limb has become quite useful, the lower frag- ment being drawn upward until it found support upon the scapula. Treatment.-In fractures through the anatomical neck or tuberosities, the treatment is limited to immobilization of the arm by a body-bandage or sling, with perhaps cool- ing lotions upon the shoulder. Fracture of the greater tuberosity is also to be treated by immobilization, with the arm rotated as far outward as is convenient. In separa- tion of the epiphysis and fracture of the surgical neck, reduction must be made by traction in the direction taken by the upper fragment, and then the limb immobilized by an outer moulded splint which covers the shoulder and extends down to the elbow. With it may be used also an internal splint, extending from the axilla to the elbow or wrist. The hand, forearm, and arm may be bandaged to prevent swelling. The hand and wrist should be sup- ported in a sling, but the elbow should be left unsup- ported, in order that its weight may make extension. If necessary, additional extension should be made by a weight suspended from the forearm near the elbow, or by continuous extension by india-rubber or a weight and pulley, while the patient is kept in bed. If the upper fragment tends toward abduction this extension should be in a corresponding line, or the limb can be maintained in the same position, while the patient is not in bed, by a long, stout leather splint folded upon itself at the centre, and so placed that the fold is in the axilla, one side made fast against the body, and the other side sup- porting the slightly abducted arm ; or a similarly shaped wooden splint, properly padded (Middledorf's triangle), may be used. When the abduction of the upper frag- ment has been extreme, a rectangular splint has been used with success, the arm being supported at right angles to the body. In compound fracture, especially when the joint is involved, absolute immobilization of the limb should be sought. 1 have seen this admirably accomplished by a combination of a plaster case upon the limb and a plaster jacket on the body, the two being united by three stout iron rods at the shoulder, elbow, and forearm. Fractures of the Shaft of the Humerus.-All the va- rieties of fracture and displacement found in long bones may occur in the humerus. Occasionally the brachial artery or a large vein is injured by the same violence that breaks the bone, and the symptoms denoting this injury may not appear until after the lapse of several hours.' The fracture may be treated by lateral splints or a plas- ter-of-Paris dressing, with the elbow flexed and the wrist supported in a sling. If the patient is muscular, and the tendency to shortening marked, extension should be made by a weight suspended from the elbow while the patient is erect, or by continuous extension in bed. In the latter case, the limb should be supported upon cushions and steadied, if necessary, by short side-splints. Stromeyer's cushion, shaped like a truncated triangular pyramid, is convenient for this purpose. If the plaster-of-Paris dress- ing is used, the forearm and shoulder should be included in it. Fractures of the Lower End of the Humerus.-They pre- sent many varieties, which vary greatly in importance. In some the fracture directly involves the joint, in others it is entirely extra-articular. In supra-condyloid fracture, the line of fracture crosses the bone through the expanded portion above the articu- lar surface, more or less irregularly or obliquely. Some- times a fissure extends into the joint, and when the exist- ence of such an extension is made manifest, as by independent mobility of the two condyles upon each other and upon the shaft, the fracture is called inter-condyloid. This latter variety is commonly the result of great vio- lence applied directly to the elbow, as in a fall upon the olecranon, and it is a very serious injury, because of the probable loss of the functions of the joint, and of the fre- quency with which it is or becomes compound. Usually the upper fragment is displaced forward, and the ole- cranon is prominent, as in dislocation backward. The diagnosis is made by attention to the relations of the ole- cranon to the epicondyles (to exclude dislocation), inde- pendent mobility, and crepitation. The arm should be placed, with the elbow flexed at a right angle, in a moulded posterior splint, and a thickly- padded anterior one, aided, when necessary, by extension made by a band passing over the front of the forearm close to the joint. Frequent inspection is necessary to detect re- currence of the displacement. In fracture of the external or internal epicondyle, the line of fracture is entirely outside the joint. The small projection which constitutes the epicondyle is broken off, with or without a portion of the ridge adjoining it on the upper side. The injury appears to be commonly the re- sult of direct violence, and occurs more frequently in children than in adults. Fracture of the external epicon- dyle is rarer than that of the inner. The symptoms are the presence of a small, movable, bony lump at or just below the seat of the epicondyle, pain, ecchymosis, and swelling. Simultaneous injury of the ulnar nerve has been observed in several cases of fracture of the internal epicondyle. Fracture of the internal epicondyle has been observed as a complication of dislocation. The treatment is, immobilization of the elbow in the flexed position for about a fortnight, and then support in a sling for the same length of time. Fractures of the Internal Condyle.-In these the line of fracture extends from a point at a variable distance above the epitrochlea downward and outward into the joint, crossing the olecranon fossa, and separating the trochlea in whole or in part from the rest of the articular surface. The usual displacement is of the fragment and attached ulna upward and backward, and it may be, though rarely, accompanied by dislocation of the radius backward, as. pointed out by Dr. Markoe. In the latter case the de- formity resembles that of a dislocation, and the differen- tial diagnosis is made by recognition of the preservation of the relations between the ulna and internal condyle, and of the mobility of the latter. Union usually takes place promptly, and is not interfered with by complica- tions, but the tendency to a recurrence of the displace- ment is so great that constant watchfulness is necessary, for the functions of the joint and the symmetry of the limb may be seriously affected by union in a false posi- tion. In children there is, further, a liability to the forma- tion of exuberant callus, which will mechanically limit the range of motion. The cause of the displacement is the contraction of the muscles of the arm which are at- tached to the ulna, and the pressure of the splints or the 246 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. sling by which the arm is supported; when the arm rests in a posterior splint with the elbow at a right angle, its weight is supported by that part of the splint which lies under the elbow and forearm, and thus the ulna, which rests directly upon the splint, is pressed upward together with the fragment. In like manner, if an anterior splint is used, the bandages which pass around the forearm re- ceive the weight and draw the ulna and the fragment up- ward. This change in the position of the internal con- dyle changes the direction of the line of the joint, so that the long axis of the forearm no longer has its slight nor- mal divergence toward the outer side when the elbow is fully extended, and the external condyle appears unduly prominent. Sometimes the ulnar nerve is pressed upon or torn by the displaced fragment. The treatment, commonly, is to fix the arm upon a pos- terior or lateral splint, or in an immovable dressing, for about three weeks, and then to carry it in a sling for another fortnight. But it is certain that this treatment frequently results in considerable deformity, because of union with displacement of the condyle upward. The difficulty is not to reduce the displacement, but it is to maintain the reduction ; and this maintenance, for the reasons above given, is endangered by a splint which makes the ulna bear the weight of the forearm. Dr. Allis, who first called especial attention to this cause of the deformity, recommends treatment with fixed dress- ings in the extended position. If care is taken to re-es- tablish the external angle at the elbow when the immov- able dressing is applied, the ascent of the condyle will be prevented ; but the dressing does not protect equally well against displacement of the condyle forward or back- ward, and therefore a large antero-lateral fenestra should be made at the elbow, or a moulded posterior splint used, so that the part can be inspected with a view to the early detection of such displacement. The position of com- plete extension can be safely exchanged for one of partial flexion after a fortnight. When the fracture is complicated by dislocation of the radius the limb must be kept fully flexed. Fractures of the External Condyle.-This common form may be caused by a fall upon the hand, the force being transmitted directly through the radius to the condyle, or by a fall upon the elbow in which the olecranon is driven upward and outward against the condyle. The line of fracture runs downward and inward from a point in the supinator ridge to another on the articular surface. It may be accompanied by dislocation of both bones of the forearm outward or backward, their attachments to the external condyle being usually preserved. The diagnosis is made by recognition of the change in the re- lations of the bony prominences, if such change exists, and of the common signs of fracture-abnormal mobility, crepitation, pain. The special point in the treatment is to prevent tilting or displacement of the fragment forward by the muscles of the forearm which are attached to it, and loss of the outward angle at the elbow by descent of the fragment. The latter is not so likely to occur as after fracture of the internal condyle, and the injury may be safely treated with the elbow flexed at a right angle, either with a grooved posterior splint or an immovable dressing. Intercondyloid Fractures.-This form is grave, not very common, usually the result of violence received at the elbow, and frequently compound. The line of fracture may have the form of a T orY, or the bone may be com- minuted. Commonly the condyles are separate* 1 laterally, and the olecranon is drawn up between them ; or they may be jointly displaced forward and upward. The de- formity is always marked, and the diagnosis is readily made by attention to the relations of the parts and recog- nition of their independent mobility. It is of the utmost importance for the future usefulness of the joint that the displacements should be thoroughly reduced, and that the inflammatory process associated with repair should not be active, because permanent change in the positions of the fragments, or an overgrown callus, introduces a me- chanical obstacle to motion, and cicatricial periarticular bands shorten the capsule in front and behind, and thus limit the range of motion. As the occurrence or mainte- nance of the displacement is largely the result of muscu- lar contraction, it is often advisable to have the aid of anaesthesia in making the reduction and applying the dressing. For the latter, if the swelling is not too great, or if its subsequent occurrence is not to be feared, a plas- ter dressing enveloping the limb from the hand to the shoulder, with the elbow flexed at a right angle, is to be preferred; under other circumstances a posterior moulded plaster splint, with the elbow at a right angle, and a small anterior splint bound on with a roller-band- age in such a manner that it can be readily removed for purposes of inspection and correction. Separation of the Epiphysis.-In this the epiphysis, with the attached bones of the forearm, is broken off and dis- placed, usually backward, so that the deformity resembles in appearance that of a dislocation backward ; but the di- agnosis is readily made by observing the preserved rela- tions between the olecranon and the epicondyles. The abnormal mobility is also greater than in dislocation, and crepitus can be obtained by reducing the deformity. The treatment is immobilization, with the elbow flexed at or within a right angle. Forearm, Fracture of the Bones of.-Fracture of the Olecranon.-This fracture is commonly produced by a blow received upon the olecranon or the ulna near it, or by the violent contraction of the triceps. The line of fracture may be at right angles to the long axis of the ulna in both planes, or oblique in either, or irregular, and at any point between the tip of the olecranon and the base of the coronoid process. The symptoms are the common ones of localized pain and swelling, crepitation, and some functional disability, especially in active extension of the elbow. The separation is sometimes slight, at others the upper fragment is drawn away to a considerable distance by the retraction of the triceps. The fracture may be com- pound by simultaneous division of the soft parts, by rupt- ure of the skin when it has previously become adherent, or by perforation from within outward. The union may be bony or fibrous ; and when fibrous, the uniting bond may vary greatly in length. Fibrous union by a long bond does not necessarily entail much disability. Failure of union is not uncommon, and in one case which I observed the upper fragment was firmly adherent to the humerus. The details of the treatment may need to be modified to meet varying conditions, such as the amount of sepa- ration, the effusion within the joint, the probability of ankylosis. If the separation is slight and not increased by moderate flexion, the arm should be immobilized in a light gypsum bandage, preferably with a fenestra through which the olecranon can be inspected and measures taken, if necessary, to press the upper fragment down against the lower one. For the latter purpose adhesive plaster may be used, or oblique turns of a roller-bandage, or even a metal hook, the point of which is engaged in the tendon of the triceps close against the bone, and which is then drawn downward and fixed to the splint by a cord. Aspiration of the joint may be advisable to remove an excessive amount of blood and synovia. In some cases of old, ununited fracture, or of long fi- brous union, the fracture has been exposed by incision, the surfaces freshened, and the pieces brought together and fixed with silver wire. The same has been done in one or two cases of recent fracture, and in several of com- pound fracture. Fracture of the coronoid process occurs almost exclu- sively as a complication of dislocation of the ulna back- ward ; it appears to have been produced also by extreme flexion of the elbow. The diagnosis, when the injury ac- companies a dislocation, is made by the easy reduction and easy reproduction of the dislocation, with slight ac- companying crepitation, and the presence of a small, hard, movable body in the line of the tendon of the brachi- alis anticus. Apparently, the separation is usually slight, the expansion of the attached tendon remaining untorn, and the union is bony. The treatment is immobilization with the elbow fully flexed. 247 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fracture of the Head and Neck of the Radius.-Par- tial fracture of the head of the radius has been several times observed as a complication of dislocation of the elbow backward, and also as the result of direct violence ; and a few specimens of fracture of the neck have been seen. Union may follow, or the fragment may remain loose in the joint, or suppurative arthritis may ensue. The diagnosis may be difficult, or impossible. The treat- ment is prolonged immobilization of the joint. Fractures of the Shaft of one or both Bones of the Fore- arm.-These fractures may be the result of a fall upon the hand, of direct violence, or of muscular action. In- complete fractures (infractions) in the young are not un- common. Single fracture of either bone is usually due to direct violence ; thus the same ulna is often broken when the raised forearm receives a blow intended for the head. When both bones are broken the fracture of the radius is usually nearer the elbow than that of the ulna. When the ulna alone is broken by indirect violence, as in a fall upon the hand, the upper end of the radius is sometimes dislocated forward and upward. The displacements are various and of especial impor- tance because of their effect, if left unreduced, upon the function of rotation of the forearm. There may be an- gular displacement, lateral displacement, overriding, and rotation ; and these may be variously combined in any one case. The action of the pronator quadratus and pronator radii teres tends to draw the broken ends of the radius toward the ulna, and the action of the biceps has a marked tendency to rotate the upper fragment of the radius about its longitudinal axis in the direction of supi- nation. The effect of this displacement is to limit supina- tion of the hand, by abolishing or restricting this action of the biceps. This displacement is most marked when the radius is broken at a point above the insertion of the pronator radii teres, and varies in known specimens from six to forty degrees, the average being placed by Mr. Callen- der at thirty-six degrees, after examination of eighteen specimens, in sixteen of which it was found. Another effect of the action of the biceps, when the radius is broken in its upper third, is to produce independent flex- ion of the upper fragment, or angular displacement, with the apex of the angle directed forward. If both bones are broken at or near the same point the callus of one may readily become fused with that of the other, or the two upper or the two lower pieces may unite with each other, or the callus may be large and irregular. Either of these accidents will destroy the function of rotation of the fore- arm. When the radius is broken in its lower third the upper end of the lower fragment is likely to be drawn in against the ulna by the contraction of the pronator quad- ratus. The diagnosis, when both bones are broken, is easy; when one bone alone is broken it may be more difficult. Independent mobility of the two ends of the radius can often be recognized by pressing the thumb firmly against the head of the bone, and gently rotating the wrist. In fracture of the ulna, alone, the diagnosis may have to rest upon the history of direct violence, the existence of lim- ited localized pain on pressure, and ecchymosis. The process of repair is liable to be complicated by ex- cessive inflammation, the effects of which may seriously restrict the future usefulness of the hand, or by gangrene of the limb, induced by extreme swelling or improper dress- ings. The latter accident is one that should be especially borne in mind in the young, the old, and the feeble dur- ing the first few days. Treatment.-The deformity is corrected by extension, when both bones are broken, and by forcing them apart laterally by firm pressure with the thumb and fingers in the interval between them. The limb should be secured in a pair of splints, anterior and posterior, long enough to reach from the palm of the hand to the elbow, and a little wider than the limb. If they are not wide enough, the turns of the bandage by which they are fastened will press upon the flesh and tend to crowd the bones toward each other. In view of the tendency of the upper por- tion of the radius to take the position of supination, it is advisable to supinate the wrist and dress the limb in that position, although the interval between the two bones is then less than it is in the position midway between supi- nation and pronation. Permanent extension by means of adhesive plaster and india-rubber I have rarely found necessary. It is required only after fracture of both bones with overriding. If the upper fragment of the ra- dius is kept flexed by the biceps, the lower portion should be brought into line with it by flexing the elbow. The arm should be supported in a sling so arranged as not to press upon a limited portion of the ulna, lest the pressure should force the bones together. A roller-bandage should not be applied to the limb underneath the splints. Colles's fracture, or fracture of the radius at its loicer end. This fracture, which is nearly, if not quite, the most common of all fractures, is habitually produced by a fall upon the palm of the hand. The line of fracture is usually at from one-third to three-quarters of an inch above the lower articular edge of the bone, and may be transverse or oblique in either plane, or the lower frag- ment may be comminuted. The common displacement is of the lower fragment backward and upward, with some crushing of the spongy tissue on penetration of it by the upper fragment, together with a double rotating movement which carries the styloid process upward and inclines the articular surface backward. In some cases the styloid process of the ulna is broken off, or the trian- gular fibro-cartilage is torn. Exceptionally, the end of the ulna may be forced through the skin. The symptoms of the fracture are in most cases a char- acteristic deformity, consisting in a prominence on the back of the limb corresponding to the lower fragment, and another on the palmar surface corresponding to the end of the upper fragment; further, the ascent of the styloid process of the radius to, or above, the level of the end of the ulna, pain along tlie line of fracture, and deepening of the transverse folds on the front of the wrist. Reduction may be difficult, and occasionally impossible. If the spongy tissue has been much crushed, reduction cannot be maintained, because of the lack of support, and in such cases recovery without deformity must not be expected. Reduction may be accomplished by trac- tion upon the hand and coaptating pressure upon the fragments. If this is ineffectual, the hand should be brought into the position of extreme dorsal flexion, and then the lower fragment pressed forcibly downward by the thumbs of the surgeon, while he grasps the limb close above it with his fingers. Treatment.-The limb should be placed upon a padded anterior splint, extending from the roots of the fingers to the elbow, with a small special pad at a point correspond- ing to the lower end of the upper fragment ; a shorter posterior splint, reaching not lower than the junction of the wrirt and hand, with a pad at its lower end, is placed on the back of the arm, and the two secured by a strip of adhesive plaster applied circularly at each end. The fingers hang over the end of the anterior splint, with or without a pad placed under the palm of the hand. Pas- sive motion of the fingers should be persistently made, to diminish the stiffness which so frequently results. Hand, Fractures of the Bones of.-Metacarpal Bones.-Fractures of the metacarpal bones may be pro- duced by direct or indirect violence. The diagnosis is made by recognition of the usual signs of fracture of a long bone, or by the fact that sharp pain is caused by pressing the corresponding finger toward the wrist. The treatment consists simply in rest, or in binding down the fingers over a pad placed in the palm. Fingers.-Fractures of the fingers are usually produced by direct violence. In fracture of the first (proximal) phalanx there is a marked tendency to angular displace- ment toward the palm, which, if left unopposed, may result in a deformity that will be the source of much in- convenience. The best treatment is to close the fingers over a firm cylindrical pad and fasten them with longi- tudinal strips of adhesive plaster. Femur, Fractures of.-Fractures of the femur con- stitute about six per cent, of all fractures, and about one- third of them arc fractures of the neck of the bone. They 248 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. are nearly three times as frequent in males as in females, although fractures of the neck of the femur are especially frequent in old women. Fractures of the Neck of the Femur.-These are far more common in elderly people than in the young, and are usually produced by moderate violence, as a fall to the ground while walking, a misstep, or even an effort to avoid a fall. The cause of this frequency appears to lie in senile rarefaction of the bone, a process which dimin- ishes the amount of solid matter and increases the size of the medullary and vascular canals and spaces. In considering the mechanism of the production of these fractures it must be remembered that the neck of the femur is somewhat flattened from before backward, and is markedly overlapped posteriorly by the great tro- chanter ; its anterior wall is continuous with that of the trochanter, while its posterior one penetrates the tro- chanter as an incomplete septum of compact bone embed- ded in the spongy tissue. This septum may disappear entirely by rarefaction. In a fall upon the buttock or outer portion of the thigh, the violence is received upon the projecting trochanter, and the bone is broken usually at the junction of the neck and shaft in such a manner as to crush or split the posterior portion of the trochanter and bend the neck backward upon it; that is, the shaft of the bone is rela- tively rotated outward, and the posterior portion of the neck is forced into the trochanter. In a fall upon the knee or foot the fracture is more likely to be situated in the narrow part of the neck, and to be unaccompanied by crushing or impaction. The old classification, as intra-capsular and extra-cap- sular, has been long recognized as unsatisfactory from both the anatomical and clinical standpoints, for many fractures lie partly within and partly without the capsule, and the recognition of the exact position of the line of fracture is commonly impossible. A better classification is as fractures of the small part of the neck (intra-capsular) and fractures at the base of the neck (extra-capsular and mixed). Fractures of the Small Part of the Neck.-In these the line of fracture crosses the neck transversely or ob- liquely, and usually is not accompanied by impaction. A portion of the periosteum commonly remains untorn, and its vessels aid in preserving the vitality of the upper fragment. Separation of the epiphysis, the head, before its final bony union with the neck, has been observed, and is to be deemed a variety of this fracture. The symptoms are inability to use the limb, tenderness on pressure in front of and behind the joint, and on the tro- chanter, shortness of the limb, which usually increases during the first fortnight and can be overcome by trac- tion, crepitation, and usually eversion of the foot. The progress toward recovery is apt to be affected, in the old and feeble, by confinement to the bed, and as the probability of reunion of the fragments has always been deemed very slight, the usual practice has been to get the patient out of bed as soon as possible. A few specimens that are in existence prove that close fibrous, and even bony, union is possible, and, therefore, the attempt to ob- tain such union should always be made and persevered in so long as the patient's general condition will allow. The resulting disability is usually great, the limb re- maining shortened and unable to support the weight of the body, but occasionally it becomes fairly serviceable. Fractures at the Base of the Neck.-In these the principal line of fracture follows more or less closely the junction of the shaft and neck, and it is commonly associated with splitting or splintering of the great trochanter. In what appears to be the most frequent form, the neck is bent backward so as to form with the shaft an angle open pos- teriorly, the change of direction being made possible by penetration of the trochanter (impaction), or by crushing of the spongy tissue adjoining the line of fracture. The name of Professor Bigelow is associated with this dis- placement and the mechanism of its production. The symptoms are inability to raise the thigh (not al- ways complete), pain on pressure in front or behind, or on the trochanter, fulness of Scarpa's space (recognized by deep pressure), eversion and shortening more or less marked, and sometimes crepitus. Repair by bony union is common, and is generally aided by preservation of such impaction or interlocking of the fragments as may exist. It is, therefore, not al- ways advisable to try to overcome the shortening, and es- pecially the eversion, lest failure of union should result. Diagnosis of both Varieties.-Inability to use, or even to move, the limb is so common, even when the frag- ments are not separated, that when it follows a fall it al- ways creates a strong suspicion of the existence of a fract- ure. In the nervous and hyperaesthetic it may be caused by a simple contusion ; and on the other hand, there are a few recorded cases in which the patient was able to move the limb freely, and even to walk upon it immedi- ately after the accident. Pain is referred to the upper portion of the thigh, and is excited by pressure about the joint or by passive motion of the limb. The foot is commonly everted, but the eversion may be very slight, and is then best recognized, as Professor Bigelow pointed out, by noticing that the limb cannot be so well inverted as its fellow. Occasionally, but very rarely, the limb is inverted. Shortening is recognized by placing the patient on his back, with the feet at equal distances from a line drawn from the centre of, and at right angles to, another line drawn from one anterior superior spine of the ilium to the other, and then measuring the distance on each side from the anterior superior spine to the tip of the external malleolus. Care must be taken that the positions of the two limbs are identical with regard to the distance from the line just mentioned, and to flexion at the hip and knee. They should be as nearly straight as possible. If there is much shortening it can usually be overcome in whole or in part by steady traction downward on the foot. The position of the trochanter should also be com- pared with that of its fellow and with Nelaton's line-a line drawn over the outer side from the tuberosity of the ischium to the anterior superior spine. Normally this line passes across the summit of the trochanter. Another measurement for determining the position of the trochanter is that of Bryant's ilio-femoral triangle, in which the dis- tance is measured from the top of the trochanter to a transverse plane passing vertically, when the patient is lying on the back, through the anterior superior spinous processes. The position of this plane is readily deter- mined by placing a small stick upright on each side of the body in the prolongation of a line joining the two pro- cesses. Crepitation may be felt during the slight manipulations necessary to recognize some of the other features, and it should rarely be persistently sought for. I have some- times obtained it in doubtful cases by flexing the thigh upon the pelvis nearly to a right angle, and then pressing upon the trochanter. The trochanter is sometimes recognizably enlarged by splitting ; and the anterior portion of the thigh covering the front of the joint is distinctly less depressible than usual, a valuable sign pointed out by Hennequin. An exact diagnosis, as between the two varieties of the fracture, is frequently impossible, and in some cases, even, it must be left to time to determine whether or not any fracture is present. The prognosis is concerned with the life of the patient and the usefulness of the limb. As regards the former, not a few patients die from the immediate consequences of the injury (excessive inflammatory reaction, fat embo- lism, etc.), or from complications such as pneumonia, or from the exhaustion produced by pain and prolonged con- finement to the bed. The prognosis in this respect has been improved of late years by the abandonment of vig- orous, inelastic extension in the treatment, and by short- ening the period of confinement to the bed. It is proba- ble that the limb will remain shortened and everted, and the range of motion in the joint limited, but it may nev- ertheless be very useful. Even after pure intra-capsular fracture, with failure of union, the patient may be able to walk, bearing some weight upon the injured limb. 249 Fractures. Fractu res. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Treatment.-The indications for treatment are deter- mined largely by the prognosis, and, in the order of their relative importance, are : 1st. To guard against the dan- gers to life. 2d. To secure union. 3d. To get union in good position. In the old and the feeble it can seldom be proper to seek completely to overcome the shortening and eversion, and the treatment should usually be limited to immobilization in a position obtained by moderate traction. The patient should be placed upon a firm bed, moderate extension maintained, preferably by weight and pulley, rather to aid immobilization than to overcome shortening, and the limb supported by cushions on its outer side, or by a long side-splint, or a Volkmann's foot- rest. It is also well to pass a broad band snugly about the hips so as to fix the trochanter against the neck, or to make pressure with the long side-splint for the same pur- pose. The plaster-of-Paris dressing, enveloping the limb and pelvis, has been used. I have tried it, but do not like it; the immobilization is not more complete than that which can be obtained by other means, and it may be- come very imperfect through the shrinking of the soft parts. The advantage claimed for it, that the patient need not be confined to the bed, is one that can be enjoyed only by those who are actually strong enough to bear confine- ment to the bed without harm ; the old and feeble are too weak to bear the weight of the dressing except in bed. It can be safely used after the fourth or fifth week if it is important that the patient should be able to leave the house and go about on crutches. Certain modifications of Bonnet's wire cuirass can be obtained which offer facilities for the care of the patient and for transportation when necessary. In a few cases of painful pseudarthrosis following fracture, operative attempts have been made to obtain union by pinning the fragments together, either by drill- ing through the trochanter or by opening the joint. Fracture through the great trochanter and neck has been observed in a few cases, the line of fracture running in a direction much more nearly horizontal than in fracture at the base of the neck, and leaving the upper part of the trochanter connected with the neck. Fracture of the great trochanter has been observed as the result of a fall. The patients have usually been able to walk after the receipt of the injury and examination has shown all normal active and passive movements of the joint to be possible and painless, except rotation. The displacement of the fragment can sometimes be recog- nized. This fragment may be large or small, and in children may embrace the entire trochanteric epiphysis. The treatment is rest, with perhaps a bandage to oppose displacement of the fragment upward and backward by muscular action. Fractures of the Shaft.-These may be produced by direct or indirect violence, or by muscular contraction. The common examples of the former are furnished by those cases in which violence has been received directly upon the thigh, or in which the patient has fallen upon the foot or knee ; of the latter, by violent spasmodic con- tractions, or by an effort to avoid a fall. The line of fracture may be inclined at any angle to the long axis of the bone, and is commonly quite irregu- lar. The displacements are angular and by overriding, and are favored or produced by the contraction of the mus- cles. As the lower fragment is drawn upward it pushes the upper one to one side, usually outward and forward, and this change of direction is favored also by the con- traction of the muscles attaching the upper fragment to the pelvis, the abductors and flexors. Outward rotation of either fragment may occur, during the progress of the case, through the action of gravity upon the unsupported corresponding portion of the limb. Thus, if the foot is left without support it comes to rest upon its outer side, and tlie lower fragment is rotated outwardly with refer- ence to the upper one ; and if the foot is kept upright and the great trochanter left unsupported, the latter may sink back in the bed, or the patient may incline his pel- vis in the same direction, and thus outward rotation of the upper fragment occurs. The effect of this latter dis- placement is ultimately the same as that of inward rota- tion of the lower fragment, and when the patient begins to walk he will find that the toes of the injured limb turn inward. Except in the lower third, and in gunshot fractures, and fractures by extreme direct violence, the fracture is rarely compound. In the lower third it is not uncommon for the fracture to become compound by perforation of the skin from within outward by the sharp point of the upper fragment. It occasionally happens, when this perforation is not complete, that the point of the frag- ment is deeply engaged in the substance of the overlying muscle, and can be withdrawn only with difficulty, if at all. Injury to the main vessels and nerve-trunks is rare. The diagnosis is made by recognition of the deformity (shortening), abnormal mobility, and crepitation. The first is recognized by measuring from the anterior su- perior spine of the ilium to the malleolus on each side, care having been taken to place the limbs symmetrically with reference to the pelvis as described in the section on fractures of the neck of the femur; the fact that the fracture is below the trochanter is proved by the normal position of the latter, and by its failure to share in slight rotatory movements communicated to the foot. Ab- normal lateral mobility is shown by passing the hand under the thigh and gently lifting it, or by holding the upper portion of the thigh firmly against the bed and lifting the knee, or moving the foot to one side. During these manipulations crepitation will usually be produced and some pain caused. The knee-joint commonly becomes somewhat dis- tended, even if the fracture does not immediately involve or adjoin it. Union takes place in from six to eight weeks, and is then sufficiently firm to allow the patient to go about on crutches, with the additional support of a splint ; but the liability to secondary fracture is so great, on account of the length of the bone and the strain to which it is sub- jected in walking, that patients should be dissuaded from an early attempt to use the limb. Some permanent shortening is frequent, especially if the fracture is in the upper third, but it does not necessarily cause a limp. Treatment.-The mode of treatment in most favor is by one of the numerous methods of continuous extension, of yhich the principal varieties are Buck's extension by weight and pulley, elastic extension by india-rubber and a single or double long side-splint, and extension by suspension (Hodgen's splint). Buck's extension apparatus (see, also, section relating to Treatment, p. 241 ), is the one in most general use in the United States. Extension is made by means of a weight, suspended by a cord passing over a pulley attached to the foot of the bed, and made fast to the leg by a broad strip of adhesive plaster which extends from the knee, or a little above it, on one side, down the leg, loosely below the sole of the foot, and back again on the other side to the height at which it began. The foot, ankle, and lower third of the leg are previously wrapped with a roller-bandage, the subsequent turns of which on the upper part of the leg cover in the adhesive plaster and keep it from slipping. A piece of wood, five or six inches long, is placed in the loop beneath the sole to keep the plaster from pressing upon the ankles. It is con- venient to use, instead of the long strip of plaster, two shorter ones, each of which terminates near the ankle in a narrow end, which can be buckled to a separate sole- piece containing the piece of wood. Through a hole in the centre of this piece of wood passes the cord that sus- tains the weight. Volkmann'8 sliding foot-rest (see Fig. 1342) is a very convenient substitute for the long side-splint which was formerly in general use to prevent eversion. The leg rests upon it, and the foot is secured to the foot-piece by a few turns of bandage, or by a broad strip of adhesive plaster extending from the upper part of the calf down behind the heel, and along the sole to the top of the foot-piece, where it is then tacked fast. The weight at first should be from fifteen to twenty pounds, as may be found neces- sary, and the foot of the bed should be raised about six inches, in order that the body may not be drawn down. 250 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Fractures. The weight may be diminished after the second or third week, and usually removed by the end of the sixth. Coaptation splints are used to steady the fragments. They are three or four pieces of thin wood, about two inches wide and ten or twelve inches long, made fast about the thigh by straps or adhesive plaster. A moulded posterior gypsum splint, or a complete encasement in the gypsum bandage from below the knee to the upper part of the thigh, may be substituted for these splints. The It is applied by enveloping the limb in a single layer of blanket cut to fit, or of raw cotton, or with a loose thick roller-bandage, and then wrapping it with roller-band- ages containing the wet plaster. The pelvis must be in- cluded in the dressing (spica), and it is well to make the portion covering the groin exceptionally thick by adding a piece of blanket or folded cheese-cloth soaked in plastic cream. Fractures of the thigh in children are frequently treated by Hamilton's double side-splint, without extension, each leg being bound fast ; but frequent inspection is necessary to detect shortening. A recent method, that has given good results, is to sus- pend the limb in a vertical position by means of adhesive plaster, the weight of the pelvis furnishing the extension. Children bear the position very well, and it has great advantages on the score of cleanliness. Consolidation of the fracture takes place in young children in about three weeks. Fractures of the Lower End of the Femur.-Fractures of the lower end of the shaft commonly receive separate mention, because of the complications arising from the proximity of the knee-joint, and from possible injury to the great vessels and nerves. The fracture is usually oblique, and the capsule of the joint is frequently opened by the extension of the fracture into it, or by perforation by the end of the upper fragment. If the lower frag- ment is much displaced forward or backward, or if it is flexed upon the tibia by the contraction of the muscles of the calf, the popliteal vessels and nerves may be danger- ously stretched across its broken edge. In intercondyloid fracture the line of fracture not only crosses the shaft, but it also sends a prolongation downward to the articular surface, and thus separates each condyle from the other and also from the shaft. This splitting of the condyles appears to be produced by the wedge-like action of the sharp end of the upper fragment, and the order of events ap- pears to be, first, fracture of the shaft, and then splitting of the condyles by contin- uation of the force. The diagnosis is made by recog- nition of the independent mobility of the condyles upon each other, or by the enlargement and deformity of the region of the knee, if the separation is great. The injury is a very grave one. Separation of the epiphysis appears to be more frequent- ly the result of traction, combined with twisting or over-extension of the knee, than of other forms of vio- lence. Volkmann caused it three times in patients af- fected with hip-joint disease by the slight traction made in applying a plaster dress- ing or in seeking for crepi- tus. Treatment. - The treat- ment is similar to that of fractures of the shaft at higher points, with the pos- sible exception that it may be desirable to keep the knee partly flexed, be- cause of a tendency in the lower fragment to tilt backward. This tendency is not so marked as some have taught, and the practice of putting a pad in the popliteal space to prevent it should certainly not be followed. Fig. 1345.-Long Side Splint. thigh should rest upon cushions so arranged as to give uniform support, and it is well to place a special pad un- der the great trochanter to prevent its outward rotation. If the fracture is in the upper third of the bone, and, indeed, whenever there is much tendency to abduction of the upper fragment the pulley should be placed near the corresponding corner of the bed, so that the entire limb shall be abducted. If Volkmann's foot-rest cannot be obtained, the foot must be kept upright by a bandage encircling it at the toes and made fast to the bed on each side, or a long side-splint, with a cross-piece at the lower end, used for the same purpose. Long single and double side splints, in which the exten- sion is made by an india-rubber cord (or a spiral steel spring, as shown in Fig. 1345), attached to the leg by ad- hesive plaster, as in Buck's extension, appears to be much used in England. Counter- extension is made, in the sin- gle splint, by a well-padded perineal band ; in the double one, by a foot-piece, against which the foot of the unin- jured limb rests. Hodgen's suspended splint (see Fig. 1337) is a valuable modification of Nathan R. Smith's anterior splint. It consists of two stout iron rods, one for each side, bent slightly at the knee, and fas- tened together by three or four anterior hoops. The leg is made fast to the lower end of the rods by adhesive plaster, as in Buck's exten- sion ; the limb rests upon straps that pass beneath it from one side to the other, and extension is made by sus- pending the splint from a fixed point above and beyond the foot. The amount of ex- tension depends upon the angle taken by the suspend- ing cords. This splint is par- ticularly useful when the knee needs to be kept partly flexed, as in some fractures in the lower third or close above the condyles. The plaster-of-Paris dressing, or starch dressing. This is much less extensively used now than it was a few years ago. The objection to it is that it cannot be safely trusted to maintain the length given to the limb at the time the dressing is applied. . Its use is, therefore, generally re- stricted to the later* stages of recovery, after a certain amount of union has taken place, when shortening is no longer to be feared, and when it is desirable that the pa- tient should leave the bed. Fig. 1346.-Hamilton's Double Side Splint. Fig. 1347. 251 Fractures. Fractures. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The Volkmann foot-rest can be raised so as to keep the knee slightly flexed, or Hodgen's suspended splint may be used. Each method has given me good results. Fracture of either condyle may be caused by direct vio- lence, or by possible lateral flexion of the leg. The dis- placement is usually slight, and may be upward, back- ward, or forward. In one case in which the nature of the injury was overlooked suppuration of the joint en- sued. The treatment is immobilization, with the knee ex- tended. As the fragment remains attached to the tibia by the lateral ligament, the displacement is overcome by bringing the leg into proper line with the thigh. Patella, Fracture of.-Fracture of the patella is a common accident, nearly two per cent, of all cases ; it is more common in males than in females, and in middle life than at other ages. It is commonly the result of mus- cular action, the contraction of the quadriceps extensor, but it is sometimes caused by direct violence, and some- times by forcible flexion of the knee when the patella is unable to share in the movement because of adhesions or periarticular thickening ; the latter appears to be the most frequent cause of refracture. A frequent cause is the ef- fort made to avoid a fall. It is occasionally observed that the patella has been slightly tender for a week or two be- fore its fracture, and in a case that came under my obser- vation this tenderness followed a violent muscular effort made while skating ; the fracture occurred, also in skat- ing, a fortnight later. Simultaneous fracture of both pa- tellse by muscular action has occurred in several cases. The line of fracture is transverse or slightly oblique, and usually at or just below the middle of the bone ; in one case I have seen it extend from the middle of the inner border to the upper outer corner, and in another from the lower inner corner to the middle of the outer border, with but slight separation in each case. Vertical and comminuted fractures are produced by direct vio- lence. The displacement is by direct separation of the upper and lower fragments, and may vary from a line or two to several inches ; it is produced by the retraction of the quadriceps. The capsule is torn transversely on each side, at points corresponding to the line of fracture, and to an extent that varies with the amount of separation. Effusion of blood and an excess of synovia into the joint is prompt and bulky, and by its distention of the capsule tends to separate the fragments still further. The fibrous investment of the anterior surface of the bone appears to be torn unevenly, producing shreds or fringes which hang down between the fragments, and are thought thus to interpose an obstacle to bony union. The symptoms are inability to walk or actively to ex- tend the leg, usually but not always complete, and many patients can walk backward by keeping the leg extended by the pressure of the heel upon the ground. There is no difficulty in recognizing the separation and indepen- dent mobility of the fragments, except occasionally when there is much bruising and swelling of the overlying parts, or an effusion into the prsepatellar bursa. The effusion diminishes gradually, and if the broken surfaces are brought together they unite by the granula- tions which form upon each. In the immense majority of cases these granulations are not transformed into bone, and the union remains fibrous. But fibrous union, if the bond is short, involves little or no disability, and it is habitually strong enough to withstand any strain that is made upon it, and it may even be stronger than the bone itself, as has been shown by subsequent fracture of one of the fragments by muscular action. The bond lengthens somewhat during the first weeks of use, and this length- ening may indeed amount to an inch or more, but rupture of the bond is exceptional. That bony union may occur has been proved by direct examination ; but failure to obtain independent mobility of the fragments, after repair, is not a proof that the union is bony, for fibrous union may be so firm and short that the fragments cannot be moved upon each other, even af- ter removal from the body. If the fragments are widely separated, the bond is formed mainly by thickening of the overlying fibrous tissues, and the lower fragment is tilted in such a way that its broken surface is directed forward and is adhe- rent to the under surface of the bond. Rupture of the bond occasionally happens, and the mechanism of its production is frequently a fall, by which the leg is forcibly overflexed ; as the upper fragment is prevented by adhesions from descending to a correspond- ing extent, the bond has to yield. Not infrequently the skin, which has become closely adherent to the bond, is ruptured transversely at the same time, and the joint widely opened. There is always some stiffness of the joint at the end of treatment, but this diminishes under use. The power of voluntary extension of the knee may remain permanently incomplete, but patients are usually unaware of the fact and do not find themselves at all disabled, or even incon- venienced, thereby. When the separation is great this defect may be so great that the patient finds himself un- able to use the limb normally in ascending or descending a staircase or ladder, or in rising from a chair, and if the joint becomes a little flexed while he is standing upon the limb, he is liable to fall through lack of proper control over it ; but the usefulness of the limb, even under such circumstances, is much greater than one would suppose. Treatment.-The treatment consists in absolute immo- bilization of the knee for several weeks in the extended position, with-dressings or apparatus de- signed to bring and keep the fragments in contact with each other. One of the simplest and most effectual is to envelop the limb, from the ankle to the upper part of the thigh, in a plaster-of-Paris dressing, with a large fenestra exposing the front and sides of the knee, and to draw down the upper fragment by means of a piece of rubber tubing crossing above it and made fast on each side to the back of the splint behind the upper part of the leg. The skin should be pro- tected by a strip of muslin, or, better, of adhesive plaster. A similar piece of tubing is placed below the lower fragment, to press it upward. The tension can be readily regulated by tightening or loosening the cords. Some surgeons use a complete en- casement in plaster-of-Paris, without a fenestra, trusting to oblique turns of the bandage above and below the fragments to keep them in place. Malgaigne's hooks are efficient, and much less painful and irritating than might be expected. The points of one are engaged deeply in the tendon of the quadriceps, close above the upper fragment, and those of the other in the ligamentum patellae, close below the lower fragment, and the two brought together by means of the screw. I have found it difficult to adjust the hooks ac- curately, and prefer a modification, which consists of a two-pronged fork, bent flatwise at the root of the prongs, at an angle of 135°. The points are passed in through the skin until they rest against the upper margin of the upper fragment, and then the whole is drawn downward by a piece of india-rubber fastened to the shin by adhesive plaster. If the effusion is so great as to prevent contact of the fragments, its absorption must be hastened by pressure, or it may be removed by the aspirator. Exceptionally the joint may be so distended by clotted blood that the fragments cannot be brought together, and it has been deemed neces- sary and proper to open the joint by a transverse anterior incision, remove the clot, and wire the fragments. The same operation has been done a number of times in cases of old fracture with separation, and in a few cases of re- cent fracture. Although the antiseptic method of treating wounds gives great security against dangerous complica- tions, I do not think it is justifiable to incur the risk when so favorable a result may be expected from other methods Fig. 1348. - Stimson's Fork for Fracture of the Patella. 252 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fracture*. Fractures. that involve no such danger. Even wiring the fragments together does not insure bony union. Quite recently {Lancet, March, 1884) it has been as- serted by a Holland surgeon that the coagulum between the fragments becomes rapidly organized on its surfaces, forming a membrane which unites the cartilaginous edges, if the fragments are not very far apart, and thus shuts off the broken surfaces from the joint, and that con- sequently a fracture which is a week or ten days old can be exposed by incision, and the fragments wired together without opening the cavity of the joint. In one of the two cases which he reports the subsequent union was fibrous. Compound fractures should be treated by cleaning and purifying the cavity of the joint, wiring the fragments, and dressing antiseptically. In old, ununited fractures, with much disability, good results have been obtained by operations which consisted in exposure of the fragments by incision, freshening of their surfaces, and wiring. Leg, Fracture of the Bones of.-Fractures of the leg comprise sixteen per cent, of all fractures. Fractures of the Upper End of the Tibia and Fibula, to- gether or separately.-These may be caused by direct vio- lence, or indirectly by a fall upon the foot or a twist of the limb. The fracture may be transverse, oblique, or comminuted, or may extend from the side of the bone into the joint, breaking off only a portion of the articular end. Comminuted fractures by indirect violence are ac- companied by impaction of the upper end of the shaft in the expanded articular end. In young people the fract- ure may be a separation of the epiphysis, and this may be followed by arrest of growth. The displacement ordinarily is not great, but in some cases in which the violence has been extreme the lower fragment has been driven far up into the popliteal space. The proximity of the great vessels makes their injury by the displaced fragments more probable than in fractures of most other regions, and the records contain many in- stances of gangrene due to pressure upon, or rupture of, one of the arteries or the popliteal vein. Fracture of the upper end of the fibula alone may be caused by direct violence, by lateral bending of the leg to the inner side, or by the contraction of the biceps. The peroneal nerve, which winds about the outer side of the bone at this point, may be involved in the injury, with consequent paralysis of the muscles supplied by it. The treatment, when the tibia is broken, consists in re- duction of the displacement by traction and by flexing or extending the leg so as to bring it into line with the upper fragment, and in immobilization in a fracture-box, or plaster dressing, or splint. It has been observed that these fractures are slow to heal. Jf the joint suppurates it must be freely opened and dressed antiseptically with the greatest care. For fracture of the fibula alone, simple immobilization is sufficient, possibly with the knee flexed, to counteract the displacing effect of the retraction of the biceps. Fractures of the Shaft.-These may be produced by direct or indirect violence, the junction of the lower and middle thirds being the most common seat of the latter. The fracture may be oblique, transverse, comminuted, or V-shaped. The latter is a form first described by Gosse- lin, and deserves especial mention from the fact that a fissure runs downward from it, sometimes into the ankle- joint ; it is marked by a sharp point at the end of the lower fragment on the antero-internal face of the tibia. The fracture of the fibula is commonly at a point somewhat higher than that of the tibia. The fracture is frequently compound, either by the action of the direct violence upon the coverings, or by perforation by the sharp end of one of the fragments, usually the upper one. The commonest displacement is an angular one, the apex of the tingle directed forward, with shortening by overriding, due to the contraction of the muscles. The position of the fracture of the tibia can be accurately de- termined by palpation of its subcutaneous surface ; that of the fibula is to be recognized by the localized pain. The abnormal lateral mobility is greater when both bones are broken than when the tibia alone is. Associated injury to the vessels or nerves, especially to the anterior tibial artery, is not very uncommon, and may be produced by the displaced bone or by the crush- ing action of the direct violence, as in a case that came under my care, of fracture by the passage across the leg of the wheel of a horse-car ; profuse haemorrhage oc- curred on the eighth day, and was found to be from an oblong, ragged hole, half an inch long, on the anterior face of the anterior tibial artery, one and a quarter inch above the line of the fracture. In compound fractures the suppuration is likely to be prolonged, and to lead to necrosis of fragments. Fracture of the shaft of the fibula alone is produced by direct violence or by lateral displacement of the foot at the ankle (tide infra). The displacement is slight. Treatment.-Reduction should be made by extension and counter-extension, and the recurrence of the dis- placement opposed by suitable dressings. Of these the plaster-of-Paris bandage or splint is the one in most com- mon use. If the swelling has subsided, or if but little is anticipated, the plaster bandage may be applied from the root of the toes to, or usually beyond, the knee. If it is applied while the fracture is fresh, first to fourth day, the limb should be protected by a thick layer of raw cot- ton, and even then it will often be found necessary to cut or remove the dressing because of pain caused by swell ing. It is, of course, desirable that the permanent dress- ing should be applied as soon as possible, but practically it is generally advisable to wait until the swelling has subsided. A convenient temporary dressing is one of plaster-of-Paris over a thick layer of cotton, but it should not be retained longer than a week. Posterior and ante- rior plaster splints can be applied before the swelling has taken place, and subsequently relieved, if necessary, by removing the anterior one or loosening the circular bands that hold it in place. The posterior splint should be made of ten or twelve thicknesses of cheese-cloth thor- oughly filled with plaster cream, and should be long enough to reach from an inch beyond the tips of the toes, under the heel, and up the calf to the middle of the thigh ; its breadth should be about four inches. The anterior splint should extend from the roots of the toes to the same height. Instead of the anterior splint a double lat- eral one, encircling the sole of the foot, may be used (Vel- peau's stirrup), or a single lateral one, which begins at one malleolus, is carried over the dorsum of the foot, around the sole, and up the side of the leg. Either of these dress- ings may be used for suspension by means of bands passed under them, or fastened to hooks or wire loops em- bedded along the anterior median line. For temporary splints the fracture-box or wire gutter may be advantageously used, or the well-padded plaster dressing above mentioned. The fracture-box is of wood, and consists of a posterior piece with hinged sides and movable foot-piece. The limb is placed in it, resting upon a thick layer of oakum or cotton, and preferably with the foot suspended by means of a broad strip of ad- hesive plaster extending from the calf, under the heel, and along the sole, and tacked fast to the top of the foot- piece. This mode of suspension saves the heel from troublesome pressure. Cotton or oakum is then placed between the limb and the sides of the box, a long narrow cushion along the shin, and the whole made fast by two or three straps passing around the box. Attempts have been made to apply continuous exten- sion, as in fracture of the thigh, but the immovable dress- ings are simpler and equally efficient, and also permit the patient to leave the bed. Compound fractures are best treated by means of strong posterior or interrupted splints made of plaster-of-Paris and iron rods or bands. Especial attention should be paid to securing free drainage, and counter-openings on the sides or back of the leg are usually necessary. For the details of the treatment of this common and impor- tant form of injury, see Treatment of Compound Fract- ures. Fractures at the Lower End of the Leg.-Of these the most common, by far, is the one known as Pott's fract- ure, which is produced by forcible eversion and abduc- 253 Fractures. Frambcesia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion of the foot, and consists in a fracture of the fibula at about two and a half inches above the tip of its malleo- lus, fracture of the tip of the internal malleolus or rupt- ure of the internal lateral ligament of the ankle, and some- times of the tearing off of a portion of the lower end of the tibia where it adjoins the fibula. The usual dis- placement is of the astragalus (and foot) outward, but in extreme cases the fibula may be widely torn away from the tibia, and the astragalus may slip up between the two bones. The fracture may be made compound by perfora- tion of the skin over the internal malleolus. The symptoms are a characteristic deformity of the ankle, consisting in the outward displacement of the foot, prominence of the internal malleolus, and a depression or angular change in the outline of the side of the leg at a point corresponding to the fracture of the fibula. The diagnosis is made by recognition of this deformity, and by pain on pressure at the fracture of the fibula and at or just below the internal malleolus. Crepitation is sometimes obtained by reducing the outward displace- ment of the foot, but is usually absent. The essential point of the treatment is to make and maintain complete reduction, and this can best be assured by placing the limb in a plaster dressing, with the foot well inverted and adducted. This position should be given to it by grasping the heel and instep firmly with one hand and pressing them inward, while counter-press- ure is made with the other hand upon the inner side of the leg just above the ankle. Reliance must not be placed upon the simple inversion and adduction of the front part of the foot, for it can take this position by mo- tion at the medio-tarsal joint, while the astragalus still re- mains displaced. The prognosis depends upon the completeness with which this reduction is made and maintained, and if this is satisfactory, the joint will in all probability be strong and useful. If, on the other hand, the displacement per- sists, the joint will be tender and weak. If the condition of the limb is such that a permanent dressing cannot be at once applied, the limb should be placed upon a long, lateral, wooden splint, thickly padded at the part corresponding to the lower third of the leg (Dupuytren's splint); this is secured on the inner side of the limb, and the foot drawn inward by turns of a band- age crossing the instep and heel. It is well to use in ad- dition an external splint, padded at its lower end to push the heel inward. Cases of faulty union have been corrected by division of the bones above the ankle and removal of a wedge-shaped piece from the inner side of the tibia, so that by inclining the lower fragment inward the foot was brought into the line of the long axis of the leg. In one case refracture of the bones was effected by an osteoclast three and a half months after the receipt of the injury, and the displace- ment corrected. I have corrected, by the hands alone, a faulty position in the seventh week. The external malleolus may be broken off, or the fibula broken just above it by forcible inversion of the foot. This is not accompanied by deformity, and the treatment consists merely in rest for two or three weeks. In supra-malleolar fracture the tibia is broken trans- versely a short distance above its articular border, and the fibula may or may not be broken at the same time. The displacement is slight, and the deformity quite dif- ferent in appearance from that of Pott's fracture, although the swelling may mask the differences. The treatment is by the plaster bandage or splint. Foot, Fractures of the Bones of.-The astragalus may be broken in a fall upon the feet, the bone being crushed between the calcaneum and tibia; and, as in two cases reported by Mr. Bryant, the upper articular half of the bone has been found broken off and necrosed, it may be inferred that this fracture was caused by forci- ble lateral displacement of the foot. The treatment is immobilization, with the foot in a good position, that is, without any inclination toward either side or any sinking of the toes. If the joint suppurates, it must be freely opened and the fragments removed. This can be con- veniently done through an incision along the outer side of the extensor tendons over the front of the joint, with a short liberating incision from the lower part of the first toward the external malleolus. The calcaneum may be broken by direct violence, as in a fall upon the heel, by contraction of the muscles of the calf, or by inversion of the foot. In the first case the bone is comminuted or crushed ; in the second, the posterior portion is broken off, and in the third a scale of bone is torn from the side by the attached lateral liga- ment. The symptoms of the first are flattening of the heel, with approximation of the malleoli to the sole, pain, and loss of function ; of the second, recognizable displace- ment of the posterior fragment in the direction of the tendo-Achillis ; and of the third, the history of the inver- sion, with localized pain, and, perhaps, crepitation at the seat of fracture. Fracture of the sustentaculum tali by forcible inversion of the foot has been observed. The symptoms upon which the diagnosis may be made are : the history of forced inversion of the foot, the immediate change in the posture of the foot from inversion to marked valgus, with permanent lowering of the internal malleolus, and short- ening of the heel by slight displacement forward of the calcaneum. Fracture of the scaphoid has been reported in two cases, discovered on the dissecting-table. Fracture of the metatarsal bones is commonly caused by direct violence, and is frequently compound. The diagnosis is made by localized pain, and especially by pain produced by pressing the corresponding toe backward. The capital point in the treatment, when the fracture is compound, is to secure thorough drainage, and to restrict the acuteness and extent of the suppurative process. Lewis A. Stimson. 1 Stimson : Treatise on Fractures, p. 37. a Ibid., p. 201. FRAGILITAS OSSIUM. 1'his term is applied to that condition of the bony system in which the slightest causes will produce fracture, and the condition is there- fore one of abnormal brittleness. It is more frequently seen in elderly people than in the young, owing, probably, to the fact that the propor- tion of animal matter in the bones grows less with ad- vancing life. It has been described as fatty or senile atrophy (Holmes). Pathology.-The pathology of this infrequent affec- tion is as yet not definitely settled, various views being entertained by different authorities. Dr. Blanchard {Chicago Medical Journal and Examiner) says it is a chronic state of osseous inanition. Dr. Lothrop {Boston Medical and Surgical Journal) maintains that the condi- tion is one of saturation of the osseous tissue with a cer- tain oily substance. Gross (" System of Surgery ") says that this condition may be the result of disease ; in some cases the bone is soft, in others it is brittle ; the areolar tissue is injected and infiltrated with bloody matter, and the periosteum is thickened, spongy, and congested. The pain which is so frequently a symptom, would seem to indicate the existence of inflammation. The pathology of this affection seems to bear some relation to that of mollities ossium. Dr. Lothrop makes the following state- ment : "In fragilitas the material necessary to the elas- ticity of the bone has become in some manner lost, . . . while in mollities the earthy material, which gives strength, has disappeared from the structure." Mr. Durham (quoted in Bryant's Surgery), in speaking of mollities ossium, says it must " not be confounded with rickets, nor with the fragility of the bones met with in the aged or demented." Fragilitas may occur before puberty, and, as a rule, the fractures are quick to repair. Mollities occurs after puberty, and the fractures are slower in unit- ing. Dr. Blanchard thinks that the disease, when it oc- curs in early life, is different from the senile form. Symptoms.-The signs of this disease, apart from the readiness with which fractures occur, are very few. Dr. Gross says that great pain in the bones is a sign of exist- ence of the trouble, and is due to the inflammatory state. This pain may be of a wandering character, and may be mis- 254 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fractures. Framboesia. taken for rheumatic pain. Mr. Erichsen holds that, in the early stages, a diagnosis must be made between this affec- tion and rheumatism. This is, however, often impossible until the abnormal brittleness begins to be manifested. When this condition is fully developed, the slightest me- chanical causes are sufficient to cause fracture. A sudden muscular movement, turning in bed, and even a slight shock, as striking the thigh with the hand carelessly, have all produced fractures in this disease. The number of such fractures occurring in a patient suffering from this affec- tion, is sometimes very large indeed. Dr. Blanchard quotes the case of a girl, aged twelve, who had sustained three fractures of the right arm, four of the right forearm, three of the left forearm, two of the right thigh, three of the left thigh, fourteen of the right leg, and eleven of the left leg ; in all, she had sustained forty fractures. These were all produced by slight causes, and were attended with but little pain. Union was very tedious in all the various localities. Dr. R. W. Greenish (in the Cincin- nati Clinic), cites the case of a boy, aged nineteen, who had sustained twenty-four fractures. Esquirol mentions a case in which two hundred fractures had occurred ; Earle, one in a child aged ten, in whom eight fractures had taken place; and Fleming, one in which fifty-three fractures had occurred between the ages of one and a half and twenty years. Two remarkable cases are quoted by Dr. Lathrop ; in one, that of a woman, aged eighty-two, the right femur suddenly broke while she was standing at a bureau ; for some time previous to the accident she had suffered from severe pain in the region where the fracture occurred; she was also a cancerous subject. The other case was quite similar, and occurred in a wo- man aged fifty-six. The patient had suffered for some months from severe pain in the right thigh, and as she was being lifted into a cart the bone suddenly snapped at a point three inches below the trochanter. In a case re- lated by Dr. Good, a lady, aged seventy, broke both fe- murs while merely kneeling, and on her being assisted to arise, immediately afterward the humerus was also broken; there was but little pain attending these inju- ries, and the bones united readily. Dr. Lothrop quotes the case of a boy, aged fourteen, who had sustained a fract- ure of the right femur in its lower third, from the slight muscular action caused by turning in bed. For some time previous to the accident he had suffered from severe pains in the limbs, which were attributed to a cold con- tracted by becoming heated in skating, and then lying down on the ice, and which were mistaken for rheumatic pains. The case of a boy, aged nineteen, is mentioned by Professor Gibson, in which the patient had been subject from his infancy to fractures from the slightest causes ; the bones always united without extraordinary delay and with little deformity ; the patient's general health had al- ways been good. Another case has been reported, in which a man fractured his humerus in unscrewing a piano-stool. This disease appears frequently as a result or an accom- paniment of other diseases, as syphilis, cancer, scurvy, and rachitis. In many cases, however, the patients are otherwise perfectly healthy; the brittleness of the bones in these latter cases frequently appears to be hered- itary. This disease would seem to have an important medico- legal aspect, but comparatively little is said on the sub- ject in works on medical jurisprudence. The condition of abnormal brittleness of the bones has sometimes been regarded as an extenuating circumstance when fractures caused by very slight blows, or other light forms of vio- lence, have been followed by serious results which have had a legal bearing. Treatment.-The results obtained by any form of treatment of fragilitas ossium are not, as a rule, very sat- isfactory. The fractures must be treated, as in ordinary fractures from violence, by mechanical appliances. The general treatment must be supporting ; tonics and nour- ishing food are indicated. If such diseases as syphilis, rachitis, or other constitutional affections exist, the treat- ment must be modified accordingly. William II. Murray. FRAILES. An establishment for bathing, located in the Province of Jaen, Spain, supplied with water from cold sulphurous springs. No special importance has been attached to their chemical nature. J. M. F. FRAMBCESI A, called also yaws and pian, is an endemic disease characterized by general and cutaneous symp- toms, occurring in the West Indies and in other tropical countries. The appearance of the eruption is usually preceded by prodromal symptoms, comprising lassitude, feverishness, vague pains in the joints and loins, and dis- turbance of sleep. This period, which is absent in mild cases, lasts forty-eight hours, at the end of which time the eruption appears in the form of small grayish-white, brownish, red, or yellow maculo-papules in the skin, giv- ing the appearance of a congeries of minutest blood-ves- sels, often accompanied by itching. These patches en- large to the size of a lentil, rapidly rise above the surface, taking the form of small, hard, dry tubercles, which; when pricked, give exit to a drop of blood. Later the epidermis becomes thinned and gives way, showing small tumors which within a fortnight acquire the size of a cur- rant, raspberry (whence the name, from/ramdo/se, rasp- berry), or strawberry. Though usually thus described, Dr. Imray takes exception to this as not sufficiently por- traying the characteristic features of the disease. He says the ordinary ' ' yaw " excrescence is not unlike a piece of coarse cotton wick a quarter of an inch more or less in diameter, dipped in a dirty yellow fluid and stuck on the skin in a dirty, scabby, brownish setting, and projecting to a greater or less extent. From the yellowish spongy surface a thin fetid fluid oozes, and this spongy body con- tinues to enlarge and projects considerably from the sur- face. The lesions may vary in the same patient from pin- head size to one or two inches in diameter. Generally they are separate, but sometimes they occur in groups. The ordinary tubercle of framboesia, which forms the yellow growth, rarely ulcerates. It attains a certain size, giving out an ichor, then begins to shrink, the discharge ceases, and a yellow crust forms and darkens as it be- comes dry. From day to day the mass diminishes in size, and finally the scab drops off, leaving what appears to be an indelible dark spot or stain on the dark skin. Every lesion does not come to maturity, some only show the fungous excrescences, the largest of which grow on the lips, pudendum, perineum, anus, and toes. Other parts attacked are the face, neck, upper and lower extremities, and the hips. The lesions are much less frequently ob- served about the trunk, and are not so often seen on the hairy scalp. They may form on the nostrils where the mucous membrane joins the skin, and here the yaws may assume an elongated form, nearly closing the nostril and hanging down on the lip. The same form may be ob- served about the eyelid. Near to the mouth they may appear in such numbers, and so closely set together, as to form almost a ring around the mouth. This is especially the case in children. Around the anus, also, they some- times coalesce and form one projecting circular band an inch or more in breadth. Framboesia differs in severity in different individuals. Usually the fungous excrescences leave a stain, but no scar. If ulceration has taken place, scars are left. It is said that should the disease not properly develop in its sev- eral early stages the general health suffers, the patient becomes cachectic, unhealthy ulcerations develop over the body, especially about the joints, which swell and become painful, and offensive effluvia are given off from the body, and the individual attacked dies a lingering death, or becomes crippled more or less by the deep ulcer- ations. Framboesia does not seem to interfere with the occur- rence of, or modify, other diseases, such as the acute fe- brile diseases, syphilis, vaccinia, etc. It was formerly- asserted that the disease was an accompaniment of syphi- lis and connected with this disorder, but more recent ob- servations show that this is not the case. Framboesia and syphilis may concur in the same person and run their course side by side without interference. Framboesia may last for months or years, especially 255 Framboesia. Franzen bad. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. when untreated, new lesions appearing from time to time, probably due to auto-inoculation. The disease is conveyed from person to person by con- tact, or by absorption of the poison through some abraded surface, though it is not infectious. The uncleanly are more liable to take the disease than the cleanly. If one member of a family becomes affected all the members susceptible to the disease are attacked in turn, i.e., among the West Indian negroes (Imray). There is some question as to one attack giving immu- nity from others. It is certain that the patient is insus- ceptible to contagion for some time after the termination of an attack. As to the nature of the disease, various views have been current. For a long time it was supposed to be in some way connected with syphilis, but such connection has been abundantly disproved of late years : 1. By the fact that, clinically, it could only be a tertiary form of syphilis, while it is essentially a primary form of disease, without such antecedents as syphilis. 2. By the observation that syphilis and framboesia may run along side by side in the same person, each following its own course, and terminat- ing independently of the other. The writer's opinion of the nature of framboesia is that it is essentially the same as condyloma or venereal wart, a papillomatous dis- ease propagated by contact, kept up by moisture, un- cleanliness, and the secretions of the body, and occurring more frequently in the tropics and among negroes, be- cause the circumstances are more favorable to such growths. The treatment of framboesia is simple, and if employed in the early stage of the disease, effective. Cleanliness and a tonic medication are first desirable. Stimulant and astringent applications, as carbolic acid solution, weak acid nitrate of mercury ointment, powdered alum, etc., should also be employed. Mercury and iodide of potas- sium are employed almost invariably in the treatment of framboesia by the West Indian physicians, but it is diffi- cult to say what good these remedies are likely to do un- less syphilitic disease is at the same time present. The writer is convinced that active local treatment, extreme cleanliness, and a system of medication directed to the pa- tient's general condition rather than with a view to any specific effect, will be most successful. yet exclusively in the lower animal forms; while glutin, keratin, and elastin occur principally in the higher ani- mals. Keratin and elastin seem to be related to the al- buminous bodies. First Group.-Tunicin, or animal cellulose, has been extracted from the mantle of some of the Tunicates. It occurs in thin, even transparent, colorless sheets. It ap- pears to have the same composition as plant cellulose (C6Hio05).r, and behaves in the same way in the presence of acids. When boiled with dilute sulphuric acid it gives a sugar which is probably dextrose. Tunicin assumes a blue color when treated with concentrated sulphuric acid and iodine. Second Group. - Chitin.-This substance is very widely distributed among the lower animals, composing the solid parts of insects and the Crustacea. When pure it is snow-white, amorphous, often retaining the shape of the part from which it is derived. It is soluble in con- centrated hydrochloric and sulphuric acids. It is not di- gested by solutions of pepsin or trypsin. Its decomposition produces glycosamin, C6H]3NO5. It crystallizes in needles, is easily soluble in water, but dis- solves with difficulty in alcohol, and has a neutral reac- tion. The composition of chitin is not yet definitely ascer- tained. Ledderhose proposes as its formula Ci6HlgNaOio. Hyalin.-Of this substance very little is known. It was obtained by Lucke from the skins or sacks of echi- nococcus. It resembles chitin and contains nitrogen. Onuphin was obtained from the rings of a species of worm, the onuphis tubicola. It forms a white mass re- sembling pipe clay, dissolving easily in water. Its for- mula is proposed as C-mELsNOjs. Third Group.-Collagen and Glutin (Gelatin).-Colla- gen is very widely distributed. It may be obtained from bones by extracting with dilute hydrochloric acid ; and from tendons by extraction with solution of common salt and digestion with trypsin in alkaline solution. Glutin, when pure, occurs in thin, colorless, transpar- ent plates, is insoluble in cold water, but swells in it and on heating dissolves. Its solution turns the plane of po- larization strongly to the left; it is precipitated from aqueous solution by alcohol; is insoluble in dilute acids. It is not colored by boiling with Millon's reagent. By continued boiling with dilute acids, glycocol and leucin, but not tyrosin, are produced. Chondrigen and Chondrin.-Chondrigen occurs in per- manent cartilage, the cartilage of bones, in bones patho- logically changed, and is also found in certain non-verte- brated forms, the tunicata. Chondrigen, by boiling with water, is changed into chondrin. The latter is best prepared from rib cartilage. It is precipitated from solution by alcohol. It bears a close resemblance to glutin, but is precipitated from solu- tion by acetic acid, solution of alum, and many neutral salts which do not affect glutin solution. It is rendered turbid by corrosive sublimate, while glutin is precipi- tated by the same substance. By boiling with dilute acids it is split up into syntonin (v. Mering), and a sugar, the so-called chondro-glucose, which turns the plane of polarization to the left, and crystallizes with great diffi- culty. V. Mering gives its composition as : C, 47.74 per cent.; II, 6.76 per cent.; N, 13.87 per cent.; S, 0.6 per cent.; O, 31.03 per cent. According to Morochowetz, chondrin is a compound of mucin and glutin. Spongin may be obtained by treating a clean bath-sponge with boiling dilute hydrochloric acid, alcohol, and ether. It is soluble, forming a clear solution in concentrated hy- drochloric acid. It contains C,II,N,O. Conchiolin is the organic substance of the shells of cer- tain mollusks (mussels, etc.). Fourth Group.-Keratin.-It may be obtained by treating finely-divided horn, the shell-skin of hens' eggs, etc., by certain solutions. It forms a white powder, giv- ing no ash on combustion, and consists of C,H,N,O, and S. The proportion of the latter (4.25 per cent.) is note- worthy. Morochowetz suggests that it belongs to the class of al- buminous bodies ; but to this view there are objections. Bibliography. Tilbury Fox and T. Farquhar : Skin and other Diseases of India and Hot Climates Generally. London, 1876. Imray and Bowerbank : Quoted by Tilbury Fox, ib. Gavin Milroy : Report on Leprosy and Yaws in the West Indies, 1873. Printed at H. M. Stationery Office, and issued in 1873. I. Rochard: Nouveau Diet, de M6d. et de Chir. Prat., vol. xxvii., 1879. Art. Pian. Charlouis: Ueber Polypapilloma Tropicuni. Vierteljahresschr. f. Derm. u. Syph., vol. viii., 1881, p. 431. Arthur Van Harlingen. FRAMEWORK SUBSTANCES (Gerustsubstanzen}. The substances included under the above general designation are characterized by the lack of any very decided rela- tions to one another, by their very marked insolubility, and by their resistance in general to the action of the diges- tive fluids. Their chemical constitution is very imper- fectly known. The following classification is based upon the results of the chemical decomposition of these various substances ; First Group.-Non-nitrogenous carbohydrates, which by their decomposition give sugar, tunicin, or animal cel- lulose. Second Group.-Nitrogenous derivatives of the car- bohydrates, whose decomposition gives reducing sub- stances (sugar, glycosamin), but no amido acids ; chitin, hyalin (?), onuphin. Third Group.-Their decomposition gives no reducing substance, but amido acids of the series to which formic and malonic belong : glutin (chondrin), spongin, conchio- lin. Fourth Group.-Give no reducing substances on de- composition, but amido-fatty acids and tyrosin : keratin, elastin (?), fibroin, sericin, byssus(?). The substances of the first group have been found as 256 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Frambnesia. Franzenbad. By boiling with hydrochloric acid and zinc subchloride, horn yields glutamic and aspartic acids, leucin, tyrosin, ammonia, and sulphuretted hydrogen. Hair is very similar to horn in its composition. Feathers are rich in silicic acid. Elastin- This substance constitutes the principal part of elastic fibres. It may be obtained in a very pure form from the thoroughly cleansed ligamentum nuchae of the ox, and when so prepared exists as a faintly yel- low powder, in which .the form of the elastic fibres may yet be seen under the microscope. It contains C,H,N,O, but no sulphur. When digested with the pancreas, it un- dergoes putrefaction, yielding ammonia, valerianic acid, leucin, glycocol, carbon dioxide, and pepton-like matters, but no phenol or indol (Walchli). With pepsin it forms hemielastin and elastin peptone. Fibroin and Seridn.-Raw silk, or the hardened secre- tion of the silk-worm, may be considered to consist of fibroin and silk glutin or sericin. Neither of these bodies contains sulphur. Byssus.-The filaments by means of which the acepha- lous mollusks attach their shells to the rocks-the so-called byssus-contain a peculiar substance allied to conchiolin, which is very insoluble, but is colored red by concentrated sulphuric acid. Its chemical properties have been but little studied. Cornein, tryptocollagen, and spirographin are substances, allied to each other, which are found in certain of the invertebrates (modified from Hermann's " Handbuch der Physiologic "). T. Wesley Mills. FRANZENBAD. A small village in Austria, renowned for its mineral springs and baths. The town is situated on the northwestern frontier of Bohemia, three miles from the old town of Eger, amid low, barren hills, about 1,300 feet above sea-level, and consists of four wide streets lined with trees. The place is dull and uninteresting, as is the valley in which it is situated, but every comfort is offered the visitors (about 8,1)00 annually) in the hotels, public institutions, and parks. The climate is mild for a mountainous district, but is subject to frequent sudden changes. The springs are nine in number, and are known as, 1, the Wiesenquelle ; 2, the Kalter Sprudel ; 3, Franzen quelle ; 4, Louisenquelle ; 5, Neuquelle; 6, Loimanns- . quelle ; 7, Stahlquelle ; 8, Mineral Sprudel, and 9, the Salzquelle. In addition to these there are a large num- ber of springs in the vicinity, most of which are little used for drinking. Of late, however, the Eastern and Western (Oestliche and Westliche) have been analyzed and described. Of the numerous gas-springs, but two are employed, one for charging mineral water for ex- portation, the other, known as the Polterbrunn (noisy spring) supplies the gas-baths. Still other smaller springs are found, some of them supplying private residences. The water of these springs appears to arise from the peat-bed from which the material is taken for the peat- baths, but their source is in reality much deeper, in the strata of mica shale, very abundant in the vicinity of Franzenbad. The springs are usually divided into four classes : 1. The Glauber salt springs, orthose which contain the largest proportions of salts, especially the sulphate of soda, represented by the Wiesenquelle, Salzquelle, and the Kalter Sprudel. 2. The alkaline ferruginous, or those which contain the most protoxide of iron, including the Franzenquelle, Louisenquelle, and Neuquelle. 3. Pure chalybeate springs, represented by the Stahl- quelle. 4. Springs used partly for drinking and partly for bathing, notably the Loimannsquelle, the Mineral Sauer- ling, the Eastern, the Western, and the numerous gas- springs. The basis for this division does not, however, appear plain, as there is little difference in Ilie relative abun- dance of salts in the various springs, as shown by the table given on the next page. The Wiesenquelle, the Kalter Sprudel, and the Fran- zenquelle are considered most important in a therapeutic sense. In composition they resemble much the springs of Carlsbad and Marienbad. The Franzenquelle is much the oldest, and has been known from very early times as the mineral spring of Egra. It is now enclosed in a cir- cular, temple-like building, the dome of which rests on strong pillars. The fount always contains 20,000 cubic inches of water ; the flow amounts to 275 cubic inches per minute. The temperature of the water remains at all seasons about 50° F., which is, with slight variation, the temperature of the other springs of this vicinity. The surface of the fount is constantly agitated by the bursting of minute bubbles of carbonic acid. The water is perfectly clear and continues to sparkle for some time after removal in a glass. If exposed for several hours to the atmos- phere, it becomes turbid, and in the course of several days a precipitation of carbonate of iron occurs. It is pleasant and piquant to drink, but leaves a slightly ferruginous after-taste. The other springs are provided with equally elegant surroundings. The Kalter Sprudel produces 3,648 cubic inches of water per minute, and so abundant is the escape of free carbonic acid (estimated at 5,472 cubic inches per minute) as to produce the sound of a boiling caldron. The taste is saline, but pleasant, and the rapid escape of gas produces a prickling sensation in the mouth. The Louisenquelle is the largest in its supply of water. Its fount contains 6,861,738 cubic inches, and the flow is 27,000 cubic inches per minute. The escape of free car- bonic acid is also tumultuous. The spring is situated immediately back of the bathing establishment on the FRANKENHAUSEN. An establishment for the admin- istration of mud-baths, at Rudolphstadt, in the principality of Schwartzburg, two hours by rail from Sondershausen. The bath is comfortably arranged and is situated in a pleasant locality. The chloride of sodium constitutes nearly twenty-five per cent, of the peat or clay that is em- ployed in the bath, mixed with river water. Sixteen ounces of the peat have been found to contain Grains. Sodium chloride 1906.480 Magnesium chloride 26.250 Lithium chloride 0.076 Magnesium bromide 0.069 Potassium sulphate 13.862 Calcium sulphate 40.473 Total solid constituents 1988.352 Cub. in. Free and partly free carbonic acid 11.260 A spring known as the Elizabethquelle is employed for drinking purposes at the institution, the water being mixed with sellers water. It is also used for bathing, strengthened by the addition of purified peat. There is an arrangement here also for the inhalation of a spray of this earth. J. M. F. FRANKENIA. Yerba Reuma ; Frankenia grandiflora; Order, Frankeniacea. This is a small herb, with a tine, rather woody, branched stem, small narrow leaves, and pinkish flowers, which grows in great abundance on and near the sea-coast of California and Mexico, and on the dry, sandy plains of the Southwestern Territories. The entire herb is gathered and dried for medical use. It is one of the domestic remedies of our western coast, and a few years ago it was offered to the medical profession in general by one or two energetic drug houses. No great demand for it appeared, and it is now but little heard from. One of the peculiar features of the plant is the very large amount of common salt incrusted or excreted upon its surface, amounting to as much as twenty-eight per cent. It contains, besides, about six per cent, of tannin. Yerba rheuma has been mostly employed locally as a remedy for nasal catarrh, gonorrhoea, etc., in which com- plaints it has some apparent value. A fluid extract, di- luted half or more, is a convenient form for administra- tration, injections, etc. Allied Plants.-The genus and order are both small, and comprise about a dozen small, salt-marsh plants, of no economic value. Allied Drugs.-The vegetable and mineral astrin- gents. IF. P. Bolles. 257 Franzen bad. FriedrlcliMlial I. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Kaiserstrasse, and supplies it with a greater part of the water used in the baths. The accompanying table shows the quantity of solid constituents, in grains, contained in each pint of water from the nine principal springs. W iesen- quelle. Kalter Sprudel. Neuquelle. L on i s e n - quelle. Franzen- quelle. Loimanns- quelle. Stahl- quelle. Mineral Sauerling. Salzquelle. Ferrous carbonate 1.789 0.275 0.317 0.441 0.317 0.565 0.537 0.268 0.096 Manganese carbonate 0.276 0.055 5.483 0.053 5.213 4.193 4.032 0.015 Sodium carbonate 8.962 7.065 8.0S7 7.326 7.257 Calcium carbonate 1.966 2.304 2 327 2.304 2.588 2.042 1.517 0.583 2.027 Magnesium carbonate 0.929 0.007 0.791 1.013 1.029 0.407 0.330 1.198 Lithia carbonate 0.030 0.061 6.758 0.046 6.113 4.692 4.446 0.030 Sodium chloride 9.315 8.593 9.144 9.223 8.755 Sodium sulphate 25.643 26.926 23.408 21.394 24.489 16.458 12.395 10.897 21.519 Calcium phosphate 0.015 0.015 0.015 ' 0.214 0.015 0.414 0.637 0.299 0.015 Silicates 0.468 0.046 0.514 0.468 0.483 Total solid constituents. 47.539 45.312 45.605 36.566 45.442 31.795 24.422 20.812 41.472 Free carbonic acid in cub. in. 34.773 45.573 54.166 37.288 42.286 28.892 44.202 32.816 MUM . The Eastern and Western springs contain : Salts Insoluble in Water. Oxy-carbonate of iron Eastern. .. 0.42(1 Western. 0.299 Carbonate of manganese Free carbonic acid and other salts. .. 0.053 0.253 Ferrous phosphate (oxidized) 1.8463 Ferric sulphide 28.4522 Ferrous sulphate 5.4533 Sodium 7.1348 Magnesium 1.3743 Argillaceous earth 2.8485 Lime 1.2239 Strontium 0.3956 Silica 2.3036 Vegetable matter 421.0572 Ceruminous matter 18.4166 Moor-pitch 25.9999 Undetermined 79.7352 Residual organic matter 153.7296 Indications.-The Franzenbad waters, especially those of the Salzquelle, Wiesenquelle, and the Kalter Sprudel, are recommended for: 1. Chronic catarrhs of the mucous membranes, es- pecially chronic gastric catarrh, habitual constipation, and cystitis. 2. Hyperajmia and moderate hypertrophy of the liver and spleen, especially in persons of debilitated constitution. 3. Disorders of the uterine system, chronic dysmenor- rhoea, with or without uterine or vaginal catarrh. 4. Scrofulous affections. 5. Gout in connection with torpor of abdominal organs. 6. As an after-treatment following a course at Carls- bad or Marienbad. The Franzenbad and Stahlquelle have been recom- mended chiefly for : 1. Anaemia after haemorrhages, as after repeated mis- carriages or abortions; exhausting diseases associated with scrofulous, rachitic, or scorbutic constitution. 2. Diseases of the abdominal organs with anaemia, and enlargement of the liver and spleen from malaria. 3. Diseases of the sexual organs, with slow develop- ment of puberty, chronic uterine or vaginal catarrhs, dis- orders of menstruation, and a tendency to abortion. 4. In nervous diseases, hypenesthesia, anaesthesia, hypochondriasis, especially when the result of anaemia. Peat-baths.-The peat-baths of Franzenbad are among the most noted in Europe. The clay or peat that is used is obtained in endless abundance from the moors adjoining the town and for miles around. The surface of these moors, owing to constant evaporation, is cov- ered with a whitish crust composed chiefly of sodium sulphate, carbonate, and chloride, and ferrous sulphate. In the bed of peat are found numerous masses of swamp- ore, plates of sulphide of iron, accumulations of mineral phosphate of iron, gypsum crystals, and beds of flint- guhr. The fresh peat is moist and waxy, of a gray or yellowish-gray color ; of a decidedly acid reaction, a sharply bitter taste, and imparts an odor resembling that of sulphurous acid. In the autumn of each year this is dug up and placed in large heaps. Here, through the action of the atmosphere, chemical changes occur in the mineral and organic constituents, forming a large num- ber of sulphates, and the-mass becomes more homoge- neous, fine, and smooth, and of a jet-black color. One thousand parts of the peat have been found to contain : When brought to the bath-houses this clay is diluted with water, for the most part from the Louisenquelle, and heated by steam to a temperature of from 70° to 80° F. The effect of the bath, as it is described, is a marked invigoration of the system, as well as a stimula- tion of the skin. The salts of the peat are prepared in a crystalline form. About two pounds of the crystals are dissolved for an en- tire bath, or one-fodrth this amount for a hand-, foot-, or sitz-bath. The peat-baths are recommended for : 1. Anaemia and chlorosis. 2. Chronic muscular and articular rheumatism, for the purpose of aiding the absorption of exudations, for gout in anaemic individuals, for scrofula, and rickets. 3. In various neuroses. Especial claims are made for them in certain paralyses, particularly paraplegia from typhus fever, in pelvic abscess, rheumatism of the lower extremities, severe cases of hysteria, paralysis of traumatic origin, concussion of the spine, in the early stages of pro- gressive muscular atrophy. Paralysis from cerebral origin, however, is a contra-indication to the use of the baths. 4. Sexual disturbances, dysmenorrhoea, blennorrhma, a tendency to abortion, prolapsus uteri, loss of virility. 5. Infiltrations of the intermuscular connective tissues in the synovial sacs and ligamentous structures, as well as in the glands. Gas-baths.-These are administered by enclosing the patient in a chamber which envelops the entire body ex- cept the head, closing securely about the neck. The clothing is not generally removed, except from the por- tion of the body to be acted upon. Gas is then intro- duced by means of a tube connecting with a pipe from one of the gas-springs, or an artificial gas-well. James M. French. Total 1000.0000 FRANZ-JOSEF. A mineral spring situated at Fiired, in Hungary, yielding an alkaline, slightly ferruginous water. An analysis of the water by von Hallo indicates that each pint contains: Potassium sulphate 0.1958 Sodium sulphate 11.4600 Magnesium sulphate 1.2411 Calcium sulphate 26.8954 Argillaceous earth 7.9358 Ferric protoxide sulphate 97.7803 Manganese sulphate 0.5693 Hyposulphides 47.9590 Silicates 0.5894 Carbonates 28.1803 Haloid compounds 0.1859 Decayed vegetable matter 29.4407 Salts Soluble in Water. Grains, Sodium carbonate 5.994 Magnesium chloride 12.799 Potassium sulphate 0.051 Sodium sulphate 169.024 Magnesium sulphate . 180.657 Calcium sulphate 9.862 Ferric oxide, with traces of manganese 0.036 Silica 0.036 Silicic acid 0.072 Total 378.531 Free and partially combined carbonic acid 6.68 Cubic in. Total 252.4390 258 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Franzenbad. Fried rich shall. Indications.-In small doses, this water is used with benefit in mild catarrhs of the gastro-intestinal tract and res- piratory organs, and in hepatic affections. In large doses it is cathartic. It has been employed chiefly in those affec- tions in which a mildly chalybeate water is required. It has been largely used in neurotic affections and in diseases of the female generative organs. Beneficial results have been reported from its use in chronic rheumatism ; but its employment in this disease has usually been accompanied by a judicious use of mineral, or hot and cold, bathing. Phthisis and inorganic affections of the heart are also among the diseases for which this water has been recom- mended, in connection with the whey cure ; but it is prob- able that the good results that have been observed were due more to the invigorating climate and other influences incidental to a change of residence. At its source the water is used also for bathing at the natural temperature of 51.8° F. There is also a Bath- spring a short distance from the Franz-Josef. Administration.-At its source this water is taken in the quantity of three or four glassfuls morning and night. As exported, the dose, is from a half to one wineglassful for a laxative effect, or double that quantity if catharsis is required. (See also Fuered.) J. M. F. FRENCH LICK SPRINGS. Location and Post-office, French Lick, Orange County, Ind. Access.-By Ohio & Mississippi Railway to Shoals Station, or Louisville, New Albany & Chicago to Orleans, thence by carriage. Analysis.-One pint contains : J. Carbonate of soda Pluto's Well. Proserpine. G. Rogers, M.D. J. G. Rogers, M.D. Grains. Grains. 1.316 Carbonate of magnesia 0.198 U.562 Carbonate of iron and alumina trace 0.312 Carbonate of lime 0.868 2.536 Chloride of potassium 0.626 Chloride of sodium 17.567 11.365 Chloride of magnesium 1.006 Chloride of calcium 0.668 .... Sulphate of soda 2.796 4.590 Sulphate of magnesia 2.264 3.666 Sulphate of lime 7.573 17.625 Silica 0.212 31.934 43.816 Gas. Carbonic acid Sulphuretted hydrogen... Cub. in. Cub. in. 1.87 1.277 3.18 2.125 5.05 3.402 FRAXINELLA, WHITE (Fraxinelle ou Dictameblanc, Codex Med.). The root of Dictamnus albus Linn. Order, Rutacew. A tall (one metre high) branching, perennial herb or shrub, with glandular, hairy branches, odd-pin- nate leaves, and large, rather handsome, slightly irregular flowers, with rose-colored or white petals, ten unequal stamens, a single recurved style, and five, three-ovuled ovaries. Leaves alternate, leaflets serrulate and punctate. Fraxinella is a native of South Europe and Middle Asia ; it is often cultivated in herb- and flower-gardens, where its property of flashing with a match on account of the large amount of essential oil exhaled from it makes it an interesting curiosity. It is an old domestic remedy in Europe, but is about obsolete so far as serious medicine is concerned. The bark of the root, which is the best, is reputed to be " tonic diaphoretic emmenagogue, anti-scor- butic," etc. It is often cultivated for ornament in this country. Dose, indefinite. Allied Plants.-The genus contains but this one species ; for the order, see Rue. Allied Drugs.-Probably the value of Fraxinella is due to its oil, and it may therefore be compared with Rue, Buciiu, Cajeput, etc. W. P. Bolles. Therapeutic Properties.-These are saline-sulphur waters of marked strength. The saline element (sodium chloride), while not in such proportion as in some of the more celebrated sulphur waters (Blue Lick, of Kentucky, Louisville Artesian Well), is sufficient to render the waters pleasantly cathartic, and increase their medicinal worth. These springs issue from the base of a hill on the banks of French Lick Creek. The surrounding country-the southern part of Indiana-is diversified with rugged hills and attractive valleys, caves, and streams. There is good shooting and fishing. Lost River, which flows beneath the surface of the earth for eight miles, is near by. There is ample hotel accommodation at the springs, and also at West Baden, one mile distant. Geo. B. Fowler. FRIEDRICHSHALL. A village in Saxony, in repute for its mineral waters. The water which is exported under this name consists of a mixture of the old " Bitter Water " and that from a more recent, drilled well, which contains a much greater proportion of solids. Friedrichs- hall water is esteemed as one of the strongest and most prompt aperient waters of Germany ; being easily as- similated by the stomach, and containing a considerable quantity of the chloride of sodium, its action is gentle. Each pint contains : FREIENWALDE. A town of Prussia, two hours by rail from Berlin, of interest for its mineral springs. These contain a considerable quantity of iron, with compara- tively little carbonic acid gas. The quantity of iron va- ries between 0.014 and 0.006 part per thousand. Two springs, known as the Konigsquelle and the Trinkquelle, are employed especially for drinking; while there are three others employed for bathing. There are at the place public and private bathing establishments, in which peat-baths are administered. Whey-drinking is also a part of the treatment at the resorts. J. M. F. Grains. Magnesium carbonate 3.53 Calcium carbonate 0.11 Sodium chloride 67.37 Magnesium chloride 31.08 Aluminium chloride 0.07 Ammonium chloride 0.06 Potassa sulphate 0.02 Sodium sulphate 41.73 Magnesium sulphate 39.55 Calcium sulphate 11.24 Magnesium bromide 0.02 Silica 0.21 FREIERSBACH, in the Black Forest of Baden, is noted for its mineral springs and " Kniebis " baths. The springs are three in number, namely, the Gas spring, the Lower spring, and the Sulphur spring. In composition there is little difference between the three, all containing, and in almost the same proportions, a small amount of iron, a relatively larger amount of the carbonates of lime, magnesia, and soda, and considerable free carbonic acid. An analysis of the Gas spring reveals, in 1,000 parts, Total 194.99 Cubic in. Free carbonic acid 5.32 Indications.-Friedrich shall water is indicated as a laxative, especially incases of chronic heart disease, inde- pendently of the condition of the valves, o'wing to its re ■ ducing the resistance to the flow of blood in the abdominal vessels, particularly in the ascending vena cava. For the same reason it is recommended in the bronchitis associ- ated with pulmonary emphysema. Mosier is quoted as having observed excellent results from the use of this wa- ter in certain cases of Bright's disease, unaccompanied by fever or other grave symptoms. As a cathartic it is pro- nounced by several eminent authorities the best, particu- larly for constant use. Dose.-A wineglassful fasting. J. IL F Ferrous carbonate 0.0516 Sodium carbonate 0.2060 Calcium carbonate 0.3650 Magnesium carbonate 0.5750 Total constituents 8.1626 Cub. in. Free carbonic acid in one pint 29.945 The water meets the indications for a mildly tonic alka- line water. J. JA K 259 Frontal Sinuses. Frontal Sinuses. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. FRONTAL SINUSES, DISEASES AND INJURIES OF. Anatomy.-The frontal sinuses are two irregular-shaped cavities, which extend upward and outward a variable distance between the two tables of the frontal bone, upon .the vertical portion of its internal surface. They are sit- uated one upon either side of the base of the nasal spine, between the latter and the orbital plate. They are sepa- rated from each other by a thin, bony partition. In size they vary in different individuals, and are, as a rule, by anastomosis of these with the lateralis nasi branch of the facial artery. Its nerve-supply is principally from the first and second divisions of the fifth cranial nerve. In the middle meatus of the nose the communication through the infundibulum of either side with the frontal sinus is partially hidden, and sometimes practically closed by a projecting fold of mucous membrane. Diseases and Injuries.-Owing to the continuity of tis- sue and similarity of anatomical structure, the affections of this cavity, like those of the antrum of Highmore, re- Fig. 1351.-Frontal Bone. Horizontal Portion. Pn, nasal spine; Ft, de- pression for pulley of superior oblique : Fea, anterior ethmoidal fora- men ; Fey, posterior ethmoidal foramen : Mno, naso-orbital articular surface : Pt, external angular process. (From " Dictionnaire Encyclo- pedique," etc.) Fig. 1349. -Anterior View of the Frontal Bone. G, nasal eminence : Tf, frontal eminence : As, superciliary ridge ; Ft, temporal fossa ; Ff, re- mains of frontal suture ; Pn, nasal spine : Mn, nasal notch : Is, supra- orbital notch or foramen ; Jis, supraorbital arch : Pt, external angular process. (From "Dictionnaire Encyclopedique," etc.) semble to a greater or lesser degree those of the nasal cav- ity. These may be conveniently grouped, for purposes of study, under the general headings of inflammation, acute and chronic, and their sequelae ; tumors, including polypi, hydatids, sarcoma, and endostoma ; injuries, such as fract- ures from direct violence ; foreign bodies ; parasites and insects, and their larvae. The extreme rarity with which these cavities become affected by disease, or are the seat of in jury, renders their diagnosis to some extent difficult. Inflammatory states of the frontal sinus may be a part of the condition resulting from "taking cold," or a co- ryza. If the catarrh involves the frontal sinuses, a feel- ing of weight and distention is experienced by the pa- tient, and vain efforts are made to relieve these by vio- lent blowing of the nose. Again, pain is experienced, referable to the forehead, and in some cases this becomes radiating in char- acter, following particularly the distribution of the flfth pair of nerves. Swell- ing of the mucous mem- brane occurs, and this leads to early obstruc- tion of the communica- tion with the middle meatus, and the conse- quent accumulation of secretion aggravates the sufferings of the patient. Sneezing, lachryma- tion, and a suffusion of the eyes are likewise prominent symptoms, in addition to the gen- eral indisposition ac- companying an attack of coryza. Inflammation in the frontal sinuses may also result from syphilitic infection in the tertiary stage of the disease. Here the pathological change begins as a peri- ostitis or endostitis, and tends to the production of de- structive changes in the frontal bone. Chronic inflammation in this locality is generally a re- larger in the male than in the female sex. The frontal sinus of the left side is commonly the larger of the two. They are sometimes subdivided by incomplete bony lam- inse. They open into the middle meatus of the nose through the infundibula, and occasionally communicate with each other by apertures in the septum. They are absent at birth, but appear during the first year of child- hood, and remain of small size up to puberty, at which time they undergo considerable enlargement from the re- cession of the brain. In advanced life they increase in size by absorption of the cancellated tissue in their vicin- ity. In their development they are practically formed from the diploe. Large frontal sinuses do not necessarily Fig. 1350.-Frontal Bone, Inner Surface. Ss, sagittal groove ; Cf, ridge for the attachment of falx cerebri : *, articular surface for crista galli of ethmoid bone. (From " Pictionnaire Encyclopedique," etc.) Fig. 1352.-Vertical Median Section of the Frontal, Nasal, and Ethmoid Bones. Sf, frontal sinus; A', nasal bone : Pn, nasal spine : E, perpendicular plate of ethmoid bone; Frc, foramen caecum. (From " Dictionnaire Encyclopedique," etc.) imply large external prominences over the glabella and su- perciliary eminences. They are lined by mucous mem- brane, this being continuous with that lining the middle meatus of the nose through the infundibula. This mucous membrane, like that which lines the antrum of Highmore, is notably thin and pale. Its blood-supply is derived chiefly from the internal maxillary and ophthalmic arteries, and 260 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Frontal Sinuses. Frontal Sinuses. suit of a chronic nasal catarrh, and occurs through an ex- tension of the diseased condition of the nose, by direct con- tinuity of structure through the Schneiderian membrane. The frontal sinus may become distended by the ac- cumulation of pent-up secretions, as a result of either of the above-named inflammatory conditions, to such an ex- tent as to form a tumor at the upper and inner angle of the orbit, disfiguring the patient by displacing the globe of the eye. In the acute inflammatory states, occurring in connec- tion with an attack of coryza, the treatment consists of the same general measures indicated by the latter, such as active purgation, the administration of opium, dia- phoretics, etc. The local distress, due to the. accumula- tion of secretion, may be alleviated by the application of one or more leeches to the frontal protuberances ; this to be followed by a hot, moist sponge. In a case observed by the writer, the patient derived the greatest comfort by the instillation into the nostril of a few drops of a four- per cent, solution of hydrochlorate of cocaine. This ap- plication seemed also, upon several occasions, to cut short an attack. It is quite easily accomplished by throwing the head well back, with the patient in the recumbent position, and using for the purpose a small glass syringe. Although the liquid probably does not reach the lining of the frontal sinus, yet its effects upon the Schneiderian membrane seemed to favorably influence the congestion and inflammation of the more remote tissue. Syphilitic disease, here as elsewhere, should be treated by the remedies appropriate to the stage of the disease at which the lesion occurs. The iodide of potassium, in progressively increasing doses, administered either in hot milk or Vichy water, but in any event well diluted, will prove to be the most efficient, as a rule. Chronic catarrhal affections of the frontal sinus are probably rare, except when occurring as complications of like conditions of the nasal mucous membrane, and con- sequently are to be treated in connection with the latter.1 When there is reason to suspect an obliteration of the communication between the middle meatus and the sinus, as evinced by excessive pain referable to this region, con- joined with distention and pressure symptoms (muco- cele), the thinned wall of the sinus may be easily perfor- ated with a small drill or cabinet-maker's brad-awl, and the fluid allowed to escape. Reaccumulation should be provided against by establishing a free communication with the nose, and introducing a drainage-tube. The inflammatory process may result in the formation of pus in the cavity. This will be denoted by the occur- rence of rigors, excessive headache, swelling, an erysipel- atous blush, and some local oedema. The pain becomes of a throbbing character. More or less fever will gener- ally accompany the onset of these symptoms. When in- flammation in this region leads to suppuration, tertiary syphilis may, with good reason, be suspected. Prompt measures of treatment should follow the super- vention of these symptoms. If the abscess is not at once freely opened, the morbid action may extend to the brain, or cause caries or necrosis of the walls of the sinus. Al- though the pus may finally find its way out through the cavity of the nose, or by breaking down of the anterior wall of the cavity, no reliance can, with safety, be placed upon the possibility of such an occurrence. The ordi- nary principles of practice should be at once carried into effect. The parts should be laid freely bare, and a small trephine applied to the most dependent portion of the sinus. After the evacuation of the matter, free drainage should be provided for into and through the cavity of the nose, and this maintained in the manner above de- scribed. The parts should be kept disinfected by irriga- tion, once or more daily, with a two-and-a-half per cent, solution of carbolic acid, or a one-to-a-thousand solution of mercuric bichloride. The opening in the anterior wall of the sinus may be allowed to close, and, upon the cessa- tion of suppuration, the drainage-tube should be with- drawn through the nostril. In syphilitic cases there is an especial proneness to caries or necrosis of the sinus walls, particularly if the case is not properly treated from the beginning. Fractures of the walls of the frontal sinus are of rather infrequent occurrence. They are usually the result of direct violence, such as blows, kicks from unruly ani- mals, or gunshot injuries. They may be simple, com- pound, comminuted, or punctured. Wounds of the fore- head in this region may break the skull, without injuring the brain. The escaping secretion from the sinus may lead to the error of supposing that the cranial cavity has been invaded. In simple fracture, the interesting phenomenon is occasionally witnessed of an emphyse- matous condition of the connective tissue of the scalp, face, and eyelids, produced by the escape of air from the nose. In compound fracture a fistulous opening may result. In comminuted fractures fragments of bone may become detached, and subsequently be discharged by the the nose. In gunshot and punctured wounds in this re- gion the brain rarely escapes injury. The treatment of these injuries is to be carried out upon the same general principles as injuries to other por- tions of the skull. Elevation of the fragments should be attempted when much depression of the anterior wall ex- ists, so as to prevent deformity. Any foreign matters that may have been driven in at the time of the accident, as well as loose splinters, should be removed at once. Should cerebral symptoms supervene, they may be due to an encroachment upon the brain of a portion of the posterior wall of the sinus. In such an event the parts may be cleared, the anterior wall cut away by bone for- ceps, and search made for any spiculae of bone causing the mischief. In cases in which an emphysematous condition of the eyelids, forehead, and face persists or occurs when the pa- tient attempts to blow the nose, the application of a com- press and bandage would be indicated. Foreign Bodies in the Frontal Sinuses.-Foreign bodies of different kinds may enter the frontal sinuses through the natural channel, or through its external walls, or they may be formed within the cavity. Among those which gain admittance through the natural pas- sages may be mentioned maggots, developed from the ova of flies (musca vomitoria and musca carnaria) depos- ited in the nose, leeches, etc. A notable instance is re- corded by Gross, of a child which lost its life from the irritation caused by the development in this cavity of an immense number of spiders, the parent of which had been inhaled while the child was smelling a flower. The ova of insects, besides being deposited upon the mucous membrane of the nose, may be inhaled from fruits or flowers upon which they have been deposited. This is said to occur particularly in India, and the disease thus set up is there called "peenash." In the course of this affection, besides the symptom of muco-purulent or fetid discharge and epistaxis, in extreme cases the bones of the face may become the seat of necrosis, the eyeball in- vaded, and the soft parts gangrenous. Centipedes (sco- topendrae), according to Fraenkel, are particularly liable to be found in the frontal sinuses, where they may re- main for years, the secretions of these cavities furnishing them with sufficient nourishment. Calculi, or earthy concretions, are sometimes formed within the frontal sinus, and are of the same character as rhinoliths, as noticed by Bartholinus. They are com- posed, for the most part, of lime. Their presence may be suspected, although it could not be positively deter- mined, from the existence of symptoms resembling those of inflammation of the cavity. Numerous examples of the lodgement of bullets and other projectiles have been recorded. The ends of knife- blades or scissors, broken off in their passage through the skull, have been arrested in the frontal sinus. Mr. Fell's case, in which the iron bolt of a gun-barrel burst upon being discharged, escaped detection as to its true nature for several days. Recovery followed upon the removal of the foreign body. The diagnosis of this class of cases must, of necessity, be extremely unsatisfactory. There probably will be pain, with a sense of weight and fulness, together with tumefaction in the forehead and eyebrow. The usual absence of all history or knowledge, on the part of the 261 Frontal Sinuses. Fruitport Well. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. patient in cases where the symptoms are dependent upon the presence of living worms, renders the case still more obscure. Foreign bodies, other than these latter, when introduced from without, can usually be determined by their history. The general line of treatment marked out for conditions resulting from inflammatory diseases of the sinus are also applicable here. The anterior wall may be simply punctured for purposes of exploration; the subsequent operative procedure will be largely governed by the posi- tivediagnosis thus established. A removal of the offending substance, thorough irrigation with antiseptic fluids, and the re-establishment of the natural channel, are indicated. Morgagni relates an instance of opening the frontal sinus, and the removal therefrom of a worm, by Caesar Maga- tus, surgeon in Bologna. Sternutatories, the inhalation of the vapor of chloroform, etc., have been employed with the view of expelling or destroying these pseudo- parasites. These measures are not likely to prove of value, however, for the reason that the opening from the middle meatus into the sinus, as a. rule, becomes closed early by the irritation and inflammation conse- quent upon the presence of the foreign substance. Tumors of the Frontal Sinuses.-These may for convenience be divided into: (1) Polypi; (2) cystic tu- mors ; (3) endostoma ; (4) sarcoma. Myxomatous growths or gelatinous polypi may either be developed within the frontal sinus, or extend into it from the nasal cavity. They are commonly smooth and single, although they may be lobulated or multiple. Fi- brous polypi occur more rarely, and are apt to be of more rapid growth. They sometimes invade the surrounding cavities, even that of the cranium. They cause great suffering and deformity, but afford no pathognomonic signs as to their character (Gross). A polypus of the frontal sinus, associated with a bony growth, is recorded by Viallet and Rouger, as quoted by Lefferts.1 In time these growths cause extreme attenuation of the an- terior wall of the cavity, resulting in the absorption of its lime salts. The parts, under the finger, present a peculiar crackling sensation, which has been likened to that of parchment. Cystic tumors, which, according to Lefferts, are found more frequently in this region than any other variety, serous or steatomatous in their nature. Langenbeck and von Bruns each record a case of supposed hydatids of this cavity. Gross,2 however, believes that these were serous cysts. During the progress of the development of the growth the eye will be pushed forward and downward, and thus notable deformity will result. The differentia- tion between the cysts and fibrous polypi or bony growths, is o£ necessity very obscure until the disease has reached a stage in which the characteristic feeling of fluctuation can be made out, and an exploratory puncture made. Endostomata, in the shape of nodulated and large, hard, osseous tumors, are sometimes connected with the bones of the skull, springing from the diploe and pressing both outwardly upon the exterior table of the skull, and in- wardly upon the vitreous table. These may have their origin in the frontal sinus, and tend to spread in every di- rection, forming large masses and pressing upon, and finally penetrating, the tables of the skull; projecting as much into the interior as on the exterior; invading the cavity of the orbit as well as that of the cranium, pro- ducing displacement of one or both eyes, compressing the cerebrum and producing epileptiform convulsions and other grave brain complications. A specimen in the mu- seum of the College of Surgeons in London which measures two and a half inches in diameter, fills both frontal sinuses and the upper portion of the left orbit. It also encroaches upon the right orbit, and projects for almost an inch on both surfaces of the skull. It is for the most part of ivory- like density, but upon its cerebral aspect, as well as in its central portion, it is composed of very close cancellous tissue.3 These growths generally consist of compact bony substance with Haversian canals and lamellar systems (Billroth), and may form either nodulated or smooth sur- faces. In parts more compact than others, however, there may be neither Haversian canals nor lacunae, while in portions less compact the canals may be large and the lacunse of irregular or distorted forms (Paget). They have a peculiar preference for this part of the body, but constitute a very rare variety of tumors (Lefferts). They are most commonly met with in youth or early adult life, and increase in size very slowly. In their early stages, prior to the occurrence of symptoms due to pressure, they are quite painless. Their slow growth, characteristic hardness, together with an entire absence of inflammatory symptoms, will serve to point out their true nature. In about one-fourth of the cases they set up suppuration of the mucous lining of the sinus (Gross). By continued pressure upon the contents of the orbit they are likely to occasion inflammation of the different structures of the eye. Sarcoma of the frontal sinus has been observed. Gross de- tails an interesting case in which a growth of this character be- gan with what was supposed to be an attack of erysipelatous inflammation of the forehead and face. The overlying bone became softened and disinte- grated, and the sinus was found to be occupied by a soft, fun- gous mass. The morbid growth presented all the physical and microscopical characteristics of a round-celled sarcoma. The treatment to be pursued in cases of tumor of the frontal sinuses will be governed by the certainty with which the diag- nosis can be made, and the nat- ure of the growth. In mucocele, simple puncture, as for acute or chronic abscess, and the after-treatment above mentioned, in connection with those conditions, will usu- ally fulfil all the indications. In polypi a crucial incision and the application of a trephine will give access to the growth, after which it may be extirpated with the knife and curette, or Volkmann's sharp spoon. In cystic tu- mors a like course may be pursued, the contents of the sac being first evacuated and then excised, or stimulated to contract by the application of tincture of iodine, drain- age being effected by opening up the passage into the nose. The treatment of osseous growths must be largely expectant, of necessity. Their position, attachment, and probable growth in the diploe ; their tendency to extend in all directions; their crowding upon and penetration of the inner table of the skull and invasion of the cavity of the cranium, as well as that of the orbit, render ex- Fig. 1353.-Endostosis of Fron- tal Sinus. (From Bryant's "Manual for the Practice of Surgery.") Fig. 1354.-Endostosis after Removal (% nat. size). (After Brj-ant.) ceedingly hazardous any attempt at their removal. Those which grow only outward, if this fact could be deter- mined beforehand, might indeed be chiselled off with advantage after turning back a flap of skin overlying them. Even here unexpected difficulties may be met with, and the operator be compelled to abandon the at- tempt. Growths of like character in the neighborhood of the supraorbital ridge, however, have sometimes either taken on a condition of spontaneous caries, as in a case of osseous tumor in the superior maxillary bone, related by Mr. Hilton,4 and sloughed completely away ; or this may 262 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Frontal Sinuses. Fruitport Well. follow unsuccessful attempts at their removal, as hap- pened in a case under the care of Mr. Lucas.5 This, nat- ure's process of removal of the bony mass, led Sir James Paget to suggest the possibility of setting up a de- structive process in the osseous structure by exposing it and applying escharotics to its surface. In a very inter- esting case related by Bryant6 the growth was enucleated from its bed in the frontal sinus by means of an elevator, after removing a portion of the frontal bone overlying it. The osseous mass must have been detached, partially or completely, to have admitted of such ready extirpation. Mr. Bryant states that the growth was evidently dying when it was removed. The usual outcome of attempts at the removal of these bony growths occurring in the frontal sinus has been death, either from septicaemia or purulent meningitis, and abscess of the brain. How far the appli- cation of the principles of antiseptic surgery to these op- erations would prevent such sequelae remains to be seen. The treatment of sarcoma as it occurs in the frontal sinus may be dismissed in a very few words. The utter hopelessness of such a condition must be obvious. No amount of importunity on the part of the patient or his friends should induce the surgeon to entertain the thought of attacking such a growth with the means now at our command. George R. Fowler. 1 Inter. Encyc. of Surgery, vol. v., p. 446. 2 Sys. of Surgery, p. 270. 3 Baillie's Morbid Anatomy, Fasciculus, x. Plate 1, Fig. 2. 4 Guy's Hospital Reports, vol. i. 6 Paget: Surgical Pathology, p. 461. 6 Practice of Surgery, p. 526. ness and numbness great care should be used in so raising the temperature, and attempts at resuscitation should be continued as long as a heart-beat can be detected. Arti- ficial respiration should be tried if at any time the breath- ing become perceptible. As slight stimulants that may do good, enemata of cold water, and holding ammonia to the nostrils may be mentioned. Very gradually as the patient becomes conscious the surrounding temperature may be raised. The parts may then be placed in a moderately elevated position and covered with cotton wool. Warm drinks may now be given, as may be also a moderate quantity of alcoholic stimulant, if necessary. In the event of excessive local reaction, cooling lotions may be applied, and strict attention must be paid to the associated constitutional indications. As one by one the different parts of the body regain vitality there is occa- sionally some pain in the limbs, especially if they are warmed too rapidly ; in these cases it is well to envelop the painful parts in cloths dipped in cold water. Such cases of general freezing rarely escape without loss of some limbs, or parts of them, and, in regard to the treatment of these frozen parts, there is not much to be done. The vesicles should be punctured and the serum evacuated ; the frozen extremities may then be wrapped in cold wet cloths, and further than that there is noth- ing to do but to wait to see whether, and how extensively, gangrene will occur. If the bluish-red color passes into a dark cherry-red the chances of restoration of the part to life are slight. Gangrene will occur in the great ma- jority of such cases. By testing the sensibility with a needle and noting the escape of blood from the puncture we can test how far the vitality of the limb has been lost; but we can know this with certainty only when the line of demarcation forms. The general condition may be- come dangerous before the line of demarcation be sharply defined; hence amputation must not be delayed too long if the inflammation after freezing assumes a phlegmonous type. The detachment of single toes or fingers we may leave to nature ; but where there is gangrene of a large part of a limb amputation is decidedly preferable. Under the head of frost-bites of the second degree may properly be considered " chilblains " (or perniones). They are of all grades of intensity, and though they are not dangerous to life, they are, nevertheless, the source of very great discomfort. Dr. Hayes, the Arctic explorer, relates the following interesting case {Boston Med. Journal, vol. Ivii., p. 48) : An Esquimau had his leg frozen above the knee-joint, stiff, colorless, and, to all appearances, lifeless. He was placed in a. snow-house, at a temperature of 20° below zero (Fahr.). The parts were bathed in ice-cold water for about two hours, and then enveloped in furs for three or four hours. Then frictions were used, first with the feathery side of a bird-skin, then with snow, al- ternately wrapping the limb in furs and rubbing it, for nearly twenty-four hours. It was next carefully wrap- ped up, and the temperature of the snow-house raised by lamps above zero. On the third day the patient was taken to his house (in the Esquimaux houses there is often a temperature of 70°or 80° Fahr.), and in seventy hours was walking about, with only a slight frost-bite on one of his toes. John McG. Woodbury. FROST-BITE. We may divide frost-bites into three grades, analogous to those of burns ; the first of these is characterized by redness of the skin ; the second, by the formation of vesicles ; the third by eschars. The first degree of frost-bite is quite well known. We might regard the so-called deadness of the fingers as its mild- est form. The finger becomes white, the skin wrinkled, sensation is diminished, and after a time these symptoms pass off ; then the skin becomes red, the finger swells, and there is a peculiar itching and prickling sensation. This increases the more, the more quickly warmth follows the cold. The redness following this degree of frost-bite may sometimes become permanent, the capillaries remaining dilated ; it is especially apt to occur in frost-bites of the nose and ears, and is usually incurable. Frost-bite in which, besides redness of the skin, there is formation of vesicles, is more severe ; it is often accompanied by com- plete loss of sensation of the affected part, and there is always danger of mortification. The formation of vesi- cles in frost-bites is of much more serious prognostic im- port than it is in burns. The serum contained in the vesicles is rarely clear, usually bloody. A limb completely frozen is said to be perfectly stiff and brittle, and small portions are said to break off like glass, if carelessly handled. I have had no opportunity to verify these statements. Billroth reports a case of a German brought to the Gottingen Surgical Clinic with both feet frozen ; during transportation to the hospital, they had become spontaneously detached at the ankle- joint, so that they hung only by a couple of tendons. The part frozen beyond recovery, or " frozen to death," as it is usually termed, at first blanched, cold, and insen- sible, soon becomes swollen and discolored, and gradually passes into a contracted or shrivelled condition ; chemical changes follow ; a line of demarcation is formed, and the dead and living tissues are ultimately separated. Mortification from severe frost-bite almost invariably involves all the tissues of the part affected. It seldom takes place immediately, but usually requires several days for its definite results to fully declare themselves. It is not unusual for a frost-bitten part to present quite a natural appearance for a day or two, and then to become discolored, passing from a light-blue color to a deeper blue, and ultimately black, and having an unmistakably gangrenous odor. Treatment of Frost-bite.-Any sudden change to a higher temperature must be avoided, but warmth must be increased gradually. Such a patient should be placed in a cool room, on a cold bed, and friction should be made for several hours. If the patient be in a state of general stiff - FRUITPORT WELL. Location and Post-office, Fruit- port, Muskegon County, Mich. Access.-By Chicago & West Michigan Railroad. Analysis.-One pint contains (C. G. Wheeler): Grains. Carbonate of soda 0.565 Carbonate of magnesia 0.308 Carbonate of iron 0.680 Carbonate of manganese 0.010 Carbonate of lime 0.443 Chloride of potassium 0.054 Chloride of sodium 58.003 Chloride of magnesium 5.851 Chloride of lime 13.888 Sulphate of soda 5.749 Bromide of magnesium 0.095 Silica and silicates 1.325 Alumina _ traces (Temperature 48° F.) 86.971 263 Fruitport Well. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Therapeutic Properties.-This is a saline water of marked value, and enjoys a high reputation among the people of the West as possessing excellent cathartic and diuretic properties. It is a favorite resort for the in- habitants of Chicago and neighboring cities. The well is situated in the southwestern part of Mich- igan, on the border of Spring Lake. The surrounding country (16,000 acres) is devoted to fruit-raising, and is owned by a Chicago company. Geo. B. Fowler. certainty to which of its ingredients it owes its value, al- though probably it is to its saline compounds, especially the iodine and bromine salts. The most common prep- aration is a solid extract, from which pills can be made. From three to six decigrams, two or three times a day, may be taken. A suitably directed regimen should also be followed out. Allied Plants.-Several other species of Fucus in- habiting the same area are frequently collected with or instead of this one ; they are said to be inferior to it in me- dicinal qualities. Probably other algae have the same powers as this ; for the Order, see Ergot. Allied Drugs.-Numerous alkaline and sulphurous mineral waters, bromine and iodine salts, etc., are em- ployed for the same trouble with some, but not marked, success. Plenty of exercise and a carefully-regulated diet are other means to the same end. IK P. Bolles. FRY'S SODA SPRING.-Location, Siskiyou County, Cal., about two hundred and twenty-live miles north of Sacramento. Access.-By Oregon Division of Central Pacific Rail- road. This road is finished to Redding, one hundred and seventy miles. As surveyed it passes within a mile of the spring. Analysis.-The only accessible description of this spring is contained in the ' ' Geological Survey of Cali- fornia," vol. i., p. 331. It is described as being strongly ferruginous, sparkling, and with a temperature of 52° F. The elevation of this spring is two thousand three hun- dred and sixty-three feet, and the locality possesses feat- ures of startling grandeur. G. B. F. FUERED, also known as Balaton-Fured, a health resort and mineral springs situated in the Tapolczaer dis- trict, Zalaer County, Hungary, on the northwestern shore of the Flatten lake, at an altitude of about five hundred feet above the sea-level, two hours by boat from Siofok, or by stage from Veszprim. The climate is moderate and healthful. Pleasant cold bathing is afforded at the lake. Warm sitz- and tub-baths are pro- vided, the water being taken either from the lake or the mineral springs. Of the mineral springs, the Franz-Jo- sef is the most important. It is to these baths chiefly that Fiired owes its reputation as a resort. The average temperature of the lake is 20° C. (68° F.), the same as that of the North Sea, but the waves are not so strong as at the bathing places on the shores of the latter. The arrangements for the care of patients are very good. Sheep's milk whey is drunk with the mineral water to a considerable extent at this place. See also Franz-Josef. J. M. F. FUCUS VESICULOSIS Linn. -(Varech vesiculeux, Co- dex Med.), Sea-Wrack, Bladder-Wrack, etc. ; Order, Fu- coidea (Algce). This is a coarse, olive-colored marine alga growing in great abundance upon the rocky shores of the North Atlantic and upon the eastern shore of the North Pacific oceans. It arises from a dilated hard disk, by which it is attached to the rock or bottom, has a short flattened stem which soon forks, and becoming broader and more flattened repeatedly branches in a dichotomous manner, and forms an open fan-shaped compound thallus, composed of numerous strap-shaped divisions. The en- tire plant is a foot or more long, the ultimate foliaceous divisions of the thallus are from one-fourth to one-half inch wide. A well-marked midrib extends to the very extremities, and numerous large oval air-bladders are arranged in pairs on each side of the midrib. The repro- ductive organs are contained in turgid, club-shaped, and forked receptacles which terminate many of the branches of the thallus. They are minute cavities (conceptacles) lying just beneath the surface, with which they com- municate through minute pores. They contain numer- ous hairs, and are either fertile or sterile ; the former contain, besides the hairs just mentioned, a few large " sporangia," developing eight spores in each ; the latter develop numerous small antheridia, each producing nu- merous ciliated " antherozoids." Fucus vesiculosus should be gathered in midsummer and thoroughly dried in the sun, when it may be coarsely ground and preserved for use. It is a comparatively old remedy, having been used more than a hundred years ago as an alterative in strumous diseases. It has also had and lost a place in several pharmacopoeias, and rather recently has been brought out of its obscurity again for a new purpose. Its composition does not differ essentially from that of many other algae : mucilage, mannite, coloring matters, a stearoptene, and a large amount of mineral ingredients ; among the last are soda, lime, iron, iodine, and bromine compounds, to the last two of which its virtues have been attributed. The early employment of Fucus vesiculosus was in scrofulous enlargement of the glands, diseases of the bones, etc., for which a charcoal made by incinerating it has been extensively employed under the name of " Vege- table Ethiops," but it was completely superseded by the introduction of iodine, cod-liver oil, etc. In 1862, Dr. Duchesne-Duparc discovered, while giving it in chronic psoriasis, that his patients lost their excess of fat with- out suffering otherwise in their general condition. This observation led to its employment for obesity, and in this direction it has maintained some reputation for usefulness to the present time, although the value at which it was rated a few years ago is known to be too high. The mode of its operation is not known, nor with FUMITORY (Fumeterre, Codex Med.), Fumaria offici- nalis Linn.; Order, Fumariacem, an annual herb with branching stem, smooth and glaucous compound leaves, and small, rather irregular flowers in axillary racemes ; the pods are one-sided, and the juice of the stems and leaves is not milky ; in other respects of structure it ac- cords with the poppy family. Fumitory is indigenous to Europe, and an introduced plant in the United States. The leaves or the flowering herb are collected for use ; they have a bitter, saline taste, but no odor. They con- tain a crystalline, bitter alkaline base, fumarine, fumaric acid, and a large amount of carbonate of soda. Fumitory is an old European house-remedy for " visce- ral, obstructive, hepatic, and scorbutic troubles." It is but little employed at present. Allied Plants.-Corydalis and dicentra are pretty flowers, some species of which are cultivated for orna- ment. There are several other species of Fumaria which have been employed also in medicine. Allied Drugs.-Fumitory is scarcely worthy of study in this respect. W. P. Bolles. FUNGI, EDIBLE AND POISONOUS. This paper will contain an account of the most important fungi, edible and poisonous, which are known to grow in this country, with the distinctive characteristics of many of them. For some of these descriptions, which will aid in identi- fying species, and enable us to distinguish more readily the benign from the virulent, we are indebted, among others, to Cordier's elaborate and elegantly illustrated work, " Les Champignons-Histoire-Description, etc." (Paris, 4th ed., 1876.) Frequent reference is necessarily made to the Carolinas, because, from the researches of the "accomplished Dr. Schweinitz," and the late Rev. M. A. Curtis, D.D.. who was associated with Mr. Berkeley, of England, and who thoroughly investigated the flora of North Carolina- materially aided by H. W. Ravenel, Esq., of South Caro- lina, the precise localities where a great number of these plants grow have been indicated and recorded. Doubt- less a large proportion of these are widely diffused, and 264 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fruitport Well. Fungi, we would gladly have given the habitat of each every- where in the United States, could they have been pro- cured.* But fungi are much more abundant in a temper- ate zone where warmth and humidity favor their growth ; so also on mountains their range is limited to certain altitudes. Many new species which have been ascertained to be eatable by Curtis, Ravenel, and others will be included ; and as Dr. Curtis tested many of these plants person- ally, we make special allusion to him in such cases. A number of others were long since known to be esculent.. The composition of such a paper by a physician occu- pied with his ordinary professional and hospital duties, and who has not made collections of the ' ' flowerless plants," is tedious, and requires great care and research in order to insure fulness and accuracy; but, we hope that it will furnish a source of reference for all those in this country who shall hereafter desire to examine, investigate, or use our native fungi. General Characteristics.-These plants, consisting of cells and fibres, bearing reproductive sporidia, belong to one of the grand subdivisions of the vegetable kingdom, namely, the Cryptogamia, and occur of all colors except pure green. In them the organs of vegetation and repro- duction are distinct. Their qualities, remarks Mr. Berkeley (" Cryptogamia of England"), are various; many are used very extensively as articles of food; a few are endowed with valuable medicinal properties; numbers are highly poisonous; and the ravages of several in dock-yards, buildings, corn-fields, orchards, etc., are incalculable. Corn-smut (Ustilago Maydis), which contains a fixed oil and a crys- talline principle, used in place of ergot, affects the male florets of maize in every country; smut also at- tacks grasses, barley, and rice-a thread-like mycelium growing at the expense of the tissues. Bunt {Tilletia caries) seizes upon the whole farinaceous portions of the grains of wheat. A few possess the remarkable property of exhaling hydrogen gas; some, however, exhale car- bonic acid, and inhale oxygen. They exist in vast profusion almost everywhere, and need only to be known to be utilized or avoided. This country is exceedingly rich in the fleshy fungi, and new discoveries will reward further research. Fries discov- ered 2,000 species within the compass of a square furlong in Sweden. Curtis, in his catalogue of the Plants of North Carolina, includes 2,976 species of flowerless plants. Mr. Berkeley says of the properties of this important order, and his remarks may be justly applied to this coun- try, that in England fungi are so generally objects of prejudice and disgust that their real importance, as use- ful productions, is little appreciated. With the exception of the common mushroom, scarcely a single species of agaric is generally accurately distinguished ; and though many speak of another kind, under the name of cham- pignon, there are few persons who know what to gather ; and that the fatal mistakes which have in consequence been made have increased the disinclination to any but the mushroom. Mr. Curtis has designated 111 species as edible, 40 of which he had himself eaten, collected within two miles of his residence.]- He had prepared a work on the " Edi- ble Fungi," still unpublished, accompanied by colored drawings from nature of many of our native species by his son, the Rev. C. J. Curtis. It has been our extreme good fortune to procure the use of these drawings, and through the liberality of the publishers of the Handbook selections from them will illustrate this paper. The " Edible Fungi" will be illustrated entirely by the Curtis drawings, which are unique and original; for the Poison- ous, the publishers will select from Cordier's work, and Prang's publication. The smaller cuts are (with the single exception of that of Agaricus procerus), enlarged from pen sketches ex- ecuted by the writer, and are used to exhibit the charac- teristic forms of some of the most important families, genera, and species. Mr. Worthington G. Smith, in his "Mushrooms : ITow to distinguish easily the Differences between Edible and Poisonous Fungi," London, 1875, has accompanied his pamphlet with two colored charts. In one of these, twenty-nine edible species are figured : " Most of them abundant and instantly recognizable when seen; every one is a wholesome and delicious object of food full of aroma and flavor." They are easy of detection, he adds, as we only use the larger species. The reproduction of Smith's charts in this country, a greater extension given to the illustrated work issued by Prang (" The Mush- rooms of America, Edible and Poisonous," edited by Ju- lius A. Palmer, Jr.), would reinforce the present efforts made by the publishers of the Handbook, and ■would tend to diffuse and make popular a knowledge of this highly important class of plants. This would add enor- mously to the food-supply of the entire country, and be greatly beneficial to poor and rich ; for the almost animal character of the mushrooms-which exist in such profu- sion at our very doors-will supply without cost a most nutritious, as well as a delicious addition to their tables. In many portions of Europe, but especially Poland and Russia, they form a most important part of the food of the common people ; and in the latter country whole tribes are mainly supported by them, scarcely any spe- cies, except the dung and the fly agarics being rejected. Even those kinds which are elsewhere refused by com- mon consent, as poisonous on account of their extreme acridity, are taken with impunity-being extensively dried or pickled in salt or vinegar for winter use. It is prob- able that this harmlessness arises from the particular mode of preparation ; for, from the exact account of Pallas, and the general diffusion of various species in various coun- tries, there is no reason to doubt the fact that kinds justly esteemed poisonous are really used ; and it is well known that the noxious qualities of that most virulent species, Agaricus vernus, are communicated to brine, vinegar, etc., and that the olive-tree agaric loses all its poisonous prop- erties when salted, and becomes eatable. The pickle is, probably, in general, thrown away ; while as to dried fungi, he had been informed by a gentleman of great acuteness and observation that in some town of Poland, where he was detained as a prisoner, he amused himself with collecting and drying the various fungi which grew within its walls, among which were many commonly re- puted dangerous ; and that to his great surprise, his whole collection was devoured by the soldiers. It is, however, the practice, in some districts, to use f ungi with- out any preparation whatever, as in their simple state they are considered more wholesome and nutritious. Notwithstanding what has been stated, some fungi, as is well known, are extremely poisonous, and great care must be exercised with regard to their use. In our re- port on " The Medicinal, Poisonous, and Dietetic Prop- erties of the Cryptogamic Plants of the United States " (Trans. Am. Med. Assoc., vol. vii., Reprint, Baker, God- win & Co., New York, 1854, p. 126), can be found a num- ber of similar examples, with a variety of information bearing on these subjects. Composition and Toxicological Characteristics. -The medical uses of fungi are being more fully devel- oped-though many which were formerly held in high repute are now neglected. According to Braconnot, most of the fungi contain a peculiar principle denominated fungin, a peculiar acid called fungic acid, usually com- bined with potassa, and a peculiar saccharine matter less sweet than other varieties of sugar, less soluble in alco- * That our course is not only justifiable, but compulsory, M. C. Cooke, LL.D. (Fungi, their Nature and Uses, London, 1875), while referring to Lea's collections in Cincinnati, Wright's in Texas, and contributions from Ohio, Alabama, Massachusetts, and New York, says : " A great portion of this vast country is mycologically unknown. Of the whole extent of the New World, only the Carolina States of North America can be said to be satisfactorily known." Special reference is made by this writer to the researches of Schweinitz, Curtis, and Ravenel-to whom is ascribed this thoroughness, which has given them a reputation which is world-wide. One genus and fifty-three species have been named after the last-men- tioned, who by no means outranks his co-workers. t We must take this occasion to express our obligations to Dr. Thomas F. Wood, of Wilmington, N. C. (who has published an admirable sketch of the botanical work of Dr. Curtis), for favors extended to us in the preparation of this article: in impartine'most liberally his choice collec- tion of plates, books, and pamphlets. We record our obligations also to our friend and correspondent, Mr. Ravenel. 265 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hol and water than that of the cane, and distinguished by some writers as the sugar of mushrooms. Fungin constitutes the basis of these vegetables, and is the principle upon which their nutritive properties chiefly depend. It is the fleshy substance which remains when they are treated with boiling water, holding a little alkali in solution. It is whitish, soft, and insipid; inflamma- ble ; insoluble in water, alcohol, ether, weak sulphuric acid, and weak solutions of potassa and soda ; soluble in heated muriatic acid ; decomposed by nitric acid and by concentrated alkaline solution ; and converted by destruc- tive distillation into substances resembling those which result from the distillation of animal matter. Letellier found in some of them one, in others two, poi- sonous principles. One of these is an acrid matter, so fu- gacious that it disappears when the plant is either dried or boiled, or macerated in weak acids, alkalies, or alco- hol. To this principle, he says, is owing the irritant properties of some fungi. The other principle is more fixed, as it resists drying, boiling, and the action of weak alkalies and acids. To this principle he attributes the narcotic properties of the fungi. He found it in Am. muscaria, bulbosa, and verna ; and he proposed to call it amanatine. Its effects on animals appear to resemble con- siderably those of opium. The term muscarine has been applied to the poison of mushrooms. It has a close simi- larity in its action to pilocarpine, and is almost completely antagonistic to atropia (see under Am. muscaria, posted). Chansarel found that the poisonous principle resides in the juice, and not in the fleshy part after it is well washed (" Repert. fur die Pharm.," Ixvi., 117; Christison on " Poisons," p. 704; see also recent researches of Sidney Ringer, Lauder Brunton, and others, on Muscarine). Paulet long ago established that fungi are poisonous to animals as well as to man. The toxic or active principle, according to Mialhe, depends upon their power to coagu- late the albumen of the blood, and hence to arrest the cir- culation (" Essai sur 1'Art de Formuler," ccxcix.). The symptoms produced by them in man are endless in vari- ety, and fully substantiate the propriety of arranging them in the class of narcotico-acrid poisons (see Agar- icus campanulatus, and panthennus). Some of them taken a long time induce a depraved state of the con- stitution, suppuration and gangrene. Ergot is a suffi- ciently strong example. Poisoning by Fungi.-In case of poisoning with the fungi there is a great difference in the interval which elapses before the symptoms begin-ranging from a few minutes to many hours. Gmelin has quoted a set of cases, seventeen in number, in which it was said to have been a day and a half? Portions of them have been dis- charged by vomiting so late as fifty-two hours after they were swallowed (Aymen, in "Hist, de la Soc. Royale de Med.," i., 344). Even the purely narcotic effects have been known to last above two days; the symptoms of irritation have been noted by Orfila to continue for about three weeks. Through idiosyncrasy, some persons have been affected by the small portion of mushroom- juice which is contained in an ordinary catsup seasoning (Christison). W. G. Smith experienced severe ill effects, for several days, from eating a deleterious fungus. The morbid appearances left in the bodies of persons poisoned by the deleterious fungi have been detailed by Christison and others : The body is in general very livid, and the blood fluid ; so much so, sometimes, that it flows from the natural openings in the dead body. In general the abdomen is distended with fetid air, which, indeed, is usually present during life. The stomach and intestines of some French soldiers who died of it (see Ag. musca- rius) presented the appearance of inflammation, passing in some places to gangrene. In two of them the stomach was gangrenous in many places, and far advanced in pu- trefaction. In the cases mentioned by Picco, there was also an excessive enlargement of the liver. The lungs have been sometimes found gorged or even inflamed, and the vessels of the brain very turgid. They were particu- larly so in a case related by Dr. Beck, where death was occasioned in seven hours by an infusion of the Ag. mus- carius in milk. Remedies for Poisoning.-In cases of poisoning by fungi, common salt, sulphuric ether, in full dose, and Hoffman's anodyne, were all found beneficial after the use of evacuants. Large draughts of warm water should be taken, which dilute the poison and promote vomiting. An emeto-cathartic should always be administered. The following prescription is advised : B. Ant. tartarizat grs. iij. Ipecac grs. xxiv. Sulph. sodse grs. vj. This to be followed by oil, and subsequently by ether. Milk has likewise been recommended. Chanserel found acids useless as a remedy, but he thought in- fusion of galls advantageous. Pau let said (1776), that salt and vinegar, or boiling, or allowing them to soak in vinegar and water, removed every deleterious principle from that poisonous species the Ag. bulbosus y-andthat the Russians are in the habit of salting their fungi, which may be the cause of their harmlessness. So the pickling and subsequent washing of the poisonous agaric of the olive renders it eatable in the Cevennes (Delile, " Lind. Nat. Syst."). Both Pallas and Orfila assure us that vine- gar will destroy the noxious power of the most dangerous (" Toxicol.," ii., 89). On some personsail mushrooms, even the very best of the eatable kinds, act more or less in- juriously-they cause vomiting, diarrhoea, and colic. In this respect they are on the same footing as the richer sorts of fish, which by idiosyncrasy act as poisons on par- ticular constitutions. To Select Mushrooms, and to Distinguish the Edible from the Poisonous.-Fodere, De Candolle, and Greville have laid down general directions for distinguishing the escu- lent from the poisonous varieties, but their rules are not safe, as they would exclude many species in common use, and the number of edible species is daily being increased. Cordier cites numerous examples to prove that there are no fixed general rules or tests to guide us in the rejec- tion of a mushroom ; for of those growing in any kind of soil or locality, whatever be their form, hue, appearance, or taste, some are exceptionally edible, or noxious. The best rules will be those derived from the identification of species, which is sufficient for all practical purposes, as the species are well marked and easily recognized by study or observation. Notwithstanding this, taste, color, aroma, and other physical qualities, often furnish im- portant indications. Messrs. Cooke and Berkeley express similar views, in saying that we must learn by experiment and observation which are the edible and poisonous mushrooms, just as we distinguish the character and qualities of any other plant. How much alike, among Phanerogams, for example, are angelica and cicuta ; each must be known and recognized to be used with safety, or to be shunned. M. Richard (" Diet, des Drogues") lays down rules to guide those who eat mushrooms in their selection of them: Those should be rejected which have a narcotic, pungent, or fetid odor, or an acrid, bitter, or very acid taste; which occasion a sense of constriction in the throat when swal- lowed ; which are very soft, liquefying, changing color, and assuming a bluish tint upon being bruised; which exude a milky, acrid, and styptic juice ; which grow in very moist places and upon putrefying substances ; in fine, all such as have a too coriaceous, ligneous, or corky consistence. The last, however, are injurious, in conse- quence rather of their indigestible than of their poisonous nature. It has also been said that of those which grow in woods and shady places a few are esculent, but most are un- wholesome ; and if moist on the surface, they should be avoided ; also that those which grow in tufts or clusters, from the trunks or stumps of trees, ought likewise to be shunned. Exceptions exist here also. Agarics of orange, or rose-red color, and boleti which are coriaceous or corky, or which have a membranous collar around the stem, are also unsafe ; but these rules are not universally applicable in other genera. In a recent letter from Mr. Ravenel he writes as fol- lows : " There are certainly some, perhaps many, poison- 266 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi. ous species, but I am satisfied that a large majority of the fleshy fungi are either wholesome or innocuous. Yet, it is well to lay stress on the fact of there being some virulently poisonous, so as to give a prudent caution to those who may not know the wholesome kinds." 1. Every mushroom should be rejected, whatever its species, which is too old, or with perforations which show the presence of maggots. 2. All of which the texture is woody. 3. All those the taste of which is acrid, burning, bitter, acid, or peppery-although some are edible which are either acrid, or peppery. Valmy says that the taste is the first and best indication of the quality of a mush room (" Les Champignons, Guide Indispensable," etc.). 4. All those which exhale a disagreeable and nauseous odor : which are slimy and deliquescent. 5. The following is an indication of danger : the pres- ence of a bulb or swelling of the base of the stem, its being surrounded by a volva, or white envelope, in the form of an egg-shell, and remaining as a socket at the base when the mushroom is pulled up; a collar or ring large and reflexed, or falling back ; lastly, the head cov- ered with the debris of the volva and made scaly and warty, as in Amanita Muscaria. In the poisonous, the scales or protuberance rub easily off, leaving the skin in- tact. In the poisonous amanitas-and death is said not to occur from eating any other family-all these signs ex- ist. So the amateur should avoid all amanitas which he does not know. It is a dangerous error that all mushrooms which change color when cut are poisonous; or that those which do not change when cut are edible. Among the Boletes, for example, the greater number which do not change color are poisonous ; among agarics scarcely one which is poisonous changes its color, but remains white ; while the best one of the edible species does change its color when cut, or becoming old. It is also a mistake to suppose that if a piece of silver, or an onion, does not change color when cooked with a mushroom, that it is edible, or vice versa ; neither will vinegar added to the water in which they are cooked surely deprive the poisonous of their hurtful qualities. To Prepare Mushrooms for the Table.-Acci- dents from eating mushrooms would be much less fre- quent if consumers would use only young, fresh, and sound specimens, and reject all those which are stale, semi-putrid, and worm-eaten. The limited space at our disposal forbids our giving many directions for the preparation of mushrooms for the table ; these may however be obtained from almost any of the works treating of them-as well as from most treatises on cookery. MM. Roques, Cordier, Savarin, and others are very enthusiastic upon the subject. Mr. W. G. Smith, Mrs. Mussey, and others make a few simple but very sensible suggestions. He says that it is apparent that the addition of " good beef gravy," " a few slices of fowl," " rich veal stuffing," and various other savory condiments, must occasionally give an extra zest to a dish of mushrooms ; but that broiled, stewed, or pickled, most species are " always good alike; " indeed, mushrooms, in their whole composition, resemble meat in so remarkable a manner that any method of cookery in vogue for delicate preparations of meat apply with equal force to mushrooms. "I must confess," he adds, " that I consider no preparation of mushrooms can ex- ceed the delicious, inviting, and grateful flavor pos- sessed by them when simply fried with butter, salt, and pepper." For special directions, see {posted) Ag. procerus, Ag. campestris, Ag. oreades, and others. Some species are stored up for future use, being dried in a current of air, in a sunny window, or in a cool oven ; and then kept in tins, or threaded on strings and kept in a dry place. If much dried, they form " mushroom pow- der," and are often sold as such. Mushrooms are often pickled by throwing them into scalding vinegar, allow- ing them to boil for ten minutes or so, and then by add- ing cayenne pepper, mace, or spices adapting them to various tastes. The liquor extracted from the various mushrooms un- der the name of ' ' ketchup " is prepared by placing the freshly gathered plants in earthen jars with layers of salt; after a few hours the ketchup exudes, and the pro- cess is completed by mashing the remains of the mush- rooms with the hands. It is then strained and boiled with spice and pepper, or strained and bottled-the corked and sealed bottles being placed for several hours in boiling water (Smith). Our common horse-mushroom (Agaricus arvensis) is particularly suitable for this pur- pose. Those possessing a firm and coriaceous flesh should not be treated in the same fashion as those which are soft and watery. Every kind of frying suits mushrooms. They should be warmed, entire or cut in pieces, by exposing them for fifteen or twenty minutes to a fire in a vessel without water; the water which has exuded from them is thrown away; then they are rolled into a mass with corn-flour, pepper, salt, onions and fine herbs cut fine, after which they are fried in butter, oil or lard. For soft mushrooms, white or fish sauces, or meat-juice, suit best. Mushrooms can be eaten alone, or mixed with any- thing to advantage ; they can be served with meats, fish, or even with legumes and eggs. In preparing young subjects the pellicle on the cap should not be removed ; they should simply be brushed with a soft towel to remove the sand and dirt, then washed in warm water. When collected, the gills should be turned up, that the spores, which possess much per- fume, may not escape. Cultivation of Mushrooms in Caves.-In " Fungi, their Nature, and Uses," by M. C. Cooke, LL.D., and M. J. Berkeley, F.L.S. ("International Scientific Series," 1875), it is stated, p. 255, that the profits of mushroom- grounds near London are very great, although only the common mushroom was cultivated. The profits amounted to from one hundred to one hundred and fifty percent. Im- mense quantities are produced in Paris, as is well known, in caves. In one of these subterranean vaults at Mont- rouge, the proprietor sends three hundred to four hun- dred pounds per day to market. Large quantities of pre- served mushrooms are exported, one house sending to England not less than fourteen thousand boxes in a year. One cave, near Frepillon, in 1867, sent three thousand pounds to the Parisian markets daily. In 1867 M. Re- naudot had over twenty-one miles of mushroom-beds in one great cave at Mery. The temperature is so equal that the cultivation is possible at all seasons. The open- air culture is also practised, and can be carried on by the gardener or the cottager. That this industry may be- come possible near our large cities, we insert in the ' ' Bibliography " the titles of several special treatises on this subject. To Cultivate Mushrooms in the Open Air.-The Paris system is the best, and is as follows, which we translate from Lamy's little brochure-only the common mushroom {Ag. Campestris') is used for this purpose : In December, in a dry and sandy soil, exposed to the south and east, a trench is made 65 to 80 centimetres in breadth, 15 to 20 deep, and of a convenient length, bor- dered with earth from the excavation. If the land is moist, the trench may be deepened and the extra space filled with a layer of lime and stones covered with a little sand and earth. On the top is placed a layer of manure, covered freely with dung which is not too large ; that of the horse is best when not fed on wheat-straw. It is dressed with a good layer of mushroom spawn (blanc de champignon). This is pressed with the feet, raised in the shape of an ass' back or a cone 65 centimetres high ; then covered with about 3 centimetres of earth and sand, and also of ma- nure mixed, if too compact. At the beginning of April it is covered 5 to 6 centimetres, more or less, with a large litter of straw, well shaken-called in France the chemise. At the end of May it will begin to produce. The trench, or fosse, may be dispensed with, and the layer may be made in any of the spring or early summer months. Lamy tates that a gardener exhibited a suc- 267 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cessful bed bearing mushrooms, at an exposition in Paris, made upon a board. To succeed well it is necessary to unite to moisture a certain heat, 17° to 18°, Reaumur, or 21° to 22°, Centigrade. This heat is maintained by means of the chemise, which is diminished or increased as necessary. In summer it is ne- cessary to moisten the layer, in order to keep the moisture at the same temperature. When the atmosphere is at 15° Reaumur, or 19° Centigrade, the layer requires no " che- mise "-the mushrooms grow naturally, as was the case at the Exposition. These layers can be made in the open air, or in caves ; they succeed better in caves, because the temperature ap- proaches 15° Reaumur, and they require less care. We should guard against allowing the chemise to become stale by too much heat or moisture; to prevent which it should be occasionally stirred or renewed. A layer of mushrooms, made at the beginning of Au- gust, can produce in two months ; and a bed established at the end of summer will produce in winter. To pre- serve the bed leave some of the mushrooms to dry upon their stems, while renewing the manure, and watering it with the water which served to wash the mushrooms which were gathered. To establish a bed, the layer of manure is covered with the dried sporidia, or seeds of the mushrooms {blanc de champignon, as the gar- deners call it), when it only has a slight warmth, which occurs about seven to eight days after they are put in position; in order to do this, little fur- rows should be traced, crossing like checkers, which are filled with the spawn, about thirty centimetres apart, only upon the upper three-fourths layer of the bed, that is : sepa- rated about fifteen centimetres from the earth. It is then cov- ered with litter (straw from stables), and examined eight days after to see if the spawn has reddened, if it possesses more smell, or has thrown out threads ; if it is working, it is watered a little and covered with a slight thickness of man- ure, and this covered with a fresh litter. A layer of mushrooms can last many years ; but it is neces- sary to renew the manure. The mushroom white, or spawn (for seed), is procured of good quality by taking it from a good bed. It can be bought, and kept either in the shade or in a cave. Our author insists that a mushroom-bed is a source of extra profit, because the material used is worth more for the garden, the mushrooms can be got at all seasons, and sell very high. They, after truffles, are the best addition to a repast; they serve as an appetizer for the rich, and a resource for the poor. Why their culture is not more extensive, in the provinces as well as in the cities, can only be accounted for by a want of knowledge, the fear of being poisoned, or both causes combined. Parts of a Mushroom.-The different parts of a mushroom are distinguished as follows (see Fig. 1355) : 1. The expanded disk, cap, or head (pileus).-On the under surface of this is the spore-producing receptacle (Hymenophore) and the organ which bears the membrane (Hymenium) upon which the spores or seminules grow. The cap or pileus is of diverse shape, structure, and color. 2. The spore-bearing membrane.-Takes the form of plated folds, leaves or lames (gills), as in agarics ; of tubes in boletes ; of little needle-shaped spines, as in the "beef tongue " (Jlydnum) ; smooth in the clavarias ; and with salient nervures or protuberances, in the morelles (Jfor- chella). Over the plated folds of the agarics, or the sur- face of the spines of hydnei, is spread the spore-bear- ing surface {Hymenium). The sporules, sporidia, or seeds, are exceedingly minute, and appear like tine dust. The gills, lames, or leaves, which form the under sur- face of the cap, are either entire, or alternate with half leaves. They are either detached from the stem, or ad- here to it; sometimes they bifurcate. They form impor- tant distinctions between the edible and poisonous mush- rooms. 3. The/W or stem. 4. The collar, or ring {annulus).-This in some species forms a partial envelope, adhering to the borders of the cap ; but sometimes becoming detached, it forms a mov- able ring around the stem. 5 and 6. The veil, a membrane, or web which extends from the margin of the cap when the plant is young, and thus encloses the gills. 7. The bulb, or swelling of the base of the stem, sur- rounded by : 8. The volva, or matrix at base of stem-a kind of membrane, sheath or wrapper, which, in many species, envelops the fungus in its early stage, and tears when it be- comes developed :-often leaving portions of its substance (9) upon the scurfy top, in the ring, on the veil, or at the base of the stem. (See also Figs. 1367, 1368, and 1369.) Structure, Reproduction, and Classification of Fungi.-It is our desire in this paper to avoid being too technical or scientific, but we should say of the fungi or mushrooms that they belong to the class Amphigens, which for the most part have no determinate axe, and develop in every direction in contradistinction to the Acrogens, the development of which takes place from the summit, possessing an axe, leaves and vessels, and which embrace mosses, ferns, etc. The fungi are entirely cellular, that is, completely deprived of vessels, but having filaments, tubes, and lames (gills). There is no frond or leaf ; no epi- dermis, and consequently no stomata. The mushroom is composed in general of two parts quite distinct : one vegetative, the other that of reproduction. The first, or the Mycelium, appears to be the origin and primitive state of every mushroom, since it results from the development of the spores, and is .composed of filaments which are slender, simple, or ramifying, naked, or uniting with the substance on which the mush- room lives as a parasite. The filaments are composed of white elongated cells placed end to end, and are com- pletely deprived of endochrome. The second, or that of reproduction, which springs from the first, of which in some sort it seems to be a dependent, is composed of spores which are naked, or are contained in a receptacle of variable form and size called the peridium in mush- rooms of round form {Richard). This last part, which is often the only visible exteriorly, is commonly regarded as the mushroom properly speaking ; for example, in the cul- tivated mushroom {Agaricus campestris). This springs from a mass of white filaments {Mycelium), which is sold in a dried state, and known as "blanc de champignon," or spawn. The plant may remain a long time in the my- celium state before it shoots up and becomes visible. The spores are sometimes simple and naked, and spring, as was stated, immediately from the mycelium, which they at times entirely replace ; at other times they are collected together in a common envelope which is exces- sively thin, and forming a theca which is a receptacle closed. In other forms, as in puffballs {Lycoperdon), for ex- ample, the spores are contained in the cavity of the plant, and are inserted upon receptacles designated basides (see Fig. 1359). These organs of reproduction develop upon different points of the mycelium, sometimes solitary, sometimes Fig. 1356.-Mycelium of Clavaria. (F. 1'. P. after Payer.) Fig. 1355.-Diagram Showing Different Parts of a Mushroom. 268 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi. many together. The process is as follows: Tubercles composed of very small and hexagonal utricles form upon the filaments, grow and develop according to the species. If it is an agaric, a kind of cap borne upon a long stem springs out of the bosom of this tubercle and fructifies externally. Is it a Lycoperdon: there forms in the cavity of its tissue a multitude of lacume, and from the circum- ference of each there arises elongated utric- les bearing four spores upon their surface (Figs. 1358 and 1359). Fungi reproduce by spores ; but the origin of these spores, their nature, and the form of the body which supports them, vary greatly. The spores are formed in three principal ways: they either grow in a spe- cial cellule or utricle, in which case the utri- cle is called a theca, and the fungi are en- dospores ; or they ap- pear at the exterior of the utricle upon which they are fixed; then the utricle is named baside, and the fungi are exospores. Lastly the spores develop in the midst of a gelatinous mass in which no distinct organization can be recognized, and the fungi are said to be myxospores. So we have these as grounds for classification. Fungi have also been conveniently classified thus : The spores in chaplets at the extremities of the fila- ments, or order of Arthrospores (&pdpov, joint, articula- tion) ; those of which the spores develop at the extremity of a filament more or less lengthened out, or second order Trichospores (0p^, a hair), as in Botritis nutans (see Fig. 1357). Those in which the spores appear by fours upon each utricle, or fourth order, or Basidiospores, as in agar- ics, boletes, lycoperdons, etc. (see Fig. 1358). The third proligerous membrane, called the hymenium which covers a special part of their surface ; it invests the gills of agarics, the tubes of boleti, the lower surface of the head of helvellas, and the periphery of the ramifications of clavaria. Gasteromycetes (spores enclosed in a cavity, or stomach, yaa-rnp). These include phallus, lycoperdon, bovista, etc. Ascomycetes (daKos, pouch or sac) include morchella, helvella, leotia, etc., which have cup-shaped depressions, lacunae, and sinuosities. We do not refer to other orders which contain genera which do not concern us in this paper. The hymenium (Fig. 1359), of which the position also Fig. 1359-Portions of the Hymenium, much enlarged, a, Paraphyses; b, Basides, or sporophores. (F. P. P. after Richard.) Fig. 1357.-Botritis Nutans. The last sub- division of a filament which disarticulates to form a spore. (F. P. P. after Payer.) varies, is formed of utricles; upon its surface, it presents, first, the paraphyses (Fig. 1359, a), elongated cellules placed parallel, the one against the other, forming a kind of vil- losity; second, the basides or sporophores (Fig. 1359, b), situated between the paraphyses ; longer than the latter; the basides are swollen utricles, terminating at their sum- mits by four tubes, each bearing an ovoid or globular spore ; in this case the spores are naked. (See, also, Fig. 1358.) Third, in the hymenium of certain mushrooms an- theridies, or male spores (as they were thought to be) exist, generally filled with a limpid or colored juice and organic corpuscles. As a consequence of the complete absence of green matter in the interior of their utricles, fungi behave like Fig. 1358.-Bovista (Lycoperdon) Plumbea, Spores in Fours upon each Utricle. (F. P. P. after Payer.) order is that of Thecaspores, where the spores spring from the interior of a utricle, a closed sporange or theca. The Myxospores (referred to above) constitute the fifth order. The more recent arrangement of fungi is, first, into : Hymenomycetes membrane, and ^vkt]s mushroom). These include the larger proportion of the edible and poisonous fungi, namely, agarici, coprinus, cantharellus, cortinarius, lactarius, boletus, hydnum, clavaria, etc. In these the sporidia are placed upon the surface of the Fig. 1360.-Clavaria. (F. P. P. after Valmy.) the colored parts of the superior plants : they always ab- sorb oxygen and disengage carbonic acid ; while they get the considerable proportion of nitrogen, which exists in 269 Fu ngl. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. them from the earth ; thus they naturally live on organic matter in a state of decomposition. The cryptogamia are to a great extent the scavengers of the earth, and the destroyers of dead and rotten matter. Some fungi, as is well known, develop upon living animals, man included, and become sources of disease: for which see researches of Robin, Pasteur, and others. Distinctive Characteristics of a Few of the Most Important Families and Genera.-We begin with the least highly organized : Clavaria.-None afre poisonous. They are simple or branching, fleshy or coriaceous, with no distinct head. Their form and color vary, with round branches resem- bling a tree, or a club, or a coral; the hymenium is com- posed of linear cellules, enclosing numerous rounded sporules which escape from the entire surface of the plant, except the stem (Fig. 1360). Curtis cites thirteen indigenous edible species. Helvella.-There is generally a stem ; the head is fleshy, membraneous, irregular, twisted, divided into lobes the reverse, the continued whiteness of the leaves and stems are unfavorable indications. J. A. Palmer, Jr. ("Mushrooms of America, Edible Fig. 1362.-Morchella. (F. P. P. after Valmy.) and Poisonous "), says that a good rule for the inexperi- enced is to avoid all the lurid boleti, all those which have the slightest shade of red to the tubes. " The mild-col- ored members of this family, having white, yellow, or greenish tubes, if pleasant to the taste, may be considered safe." The boletes dry easily, and are readily preserved. They can be added to any kind of .sauce ; and are eaten fried, Fig. 1361.-Helvella. (F. P. P. after Valmy.) folded or depressed, free or adherent. The stem is pol- ished or furrowed, or simply hollowed. Curtis has four edible species. Morchella.-The fleshy cap, or pileus, is globular, ovoid, or conic, with a stem, relieved externally by anastomos- ing elevations which form large polygonal cavities, in which the grains are concealed. They all come from the earth, and are edible (Cordier). Two indigenous edible species. Hydnum.-These are fleshy, coriaceous, sessile, or pe- diculated ; some are sinuous or scaly. The cap, which is not always distinct, but often twisted, inform, convex and concave, is garnished below, and sometimes above, with cylindrical or conical sharp needles or spines, dis- tinct the one from the other, and which contain the spores at their extremities. The latter resemble the papillae which cover the tongues of ruminants-hence the name "beef's tongue." The sporules are small and round. They possess neither lames, sporules under the cap, volva, bulb, nor collar. Clavaria, helvella, morchella, and hyd- num contain no poisonous species. Curtis gives five edi- ble species. Boletus, Boletes.-In these there are no lames or leaves ; the spore-bearing membrane (hymenium) is formed of tubes reunited together, and separable from the cap. We have here the first complete type, with a regular head, sporules in large quantity collected in bundles under the cap, and prominent stems. These change color if cut, when the snecies is poisonous. In agarics it is exactly in an omelette, or seasoned and cooked in lard or olive- oil. The membrane should be removed from the cap if the plant is old. In perfume it rivals any other mush- room. Curtis cites eleven edible species found here. Fig. 1363.-Hydnum. (F. P. P. after Valmy.) 270 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi. Cantharellus, Chantarelles.-They resemble hydnum, but are allied to agarics. The cap, stem, and leaves are generally of a beautiful golden color. The leaves, or lames, serve specially to distinguish them, as they are thick, in the form of irregular, branching nervures or protuberances, springing from the middle of the stem, like a grain of mustard-seed, which is subsequently de- veloped into the full-grown plant. The spore-bearing membrane is formed of leaves, plates, or folds, capable of being separated into two layers radiat- ing from a com- mon centre. The cap is fleshy or membranous, en- tire or divided, with the gills or leaves on the un- der surface ; these have a sharp border, with a floc- culent or cottony layer united with the head. Agarics differ from the boletes, as the latter have tubes collected in bundles on the under surface of the heads, in place of leaves. In agarics these leaves or lames pass in a transverse direction from the stem directed toward the circumference, like the sticks of an umbrella. They are simple or bifur- cated, and they serve to distinguish the poisonous from the edible. This large fam- ily is subdivided into eleven sec- tions ; among which are, the Amanitas; the Agaracini, or gill- bearing meadow mushrooms (Ag. campestris and Ag. arrensis); Russules ; milky agarics (Lactarius)-, Coprins, or dung agarics {Coprimes); Cor- tinaires {Cortinarius), etc. The Amanita subdivision of agarics (see Fig. 1366), containing many dangerous species, as well as a few edible, is the most ad- vanced and most complicated of Fig. 1366.-Agaricus (Amanita Muscaria). (F. P. P. after Valmy.) Fig. 1364.-Boletus. (F. P. P. after Valmy.) ascending and bifurcating with it in their course under the head ; the stem, at its junction with the head, is swollen, larger at its union with the head than at its base, and scarcely to be distinguished from it. The head is often turned down like an irregular ear, more spread out. on one side than the other, sometimes with a border folded above. They are often confounded with hydnum repan- dym, having the same color, size, and habit of growing Fig. 1365.-CantharelluH. F. P. P. after Valmy.) in numerous groups ; but hydnum has sharp spines un- der the head. Agaricus, Agarics.-In these the rooting, slender fibres termed the mycelium, or spawn, which is an agglomer- ation of vegetating spores, traverse the soil; at first the mushroom is only a small, nearly globose budding, Figs. 1367, 1368, and 1369.-Different Stages of Development of Agaric. (F. P. P. after Payer.) 271 Fu ngi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. this order. The cap is well formed, the leaves regular, they possess a stem, a collar or veil, a bulb at the bottom, and, unlike any poisonous species, it is smooth. All the poisonous species have dull, lurid colors, marked with circular, colored bands upon the head, like the rainbow, The edible species have a color like those which are edi- ble in other families (Lamy). This family is most fruit- ful in number of species. The Cortinaires {Cortinarius) are all edible. They are distinguished by a mem- brane resembling a spi- der's web, of a light color and connecting, from the birth of the mush- room, the head to the stem-very much like the collar of the com- mon mushroom. and a volva. The beautiful " Imperial " orange-colored agaric (Aff. Caesarius), which is so greatly prized for its delicious taste and perfume, ' ' never has the remains of the volva upon its brilliant head." The leaves of the stem serve better to distinguish the species than the color of the head, which varies in- finitely in shade, even in identical species. The fol- lowing are almost positive marks of deleterious amanitasthe pres- ence of a bulb or swelling of the base of the stem, its be- ing surrounded by a volva or white envelope in the shape of an egg- shell, a collar, lastly the cap covered with the (warty) debris of the volva. Lamy asserts that nearly all species of agarics of which the flesh and the leaves do not change color when gath- ered are poi- sonous. It is quite the con- trary with bo- leti, as was stated. To distin- guish the ama- nitas we must greatly de- pend also on the perfume ; if it is nil or repulsive, the plant is dangerous ; if pleas- ant, it is edible. The amat- eur should avoid the amanita family of agarics, unless he knows the few edible species. The edible species of the family of Russulas, a subdi- vision of the agarics, are easily recognized by their pleasant flavor; while the non-esculent are hot and nauseous to the taste ; it is therefore best to avoid all plants re- sembling russulas, the milk of which is not pleasant (Palmer). In the edible milky agaric (Lactarius), one test is the sweet and pleasant taste of the milk, almost identical with the milk of animals. The cap is of a yellow, ochre color, Fig. 1372.-Cortinarius. (F. P. P. after Valmy.) Fig. 1370.-Agaricus (Russula) Alutaceus. (F. P. P. after Valmy.) In the Puff-balls (Lycoperdon) there is a receptacle (or peridium) which envelops the reproductive corpuscles ; at first closed in every part, it opens only at the time of maturity. It is filled by a fleshy substance, in the midst of which are hollowed out a number of sinuous cavities lined with spore vessels ; at maturity this multilocular structure disappears, and to spongy tissue perforated with spores succeeds a confused mass of fine, dry, blackish, or brown dust, and stiff and hairy filaments. All are edible which appear in little balls on the open ground after rains, if fresh, white inside, and hard ; if soft and yellowish, or black in the pulp, they are approaching decay, and should be avoided. (See Lycoperdon, postea.) Phallus.-The hymenium is at first enclosed within a Fig. 1373.-Lycoperdon Bovista, Puff-ball. (F. P. P.) Fig. 1371.-Lactarius. (F. P. P. after Valmy.) 272 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi, sort of peridium or universal volva, maintaining a some- what globose or egg shape. When young the spore-pro- ducing tissue (hymenium) is fleshy; in the interior of which cavities are hollowed out which are more or less sinuous,and covered with greenish spores disposed in fours or sixes upon the little bodies (basides) (see Figs. 1358 and 1359), springing from the receptacle-the plant having the general form of a long, erect, cellular stem bearing a cap. The volvas break at the summit, and form a sheath which surrounds the foot of the spore-bearing membrane (Hymenophore). The head is naked, as well as the tissue which covers it. Very soon the tissue softens and becomes a viscid mat- ter, like mucilage, which melts and carries off all the spores, becoming so offensive as to be perceptible to the sense of smell at a great distance. In P. impudicus, which is represented in Fig. 1374, from one of our sketches, the spore - bearing mem- brane is hollow, cellu- lar, cribriform, with the head reticulated, pervious, and naked below. Fibrils or root- lets are seen in this family. Clathrus belongs to a tribe of the family Phalloides, and is therefore related to it in structure. various processes for serving it up. He intimates no in convenience from eating the plant. Cordier speaks very Fig. 1375.-Leotia geoglossoides. (F. P. P. after Payer.) highly of it, and says it can be eaten raw, " etsansaucun appret." Curtis cites it among the edible species. A remarkable set of cases, however, are related by Dr. Fig. 1374.-Phallus impudicus. (F. P. P.) We insert Leotia only to exhibit another form-though it is in the same tribe with agaricus, clavaria, etc. {Hy- menomycetes). In this the fleshy and tuberculous recep- tacle is capitate upon a stem. ' We have no indigenous edible leotias(see Fig. 1376). II. Edible Fungi.-Agaricus procerus, Scop.; Agaricus colubrinus, Bull.-Parasol, scaly, or large shaggy agaric ; "Gardens, Hedge Banks, Pastures and Woods;" S. C. to Penn.; common ; Curtis and Rav. This species is of remarkable beauty, and is known by its long, hollow, bulbous, spotted stem, which is received into a depres- sion of the head ; by the ring that is persistent and mov- able ; its cap in the form of a parasol, but more or less mammelonated, imbricated, scaly formed by the epider- mis which is raised. The leaves terminate at a certain distance from the stem, are pale, unequal, and much re- tracted at their base. This plant was known among the Romans ; its taste is sweet and odor pleasant; according to Roques, " forming on the Continent a frequent article of food "-who gives Peddie {Edinb. Med. and Surg. Journal, vol. xlix., 192), where pure narcotism occurred from eating this fungus : Fig. 1376.-Agaricus procerus. 273 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. giddiness, staggering, convulsive spasms, furious delir- ium, frantic cries, and a state resembling delirium tremens •occurred. The above cases plainly show, if Dr. Peddie was cor- rect in his species-which, however, is quite doubtful- the possession of a narcotic property. In the three cases ho pain was felt at any time, nor were the bowels affected. Dr. W. G. Smith says of it, "Its esculent properties are of a very high order," and in an article illustrated with wood-cuts and recently published in the Gardeners' Chronicle, and which has been reproduced in the supple- ment to tlie Scientific American, he reaffirms the admira- ble qualities of this species. Mr. Berkeley, Mrs. Hussey, and others declare it to be unsurpassed among the escu- lent fungi. Roques, Paulet, and others also launch out into extrava- gant expressions in its favor-the latter giving recipes for its preparation. As it is impossible for us to enter fully into culinary matters, we introduce in a note instructions from Dr. Bull, and which have been accepted by clubs in England, for the several preparations of this species for the table, which will, doubtless, apply to any other agaric.* Agaricus rachodes, Vitt.-Base of stumps and trees, N. C.; edible, Curtis. Cordier says it resembles very closely A. procerus, some regarding it as only a variety. Fries said that it had a disagreeable taste and was not eatable ; M. Hussey, on the contrary, says it is next in value to the A. procerus. They are sold in the London markets indis- criminately. Agaricus rubescens, Pers.; Agaricuspustulatus, Schoepf. -A. rubes, of Fries ; summer and autumn ; woods ; N. C. to Pa. The cap of this is first convex, then almost flat, eight to ten centimetres in size, of an indistinct, reddish- tawny or vinous-red color, more highly colored in the cen- tre, not streaked or only a little so on the borders, covered with reddish-white scales. The leaves are large, numer- ous, straight, unequal, the shorter abruptly cut off, but rounded at their extremities, not decurrent, of a pure white. The stem is bulbous at the base, and nearly round the rest of its extent, is eight to twelve centimetres in length, generally hollow, of a vinous-red, darker at the lower part where some debris of the volva scarcely ex- ists, covered throughout its length by little excrescences {peluchures), provided with a large ring of the color of the stem, and often preserving the impress of the gills. The flesh is fragile, white, reddish under the skin. Smell strong, like that of mould, taste not pleasant; and according to Roques poisonous ; he at least cautions us against con- founding it with A. asper. Curtis says it is edible. Smith asserts that it is one of the most " valuable of all the Brit- ish agarics," care being taken to select young and fresh specimens. " I well know it to be delicious and perfectly wholesome." Cordier says, " C'est un manger des plus delicate," and largely consumed in parts of France. It is excellent in the preparation of ketchups. Cordier cites this with other edible fungi which are unpleasant, acid, or pungent, yet still edible, such as Fist, hepatica (which is acid). Ag. melleus and this plant are acrid and disagree- able, while Hydnum and Chantarelle are pungent-all es- culent. Agaricus melleus, Vahl.; Agaricus annularius, Bull, and Roques' Hist.-Honey-mushroom, black-scaled agaric ; " near or upon old stumps ; " September, October ; S. C. to Pa, (See colored Pl. XII., Fig. 7.) The stem is yellow- ish, slightly black at the base, bent upon itself, with an entire collar at the top ; the cap is yellowish-red, mixed sometimes with green ; convex with a prominent centre, marked with little brown scales, the border thin, feebly striated, odor agreeable, taste like that of A. campest ris, with a slight degree of acidity ; some have supposed it to be poisonous, perhaps only on account of its taste, not- withstanding Trattinick's assertion of its good qualities and frequent use in Austria. Orfila cites it among the poisonous species, and Roques says it has a disagreeable styptic taste, and that administered to animals it causes an inflammation of the alimentary canal and death. There must be some mistake by the above-mentioned authors in regard to species, as Curtis cites it among his edible spe- cies, and his personal experience is sufficient. Cordier says that its aspect and taste not being inviting, it is edi- ble, but not much sought after. Agaricus eburneus, Bull; D.C.-Ivory agaric; N. C.; Curtis cites Ag. eburneus of Fries as eatable. On ac- count of its humidity, this is placed in the tribe Hygropho- rus. It is ivory white, shining, very viscid in wet seasons. The cap is at first hemispherical, then flat, and some- times even concave, but always prominent in the cen- tre, fleshy, polished on the borders, which when young- are turned down ; the leaves are narrow, unequal, nu- merous, slightly prolonged upon the naked stem, which is full, round, and generally short, sometimes frail and lengthened, covered upon its summit with little scales or brownish asperities. Roques says that it is not disagree- able, and is eaten in Italy. Cordier places it among the edible species, with an agreeable odor and taste. He re- marks upon its viscidity as no evidence of its being hurt- ful. Agaricus Russula, Schoeff.-N. C.; edible, Curtis. The cap is fleshy, of good size, at first convex, then flat and even a little depressed in the centre, viscid, granular or covered with little hairy masses, brown, and scaly. The leaves are unequal, white, thin, rounded, sinuated, and are almost free. The stem is naked, generally cylindri- cal, short, of a red-rose color, full, having the summit granular and viscid. Roques cautions us against con- founding this, which has an agreeable taste, with the Ag. emeticus, the head of which is red, but has no scales. Cordier says it is eaten in Austria, and that it may be confounded with two poisonous Russules {Ag. emeticus and Ag. roseus), but these have their leaves of equal length, while those of our plant are unequal. Agaricus albellus,D. C. (von Schkeff), Bull.-N. C.; Curtis, edible. The cap is fleshy, compact, convex, sub- mammelonated, sometimes irregularly rounded, shining, at first white, then of a gray slightly tawny, often cov- ered with non-persistent, squamous spots, with borders thin, shining, and folded down. The leaves are numerous, unequal, white ; the longest adherent to the stem, and terminated by a little tooth. The stem is naked, white, fibrillar, full, slightly expanded at the base, and partly stuck in the earth. This is the Mouceron of the French -called so because it grows among mosses. This is eaten in the northern provinces of France, and is much sought after by some amateurs. Roques gives a number of modes of preparing them. Cordier ranks it among the most ex- quisite and everywhere appreciated. Paulet says it is the finest and most delicate of all; and Bose, " a delicious food which is beyond comparison." The flesh is white * The late Dr. Bull, of Hereford, carefully wrote out, from experience, the best modes of cooking A. procerus, and for the following methods fungologists are chiefly indebted to him. The modes are approved by the writer, and are adopted by the Woolhope and other clubs: Modes of Cooking Agaricus Pbocebus.-It may be cooked in any way, and is excellent in all. Broiled.-Remove the scales and stalks from the agarics, and broil lightly over a clear fire on both sides for a few minutes ; arrange them in a dish over fresh made, well-divided toast ; sprinkle with pepper and salt, and put a small piece of butter on each ; set before a brisk fire to melt the butter, and serve up quickly. If the cottager would toast his bacon over the broiled mushrooms, the butter would be saved. Baked.-Remove the scales and stalks from the agarics, and placethem in layers in a dish : put a little butter on each, and season with pepper and salt. Cover lightly, and bake for twenty minutes or half an hour, according to the number placed in the dish. Put them on hot toast in a hot dish. Pour the hot sauce on them, and serve up quickly. Stewed.-Remove the scales and stalks from the freshly gathered agarics, and stew them for twenty minutes in milk and water, which will be improved by a little good gravy ; then season with pepper and salt, and add a blade of mace if desired. Thicken the same with a spoonful of flour, a little cream, or the yolk of an egg. Boil for a few minutes, and serve up quickly in a hot, well-covered dish. Delicately Stewed.-Remove the stalks and scales from the young, half- grown agarics, and throw each one as you do so into a basin of fresh water slightly acidulated with the juice of a lemon or a little good vine- gar. When all are prepared, remove them from the water, and put them into a stewpan with a very small piece of fresh butter. Sprinkle with white pepper and salt, and add a little lemon-juice. Cover up closely, and stew for half an hour. Then add a spoonful of flour, with sufficient cream, or cream and milk, until the whole has the thickness of cream. Season to taste, and stew again gently until the agarics are perfectly ten- der. Remove all the butter from the surface, and serve in a hot dish, garnished with slices of lemon. A little mace, nutmeg, or ketchup may be added; but there are those who think the spice spoils the mushroom flavor. 274 Reference Handbook of THE Medical Sciences. PLATE XII. 4 3 'J 1 6 7 8 9 10 15 11 13 14 12 EDIBLE FUNGI. ( FROM ORIGINAL DRAWINGS MADE BY THE REV. CHARLES I. CURTIS OF NORTH CAROLINA.) H BENCH E, LITH. N. Y REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi. dier says it is eatable-the flesh being white, soft, of a fungous taste and very little odor. Agaricus cespitosus, M. A. C.-Cluster mushroom ; edi- ble, Curtis. Agaricus castus, M. A. C.-White dough mushroom, N. C., edible, Curtis. Agaricus frumentaceus.-Red dough mushroom, N. C.; edible, Curtis. Agaricus consociatus, M. A. C.-Yellow dough, N. C.; edible, Curtis. Agaricus radicatus.-Spindle- or tap-root fungus, N. C.; edible, Curtis. Mr. Curtis has been the first to declare that the five above are esculent agarics. Coprinus comatus, Fr.; Agaricus comatus.-Maned ag- aric, N. C.; stable-yards; edible, Curtis. It should be gathered when the gills are white and just changing to pink, for they become vinous and black, dissolving into a black matter. When gathered in rich pastures, it is of snowy whiteness, the top being somewhat fleshy and broken up into scaly, white hairy patches (peluches); there is a white, powdery, fragile movable ring around the hol- low stem, which is soon broken and falls away. Smith says that "it is singularly rich, tender and delicious," and he would prefer no species before this one. The black matter from this and from A. atramentarius is used in designing. To cook, for about twenty mushrooms, put into a saucepan one gill of milk or cream, add salt and pepper to the taste, with a piece of butter the size of the larger specimens ; when it boils, put in the stem and small hard mushrooms ; after ten minutes' boiling add the larger specimens ; keep the dish covered and boiling for ten minutes longer, then pour the stew over dry toast and serve. Very little fluid is needed in cooking this mushroom, as it yields a rich juice of its own. It should be cleaned before cooking, by scraping it smooth until it is white. (J. A. Palmer, Jr.) See also Ag. campestris and Ag. procerus for methods. Agaricus violaceous, L.-Woods; autumn; N. C. to Pa.; H. W. R. Fleshy, all over of an obscure violet; head at first convex, then flat, dry, hairy as if scaly, size eight to sixteen centimetres. The leaves distant, large, thick, unequal, almost of a violet-black when young, ad- herent to the stem which is cylindrical, more or less swol- len at the base, slightly downy, eight to ten centimetres in size, of an ashen-violet color in the interior. When young, a membrane, so fine as to resemble a spider's web, binds the borders of the cap to the stem. Roques and Cordier place it among the edible species; and Micheli says it is eaten in Tuscany. Agaricus deliciosus; Lactarius, Fr.-Orange milked agaric ; September to October; S. C. to Pa.; edible, Curtis. (See colored Plate XII., Fig, 15.) The stem of a yellow or slightly spotted color, five to six centi- metres long, is naked, firm, thick, at first full, then hollowT. The cap, fleshy, orbicular, eight to twelve centimetres in size, at first convex, then flat or de- pressed in the centre, with reflected borders, slightly vis- cid, at first yellowr, afterward tawny and even reddish, is marked sometimes by yellow zones. Lames unequal, of a brick or saffron red. The flesh and the gills when wounded take a sombre green color, odor and taste agree- able, like Cantharellus cibarius, but slightly acrid. Cor- dier says it is not greatly esteemed in France, but held in high esteem in Sweden, and preserved for winter use by the Germans. It may be confounded with Ag. torminosus and other poisonous ones, but is distinguished by its milky juice, of orange-red or saffron color. Agaricus alutaceus, Pers.; Agaricus pectinaceus, Bull. -Buffed gilled agaric ; common in woods ; July and Octo- ber; S. C.to Pa. (H. W. B.) Russula alutacea, Fr. (see Fig. 1370). It possesses a white flesh, fragile and agreeable to the taste; the cap, eight to ten centimetres in size, rounded, with borders rarely regular, flat in the centre or depressed ; of a violet-red, or a slightly tawny-red, even blood-red, more marked in the centre, the border thin, peeling easily, finally becoming striated and slightly downy ; the leaves straight, rather close, equal in length, not turned down, of a pale ochre or yellow-white color ; the stem four to and firm, peels with difficulty, but preserves its agreeable odor when dried. Agaricus niveus, Schaeff.-White field agaric. Roques cites it as eatable, and a fine mushroom. Curtis has Coprinus niveus, Fr. among his N. C. species, not cited as edible. Cordier does not refer to it. Agaricus Casarius, Scop. ; Amanita aurantiaca, Pers. Imperial Orange Agaric ; common in oak forests ; N. C.; Curtis. (See colored Plate XII. Figs. 3 & 5.) This is of a rich and elegant yellow color ; the cap is almost Hat, or- bicular, the borders being striated and often cut and turned under, never being viscid, or marked with holes ; the leaves (gills) are large, thick, unequal, yellowish, very adherent to the flesh, but not to the stem, which is yellow externally, white within, polished, full, bul- bous, provided with a yellow ring, large and reversed. When young it is wholly enclosed in a white volva, which gives it the appearance of an egg ; to give passage to the plant the volva tears and remains complete at the bottom of the stem. (See Fig. 1368.) Roques and Cor- dier regard it as the finest and most delicate of mush- rooms, the perfume and taste being exquisite. It was widely celebrated among the Greeks and Romans. Dr. Curtis praises it very highly in his letter to Mr. Berkeley. It should be carefully distinguished from the Amanita muscaria. (Sec Plate XIII. fig. 1.) The former has a complete volva, while in the latter it is incomplete and exhales a disagreeable odor. The poisonous species is spotted on the top, while this is of a yellow-orange color, without spots. Agaricus castaneus, Bull.; Cortinarius, Fr.-Common in woods ; S. C. to Pa. The cap of a chestnut or tawny color, ordinarily paler at the borders, is shining, little fleshy, convex, slightly mammelonated, often concave when old, by the falling of the borders which split. The leaves are unequal, large, adherent to the stem, same color as the cap, paler upon their cut surface. The stem is full, cylindrical, firm, of a white color, shaded with a violet- brown, and bearing the remains of a web collar which is white. It has the taste of a good mushroom, and is eaten in Italy. Curtis marks it edible. Cordier says it is in- odorous, agreeable and edible. Agaricus personatus, Fr.-Blue-stemmed agaric ; past- ures and near rotten logs; S. C. and N. C. ; edible, Curtis. The cap is compact, fleshy, regular, convex, glabrous, polished, moist, of a violet or lilac color, some- times ashen or pale tawny, with borders slightly re- curved under, and tomentose. The lames (gills) are close together, of a dull white, or faded violet color, rounded back and free. The stem is thick, pulverulent, or hairy, lilac or violet, slightly swollen at base and hollow. It resembles the Cortinaires. Sold in Covent Garden Market under the name of Blewits (Sowerby). W. G. Smith says of this "a substantial and delicious species;" but the plants should be gathered young and in dry weather for they readily absorb moisture. Cordier reports that it is much esteemed in France. Agaricus amygdalinus, M. A. C.-Peach-kernel agaric, N. C.; edible, Curtis. Agaricus mastoideus, Fr.-Nut mushroom ; woods ; N. C.; edible, Curtis. (See colored Plate XII., Figs. 2 and 4.) The cap is a skin white color, slightly fleshy, soft, convex, strongly mam±elated, thin skinned, tearing into scales which are thin and scattered ; the leaves are widely separated, of a pale white ; the stem hollow, weak, slightly villous, scaly, almost round, bulbous at base, with an entire movable ring. Cordier says: "Eatable, but little es- teemed." Agaricus excoriatus, Fr.-Collar mushroom, N. C.; edi- ble, Curtis. This closely resembles A. procerus, only that it is smaller, with a stem shorter and rarely bulbous. The cap is large, five to six centimetres, at first convex, then flat, but prominent at the centre, of a tawny-ashen color. The epidermis is thin and raised into little scales. The leaves, of a pale white, very numerous, thin, une- qual, large, salient, sometimes divided and not attached to the stem. The stem is round, sometimes bulbous at the base, hollow, smooth, polished, white, or of the color of the cap ; it has a large, movable, persistent ring. Cor- 275 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seven centimetres long, polished, full or spongy, white, oftener stained of a pale red. Taste mild, pleasant, acrid when old. " By common consent pronounced esculent; but individual specimens occur which prove almost as acrid as A. emeticus," (" Crypt, of England "). The edible can easily be distinguished by the possession of gills which are always white, while the poisonous have them yellow. (Roques.) (See our Report to Am. Med. Assoc., vol. vii., for fuller details.) Curtis cites A. alutaceus, of Fries, as edible. Cordier includes it among the esculent fungi, and very much sought after in Lorraine. Agaricus marasmius ; A. oreades, Fr.-Fairy ringed ag- aric ; false mousseron, Scotch bonnets. Hill-sides ; N. C.; Schw. This does not resemble the true " mousseron," ex- cept by its color of a pale yellow, tending to red. The stem is naked, round, full, four to five centimetres long, not hairy at its base, weak, tenacious and bent when dry. The cap, at first hemispheric, then conical, and sometimes flat, often mammelated in the centre, little fleshy, is only about three to four centimetres in size. Leaves unequal, not numerous, of a pale white, more colored upon the side (la tranche), not adherent to the stem. It has a feeble odor and an agreeable taste ; much used as an article of food on the Continent. W. G. Smith says of it: " One of the most exquisitely delicious of all our fungi, is often neglected." Mr. Berkeley says "It is the very best of all our fungi." It may be pickled, used for ketchup, or dried for future use. It may be distinguished by having no downy hairs at the base of the stem; other species are dangerous which possess this hairy down (Smith). To broil: Place the tops like oysters on a fine wire gridiron ; as soon as they are hot, butter them lightly, and salt and pepper to the taste. Put them back over the coals, and ■when heated through they are cooked. Butter them, if required, and place in a hot dish (J. A. Palmer, Jr.). When they are dried, swell them in water before using. Agaricus scoradoneus, Fr.-Small garlic agaric ; past- ures ; N. C.; (Schw.) eatable, Curtis. The head is some- what fleshy, thin, convex or flat, at first shining, then slightly rough, or in folds, about one to two and a half centimetres in size, color pale-red or earthy. The lamel- lae (plates) are contracted, whitish, a little separated, ad- herent to the stem-which is hollow, round, about two to three centimetres in length, two millimetres in thickness, glabrous, shining, reddish, becoming brown with age. Persone and Trattinick cited it among the edible mush- rooms. Cordier says it is eatable, and of frequent use in the Lusace as a seasoning; it exhales a strong odor of garlic. Agaricus esculentus, Jacq.-Small esculent agaric; N. C. to Pa.; edible, Curtis. The cap is scarcely three centimetres in size, a little fleshy, almost fiat, obtzise, smooth, not streaked, of a tawny or yellow earthy color, taste slightly bitter ; lames white, rather close, supple, ad- herent to the stem, about five to eight centimetres long, hollow, slight, very glabrous, tenacious, strongly fixed to the ground, same color with the cap. Much eaten in Austria, though taste is bitter. It is dried and preserved. Cordier says that it is sold in the markets in Vienna. Agaricus frumentaceus, Bull.-Red dough mushroom; woods; N. C.; eatable, Curtis. Roques placed it among the eatable species. It exhales an odor like the farina of grain. Agaricus prunulus, Scop.-French or plum mush- room, Mousseron ; woods and pastures, June, October ; Curtis, edible. Recognized thus: Cap fleshy, thick, compact, at first convex, regular, then depressed with twisted borders, top dry and of a fine prune color, five to eight centimetres in size ; lames numerous, narrow, linear, of a white which becomes feebly cherry-rose when growing old, pointed at both extremities, very decur- rent, not close ; stem two to three centimetres high, thick, striated, naked, swollen and hairy at the base, the color of the cap. It differs from A. albellus by the lames, which are slightly rosy, decurrent, and terminated by a point at the two extremities. It has a firm white flesh, and a delicious taste and odor -like that of fresh meal ; much esteemed in Europe as an article of food. It is dried and much used in France-a large price being paid for those growing near Bareges. Cordier ranks this among the best of mushrooms : " Est tres bond manger." The flesh is firm, juicy, and full of flavor ; and whether broiled, stewed, or however prepared, it is a most delicious morsel (W. G. Smith). Agaricus nebularis, Batsch. - Gray agaric ; damp woods ; N. C.; edible, Curtis. This fleshy mushroom has a cap eight to ten centimetres in size, convex at first, then flat, rarely regular, with its centre almost always prominent, of an ashen-gray color, darker in the centre, the borders being thin, slightly curved downward, the top sub-farinaceous in young individuals, polished later. The leaves are slightly decurrent, and of a pale white, unequal, numerous, thin, narrow, sharp at the two ex- tremities, upon a stem four to six or eight centimetres in length, white or grayish, a little thick, round, some- times twisted, full or cottony (floconneux), substriated lengthwise, tomentose at the base. The flesh is white, compact, with a fungous odor and a special taste. When cooked, the firm and fragrant flesh has a particularly agreeable and palatable taste (W. G. Smith). Cordier, who has eaten young plants and suf- fered therefrom, also another who ate of the same, ex- presses great doubts of its esculent qualities, notwith- standing the favorable testimony of others. Il est mal- faisant." Agaricus squarrosus, Mull.-Found on oak-stumps, in autumn ; N. C.; Curtis, edible. The cap is six to eight centimetres in size, of a clear tawny color, covered, as is the stem, with numerous scales, which are arranged from the circumference to the centre of the cap, a little darker in color toward the centre of the cap, which is at first rounded, circular, then flattened, with borders slightly turned down. The lames are of a pale white, bent, unequal, straight, numerous, reaching the stem, but not decurrent, finely touched with white on their sides. The stem, six to ten centimetres long, is round, twisted, attenuated at the base, full or hollow, with a fixed ring on the upper part, scaly below the ring, not above. Cordier says he has often eaten it; that the flesh is flrm, of a yellowish white, a feeble odor, with a fungous but agreeable taste. It peels with difficulty. Agaricus strobiliformis, Vitt. - Fir-cone mushroom; common in woods of N. C.; Curtis, edible. Entirely white and of large size ; the head is fleshy, at first con- vex, then level, the surface like satin, the margin not striated, full of scales, or angular excrescences, strongly adherent, gray, formed of the debris of the volva which is torn early and leaves only traces of itself at the base of the stem. The lames are unequal, the shortest rounded at their extremities, the longest free. The foot is thick, solid, cottony, when young with a fugitive ring, swollen into a bulb at its base, where it is marked by a circular furrow. The solid compact flesh, fine ring, bulbous stem and patched top mark this species. The patches on the top are persistent and like the scales of a fir-cone. Smith says its esculent qualities are of a high order and regrets that it is scarce. Cordier remarks upon its rarity, its slight odor, and agreeable sharpish taste, and places it among the edible species. Agaricus bombycinus, Schoeff.-Silky wrappered agar- ic ; inside of trees, on stumps ; S. C. and N. C.; edible, Curtis. Agaricus ulmarius, Sow.-Dead trunks of ash and poplar ; N. C. to Pa.; edible, Curtis. Cordier describes A. ulmarius of Bull. The stem is round, always bent so as to keep the head horizontal, naked, of a dirty white or gray color, sub-tomentose, six to nine centimetres long, fleshy, full, firm, continuous with the flesh of the cap in which it is inserted rather laterally. This head is fleshy, compact, glabrous, and can reach fifty centimetres in diameter, but oftener from twelve to eigh- teen ; it is somewhat rounded, of a pale or gray white, but often marked with rounded spots, which are darker-col- ored. The lames are numerous, large, unequal, cut out (echancrees) at their base, adherent to the stem, at first whitish, then a dirty yellow. Rarely attacked by worms. Cordier says it possesses a firm flesh, of an agreeable taste and odor, that peels with difficulty and is edible. 276 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi, Agaricus tessellatus, Bull.-Pine trunks ; N. C.; Cur- tis, edible. The cap is fleshy, flat-convex, glabrous, rounded when young, more developed on one side than on the other when older. In these it resembles A. ulmarius; it dif- fers in the cap being smaller, tawny yellow, or iron color, with spots or marks of a clearer yellow; almost hexagonal. The lames, white or yellowish white, large, unequal, close together, adherent to the stem, are cut at their base. The stem, from six to eight centimetres, is white, naked, full, fleshy, round, slightly eccentric, is always bent back so as to keep the head horizontal. Cordier says that the flesh, though rather coriaceous, is not disagreeable, like that of fresh flour, and can be eaten. Agaricus glandulosus, Bull.-Carolina to Pa.; Curtis, edible. Flesh firm and white, and of an agreeable odor and taste (Roques). Cordier includes this as a variety of A. ■ostreatus, Jacq. Agaricus ostreatus, Jacq.-Carolina to Pa.; dead trunks; edible, Curtis. It grows in tufts, often imbricated. The head is fleshy, polished, subdivided, in form of a conque, at first blackish, then yellow-ashen, and finally pale, about six to nine centi- metres or more in size, with borders bent downward ; the lames decurrent, straight, unequal in length, of a pale white, not close, anastomosing at base, loaded with glandu- lar expansions (houppes) in variety A.; the smallest num- ber of these leaves reach the stem, which is lateral, short, thin at the base. Grows in large masses on trunks and trees; gills and spores white ; flesh white and of good taste. W. G. Smith does not give it a high rank among the esculent mushrooms, but it has been much recommended by others. ' ' A dish of this species stewed before a very hot fire' has proved as enjoyable and nourishing as half a pound of fresh meat." Cordier says the taste is not disa- greeble, and it is generally eaten in the Vosges. Agaricus tigrinus, Bull.-S. Carolina (H. W. R.); not in Curtis' catalogue. Agreeable taste and odor, eaten in Europe (Roques). Cordier also says that it possesses a firm flesh and is agreeable and edible. The cap is marked with little excrescences or scales which are brown or grayish- yellow. It is always umbilicated. Agaricus infundibuliformis, Schoeff.-Autumn ; S. C. (H. W. R.); not cited by Curtis as edible. Has a strong odor, but agreeable, and may be eaten (Roques). Cor- dier says the taste is astringent, but that it has a pleasant flavor and is edible. It is sub-coriaceous, the cap a pale yellow, approaching cinnamon, slightly prominent in the centre, hollowed in cup form ; lames a pale white, decur- rent, upon a stem naked and swollen at the base. Agaricus odorus, Bull.-N. C. (Schw.) Curtis, edible. Odor penetrating, but agreeable. Cap slightly Heshy, four to eight centimetres in size, glabrous, not viscid, of a clear gray-blue, or dull, bluish green, at first convex, then flat, but lightly mammelated in the centre, with the bor- ders sub-sinuated and sometimes even raised. The lames, a third of which reach the stem, are attached (adnes), sub- decurrent, not close, of a pale white very slightly rose- color. The stem is weak, round, full, naked, three to five centimetres in length, of the color of the cap, but fainter. It exhales an odor like anise-seed. Cordier says its taste is agreeable, and it can be employed as a condi- ment. It is suspected by Reviel. Agaricus cuneifolius, Fr.-N. C. Roques says it has a sweet taste and the smell of farina; and is eaten either fresh or dried. Not on Curtis' list as edible. Agaricus campestris, L.-Common meadow, or pink gill mushroom, Boule de neige ; pasturesand meadows ; S. C. to Pa. and Ohio. (See Plate XII. Figs. 10-12). These are known by their pink gills, which become deep-brown, not reaching the stem, which is round and sometimes swollen at the base, and which carries a well-marked white, persist- ent ring. It is so well known that only a few character- istics may be mentioned. The cap is fleshy, flat-convex, of a reddish or brown bistre color, sometimes yellowish, or even entirely white ; the surface dry, slightly scaly or hairy (peluchee), rarely polished. The flesh is firm, thick, white, more or less stained with reddish-brown, especially when bruised ; gills very unequal, at first of a beautiful pink ; the edge white and minutely denticulate. Cows, sheep, squirrels, and birds eat raw mushrooms and other fungi. " The most generally used of all the agarics and the safest." It is extensively cultivated. It was cultivated among the Romans with particular care, and alluded to by Horace and others. "It is excellent whether boiled, pickled, stewed, fried, or prepared in any other way " (Smith). M. Roques advises us to avoid those which have at- tained their full development, and Berkeley (" Crypt, of England ") uses these words : " Too much caution cannot be used in the eating of dark-gilled agarics." According to Vauquelin's analysis it consists of adipo- cire, albumen, a sugary matter, osmazome, an animal sub- stance, insoluble in alcohol, fungin, and the acetate of potash. We should not confound this with the poisonous Ag. bulbosus and Ag. pantherinus, which always have white gills and possess a volva. To Prepare for the Table.-Cut them just below the cap, don't pull them, they then need no washing or peeling. Stew in milk or cream. To Serve with Meat.-Chop the mushrooms fine, let them simmer ten minutes in one-half gill of water, with butter, salt, and pepper as for oyster-sauce, thicken with flour or ground rice, pour over the meat and cover quickly. 7b Boast in the Oven.-Cut the larger specimens into fine pieces, and place them in a small dish, with salt, pepper, and butter to taste ; put in about two tablespoon- fuls of water, then fill the dish with the half-open speci- mens and the buttons ; cover tightly and place in the oven, which must not be overheated, for about twenty minutes. The juice of the larger mushrooms will keep them moist, and, if fresh, yield further a most abundant gravy (I. A. Palmer, Jr.). Agaricus arvensis, Schaeff. - Common horse-mush- room; diffused ; pastures. Cordier says it is with difficulty distinguished from the A. campestris. It is snowy-white when young. The cap fleshy, at first convex, then a little flattened, eight to ten centimetres in size, the surface at first tomentose or farinaceous, afterward glabrous and dry. The gills, free, unequal, larger toward the circum- ference, of a tender rose or lilac color, becoming a violet black. The stem, firm, hollow, or spongy, eight to ten centimetres high, is white, provided with a collar which is very large, turning over, generally double, and of which the exterior is sometimes cut into rays. It is distin- guished from the A. campestris by its purer white, paler gills, white flesh which does not change color when cut, the lamellae remaining pale and not becoming deliquescent by age. It has an agreeable odor, and is perhaps less delicate than the A. campestris, but it should be much more ex- tensively employed as an article of food. W. G. Smith says it is the species exposed for sale in Covent Garden market. He says that the gills have not the pure pink of the meadow-mushroom, "but are dirty and brownish." For cooking, see A. campestris. Agaricus cespitosus, M. A. C.-Common ; base of stumps; N. C.; edible, Curtis. This is closely related to A. deal-batus, which is highly praised by Smith as a del- icacy of the first degree. Agaricus fabaceus, Berk.-S. C. Mr. Ravenel informs us that it is an alliaceous, edible mushroom. Not found in Curtis' catalogue. , Agaricusatramentarius, Bull.-Inky agaric ; fieldsand gardens ; spring and autumn ; edible, Curtis. The cap is yellowish or pale tawny; marked on the summit by little reddish or brown stains ; the stem is white, smooth, hollow, small above where it preserves a circular mark, the vestige of a ring. It contains a black matter which may be used as ink. The juice will efface writing made with ordinary ink. Cordier says that this and coprins generally are eatable when young. The larger species only are sought after. In England they serve to prepare ketchup. 277 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Agaricus cretaceus, Fr.-Common ; earth and wood ; N. C.; Curtis, edible. This is chalk-white when young and of middle height. The head is convex, flat, fleshy, generally polished, at other times, hollowed out or sub-^caly, slightly tawny at the summit in the old ; it is eight to nine centimetres in diameter; the leaves are numerous, unequal, straight, large at the circumference, not ad- herent to the stem ; they even slightly separate from it; white at first; they become colored later to a feeble red flesh-tint. The stem is round, slightly swollen at base, oftener hollow, five to eight centimetres high, sometimes twisted, white, with a horizontal ring, large. At first view it w'ould be taken for a Lepiota on account of its white leaflets ; but later they become flesh-colored and pass to a tawny hue when the mushroom is decomposed. Cordier says it is eatable and of excellent quality ; its odor is feeble, its taste agreeable; the epidermis suf- ficiently thick is easily detached from the cap. Palmer advises that it be cooked with other mushrooms, with the addition of spices, garlic, or sauces. Agaricus pratensis, Pers.-Reddish field agaric; past- ures ; Curtis, edible. Of a reddish tawny color, some- times ashen or whitish ; the head fleshy, at first convex, then flattened, with the centre prominent, smooth, humid, the borders thin; leaves very few, bent, unequal, thick, distant, of the color of the head, or whitish, very decur- rent, upon a stem short, full, whitish, shining, attenuated at base. Cordier says the flesh is slightly coriaceous, with an agreeable flavor whjch resembles the melon. W. G. Smith refers in strong terms to the excellency and piquancy of flavor of this species. Mrs. Hussey and Berkeley all say it is edible. Agaricus salignus, Pers.-Stump-mushroom ; common on trunks and stumps ; Curtis, N. C. This is a large mushroom, the head being six to eight inches in dia- meter, subimbricated, fleshy, divided or dilated into a fan-shape, convex, flat, smooth, polished, fissured, of a walnut or cafe au lait color, depressed at the base; the leaves, sufficiently close, are thin, large, of unequal length, white or shaded, of the color of the cap, not glandular, sharp at the two extremities, rather branching, eroded, decurrent. The stem is short, white, downy, full, firm. It resembles the oyster agaric. Dr. Curtis, in a letter, quoted by Dr. Wood in his sketch of Curtis, writes as follows: "Indeed,! have found several persons who class this among the most palatable species. To such persons, a dish of fresh mushrooms need seldom be wanting, as this one can be had every month of the year in this latitude." It is better flavored when gathered from the mulberry and the hickory ; and those of rapid growth are best. Cordier says that when young it is a delicate food and much prized ; when old it becomes black and coriaceous. Cortinarius violaceus. - Purple cobweb-mushroom ; woods; N. C. ; Curtis. When young it looks like a bright purple silk ball in the grass ; there is always a cottony web which represents the ring, and which is colored by the red spores. " Broiled with a steak, this is a most exquisitely rich luxury" (Smith). Lactarius subdulcis, Fr.-Common; N. C. ; eatable, Curtis. The juice is white, milky, at first pleasant, then slightly acrid ; the flesh, which is reddish, does not change color ; the cap fleshy, about two to five inches in size, moderately thick, at first convex, then depressed in the centre, and remaining sub-mammelonated, polished, with- out zones, dry outside, of a reddish tawny color; the leaves are numerous, fragile, unequal, narrow, of a cherry-rose, or reddish color, sub-decurrent; the stem, full at first, then hollow, cylindrical, one to three inches long, slightly thick, of the same color as the head. * ' I have eaten this several times, and was not incom- moded, therefore it is esculent " (Cordier). Lactarius piperatus, Fr.; Agaricus acris, Bull.-Pepper agaric; woods ; July, August; S. C. to Pa.; common ; edible, Curtis. It is wholly white, with a head four to six inches in size, at first convex, then flat, and finally concave, or funnel-shaped, smooth (glabrous), but sometimes farinaceous, not zoned, the borders being undulated and curved under; the leaves very numerous, narrow, close together, unequal, sometimes bifid, white, but assuming a yellowish tint upon growing old, slightly decurrent, upon a stem naked, thick, round, fleshy, full, which never attains more than three to four centimetres in height. Flesh compact, flrm, juice white, milky, ex- cessively acrid (Cordier). Its color is sometimes white as snow, " at others it inclines a little to cream with a white milk which is unchangeable.'' Though acrid when raw, it loses its bad qualities by cooking ; extensively used in Eurppe prepared in various ways. It is preserved for winter use by drying or pick- ling in a mixture of salt and vinegar. W. G. Smith ac- tually places this in his chart among the poisonous species. Cordier says that it is eaten in many countries, especially in Russia. Cows eat it with avidity, but it makes their milk and butter nauseous. This agaric contains a gelat- inous principle, and a milky fluid which becomes con- crete and dissolves in alcohol; the resulting tincture is of a golden color, and furnishes albumen, adipocere, crystals of sugar and acetate of potash. Lactarius deliciosus.-Green tint or orange-green mush- room ; pine woods ; N. C.; edible, Curtis. (See Plate XII. Fig. 15.) It is at once known by the orange-colored milk which it exudes on being bruised, which soon be- comes dull green. The plant is solid, and the top richly colored. " When cooked with taste and care, it is one of the greatest delicacies of the vegetable kingdom " (W. G. Smith). Lactarius volemus, Fr. - Milk red, milky agaric; ■woods, July ; common ; eatable, Curtis. W. G. Smith says that its taste, when fried, has been aptly compared to lamb's kidney, and it resembles in flavor L. delicio- sus. The species is recognized by its rich coloration, mild taste, white milk (changing to a dull dark when plant is bruised), white gills becoming of a yellow buff, and the full sienna top (Smith). Cordier says of Ag. volemus that he eats it raw in the woods, and like A. procerus and Clavaria coralloides, they can be eaten without preparation or addition. Russula alutacea, Fr.-Yellow-gilled mushroom ; com- mon ; woods ; N. C. ; Curtis, edible. The flesh is white, friable, pleasant to the taste, the cap eight to ten centi- metres in size, rounded, the borders rarely regular, flat in the centre or depressed, of a violet red, or slightly tawny red, even blood-red color, darker in the middle, the borders thin, peeling easily, finally becoming striated, or sub-downy; the lames straight, not close, equal in length, not decurrent, of a pale ochre color, or yellowish- white ; the stem long, four to seven centimetres, polished, full or spongy, white, oftener shaded of a. pale red. The surface of the flesh is often reddish when the epidermis is peeled off. The gills distinguish it from the emetic mush- room R. emeticus, which are pure white and always re- main so. Cordier says it is edible and very much sought after ; and Smith declares that when well prepared few species prove more satisfactory. Russula lepida, Fr.-Low pine woods, N. C.; edible, Curtis. The cap is eight to ten centimetres in size, of a violet red (cherry red), or slightly tawny, paler at the cir- cumference, fleshy, compact, convex at first, then flat, and depressed in the centre, sub-pulverulent, not shining, not polished, a little or not striated at the margins, cracking when dried ; the leaflets are large, thick, straight, not very close together, dull white or feebly yellow color, rounded and larger at the circumference, equal some of them, sometimes bifurcated ; the stem, six to eight centimetres, full or with holes, solid, compact, often twisted, round or a little swollen at the top, white, and almost always with a tint of rose or of red. Cordier says it is eatable, excellent and of a sweet taste ; odor feeble, flesh white and friable, spongy, when the pel- licle is peeled from the cap ; the flesh has a reddish tint. Insects and worms live upon it. Agaricus ruber, which is poisonous, closely resembles R. lepida ; but the former is distinguished by its cap, dry, polished, shining. Russula virescens, Fr.-Woods ; N. C. ; edible, Curtis. 278 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi. The cap is first convex and regular, then slightly concave and irregularly rounded, eight to ten centimetres in size, of a verdigris, or eye-green (vert d'anllet) color, more pro- nounced in the centre, the surface always dry, covered with little roughnesses or greenish granulations, sometimes marked with colored circles; the lames straight, free, of quite a pure white, not close, sometimes anastomosing, al- most reaching the stem, but not decurrent; the stem rarely straight, four to six centimetres, quite thick, round or slightly swollen at the base, full, white. Cordier says of this agaric, " est un manger delicieux ; " its perfume is agreeable, taste delicate, flesh white, fra- gile, the epidermis being with difficulty detached from the centre of the cap. Canthardlus cibarius, Fr.-Chantarelle, common in woods, summer and autumn, Carolina to Pennsylvania. (See Plate XII. Figs. 9 and 11.) Of a yellow chamois color, more or less dark. The stem is naked, full, fleshy, glabrous, ten to twelve millimetres thick which expands into a cap, always glabrous, at first rounded and convex, then twisted, sometimes lobed, hollowed like a vase, almost always more prolonged on one side than the other, and of which the under surface is covered by veins or bi- furcated folds, thick and separated which extend down upon the stem. " Its smell," says Berkeley, " is like that of ripe apri- cots." The flesh is white and milky, and of a piquant, but agreeable taste. Cordier says it is an excellent mush- room, and a main article of food in many districts of Europe-though dangerous when eaten raw. It is more tough and less highly flavored than some other mush- rooms. It is put up in jars for winter use. W. G. Smith advises that being big and solid, it should be cut up before using, and if stewed, allowed to simmer gently, and be served with pepper, salt and butter. Boletus granulatus, L., Fr.-S. C. to Pa.; H. W. Ra- venel. Pine lands ; edible, Curtis. This closely resembles B. luteus, and differs only by the absence of a membranous ring. The cap is eight to ten centimetres in size, at first hemispherical, then flat, slightly undulating, tawny, or brown, little fleshy, surface covered with a viscid matter, especially in young individuals. The tubes are narrow, short, granular at their orifice, at first of a pale white, then brownish-yellow, are adherent or slightly decurrent upon a stem round, sometimes attenuated above, short, yellowish, the summit covered with granulations. They often assume the form of a 'circle ; hence Persoon calls it circinans. Eatable according to Persoon and Withering. Reveil considered it suspicious, but Cordier ate it with impunity. Boletus collinitus, Fr.-Pine bolete ; N. C.; edible, Cur- tis. Cordier places it among the edible boletes. I. A. Palmer, Jr., remarks that all lurid boleti should be avoided, i.e., those with the slightest shade of red to the tubes-though he has eaten such. (See Plate XIII. Fig. 2) "The mild colored members, having white, yellow, or greenish tubes if pleasant to the taste, may be consid- ered safe." Boletus scabes, Bull.-S. C. to Pa. ; edible, Curtis. Roques also said that it was safely eatable when young, even in large quantity. Boletus hepaticus, Schoeff ; Fistulina hepatica, Witt- Beef's tongue ; stumps, common in woods ; F. hepat. of Fr., S. C. to Pa., H. W. R.; edible, Curtis. (See Plate XII. Figs. 6 and 8.) Roques says highly prized in Europe as an article of food. (See our Report, vol. vii., "Trans. Am. Med. Assoc.") It is filled with a blood-colored fluid, and tastes like a muskmelon. It is truly, states Smith, a " vegetable beefsteak" for the taste resembles meat in a remarkable manner. He advises that it be cut up in thin slices, broiled with a steak and dressed with butter, salt and pepper. Its acid taste gives a zest and piquancy to the dish. Boletus subtomentosus, L.-Woods,summer and autumn; S. C. to Pa.; edible, Curtis. This varies much in form, color, and dimensions. Its stem, weak, twelve to fourteen centimetres long, generally twisted, oftener round, nar- rowed, at other times swollen at the base; striated, re- ticulated, or punctated at the upper portion, color yellow, often streaked with red, supporting a cap which is or- bicular, convex-flat; sub-tomentose, reddish-brown, olive- brown, or bronzed, with a diameter of eight or twelve centimetres, subject as it ages to be hollowed out in areas, of which the interstices are a yellowish color. The tubes are yellow inclining to green, irregular, large, lengthened out; those which rise near to the stem are shorter, leav- ing a sort of vacant space around the stem. The taste is not unpleasant, eaten in Germany, though Roques considers it hazardous ; young specimens safer. Cordier says that its flesh is fragile, soft, yellowish-white, rather changeable, turning bluish upon fracture, of a special taste, agreeable odor and edible. Boletus bovinus, L.-Woods ; common ; N. C. to Pa. ; Curtis, edible. It grows in tufts in pine forests, the flesh is white, the taste not acrid ; the cap flat, undulated, viscid in wet weather, glabrous and brilliant in dry ; red iron color, five to eight centimetres in size ; the tubes are sub-decurrent, angular, somewhat irregular, quite large, of a red iron gray ; the stem round, shining, of one color, somewhat twisted, without a collar, three to four centi- metres long, somewhat thick. This species is very simi- lar to B. luridus which is poisonous. Cordier says that it is eaten in England. Boletus luteus, L.-Pine woods, N. C. It is distin- guished from most of its congeners quite readily by the presence of a membranous ring, which often disappears quite early, and which is on a stem three to five centi- metres long, slightly thick, cylindric, full, yellowish, punctated with granulations above the ring. The cap is convex, of a tawny yellow, or tawny brownish, some- times stained with reddish lines, eight to ten centimetres in size, covered in wret seasons by a viscid matter; the tubes are small, round, sometimes sub-decurrent, of a dark yellow. It resembles B. granulatus, but the latter has no membranous ring. Curtis classes it among his edible species, though De Cand. forbids its use-in which Roques coincides. Letel- lier says it is indigestible ; he gave one hundred and fifty grammes to a cat, which caused vomiting. Lenz affirms that it is largely consumed in Bohemia, and Cordier adds, " Je Vai mange, et Vai trouve bon." Boletus castaneus.-N. C.; Curtis, edible. This is en- tirely of a chestnut or brown-red color, with the excep- tion of the tubes which are first milk-white, then yellow- ish, and the borders of the cap which are sometimes yellowish. The cap is at first convex, then nearly flat, five to seven centimetres in size, with a velvety look. The tubes are short, the orifice of small size. The stem soft, spongy, then hollow, cylindrical, often swollen and fis- sured at the base, rarely straight. Cordier says that the flesh is soft, like cotton, of an agreeable taste, does not change color, and is edible. Boletus edulis, Bull.-Esculent bolete, ceps ; woods and pastures, under oaks, summer and autumn ; Carolina to Pa.; II. W. R. It rises to a height of fifteen to twenty centimetres. The stem is thick, full, cylindric, some- times swollen at the base, and then shorter, whitish, yel- low or clear tawny, reticulated. The cap is thick, convex, glabrous, moist in wet weather, fifteen centimetres and more in size, of a dull yellow, brown, reddish or ashen- brown, or even whitish, with tubes lengthened, small, at first white, then of a pale or greenish-yellow. The flesh is thick, of a white or yellowish color, sometimes with a wine tint under the skin, not changing when the plant is broken. The taste is agreeable; no smell. This plant was well known among the Romans ; is one of the most valu- able articles of food, much eaten in Europe, and un- deservedly neglected in this country, as it abounds in sea- sons when others are scarce. It resembles closely in taste the common mushroom, and is quite as delicate. Roques, W. G. Smith, and authors generally, give full directions for its preparation. " Whether boiled, stewed with salt, pepper and butter, fried or roasted with onions and but- ter, this species proves itself one of the most delicious and tender objects of food ever submitted to the operation of cooking" (Smith). Cordier says it can be eaten raw, and is of frequent use as a food and as a seasoning in the 279 Fungi. Fungi. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. south of France. Dr. Thore advised that this species be cultivated like the meadow agaric : An oak wood is wa- tered with water in which a large quantity of this species is boiled; taking care to keep out horses, hogs, and horned animals, which are fond of this fungus. Polyporus suaveolens, L.-Sweet-scented polyporus; New York (H. W. Ravenel). It is an oak fungus, rather soft, downy, at first snow-white changing to a bistre tint, and zoned, with the cap convex, sessile, attached laterally ; it can reach as high as thirty to forty centi- metres in diameter and three to five in thickness. The pores are lengthened, large, irregular, rounded, some- times unequally'prominent, at first white, then of a white slightly reddish color. The flesh is white. Roques regarded it as of great value as an article of food. A powder with honey has been much used against excessive sweating in phthisis. The odor is like vanilla and anise, and Cordier says that it is sufficiently persist- ent and delicious to be used as a perfume. Polyporus sulphurous, Bull.-Sulphur-colored polypo- rus ; on trunks of trees; common in summer; 8. C. to Pa.; Curtis, edible. The top is of a yellow citron inclined to reddish, under surface sulphur-yellow, chamois color when growing old, glabrous, undulated, irregular sessile, attached by its side; it may reach thirty to forty centi- metres in size. The pores, very short, with orifices ex- tremely small and difficult to be seen, emitting at maturity a very abundant, white seminal powder. It is sometimes imbricated and forms tufts. The flesh is yellowish, slightly raw and acrid to the taste. It becomes friable and discolored when old. It is employed to stain in yellow. Paulet ate it with- out inconvenience and found it good. It soon becomes too leathery. Cordier says a specimen was found perfectly luminous on an old oak in the Bois de Boulogne. Polyporus frondosus, Fr.-Turnip polypore ; on roots of oaks ; September and October ; 8. C. to Pa.; II. W. R. (See Plate XII. Fig. 13.) This enormous mushroom is formed by the reunion of a large number of heads, im- bricated, divided, from four to six centimetres in size, lobed, reddish, slightly fissured or tuberculous on the upper surface, of a grayish brown. The pores are very minute, irregular, whitish, same as the trunk from which springs the cap. " Smell like that of wine, esculent." The flesh is nearly white. It sometimes attains a weight of thirty pounds or more ; and Woodward found a mass two feet broad. Its good qualities have been much lauded. Curtis does not cite it as edible ; but Cordier says that the flesh though coriaceous has an agreeable taste and odor, and that the people in the country regard it as a happy acci- dent to encounter it, for one suffices as a repast for a nu- merous family. Polyporus giganteus, Pers.-Giant polyporus ; on logs ; October to January ; Curtis, edible. Attains an extraor- dinary size. Should be cooked a long time. Cordier makes little mention of it. Polyporus ovinus, Schoeff.-N. C.; Curtis, edible. This is fleshy, compact, but fragile. The cap is of a pale white, oftener irregular, sometimes covered with little scales, cracks in dry seasons. Stem short, unequal, white. Pores small, round, equal, of a citron white. It grows among pines and is of medium size, variable iu form and color, and at a distance would be taken for an agaric. These are eaten in Germany (Roques). Cordier says it possesses an agreeable, almond odor ; and that Fries and his companions, in their mycological excursions, ate it even raw. Polyporus confluero, Pers. -Lobster polypore ; N. C.; edible, Curtis. Not cited by Cordier. Polyporus poripes, Fr.-Nut polypore; N. C.; edible, Curtis. Not cited by Cordier. Polyporus Berkeleyi, Fr.-Pepper polypore ; N. C. ; Curtis. In his letter to Berkeley (published in the Mono- graph by Dr. Th. F. Wood, of North Carolina, on Mr. Curtis) the edible qualities of this species is referred to. No reference by Cordier. Hydnum imbricatum, L.-Scaly hydnum; barbe de bouc ; N. C.; edible, Curtis. Cap fleshy, at first rounded and convex, then flat and sub-umbilicated, often difform, eight to ten centimetres large, dark earth color, covered with thick scales upright, cottony, spines polished, decur- rent, of an ashen white ; stein, short and polished. Cor- dier says the flesh is firm, pale white and edible. Hydnum coralloides, Fr.-Moss mushroom ; N. C.; ed- ible, Curtis. Sessile on old trunks of living trees, at first white, then yellowish, resembling when young the chou- fleur. From its base, which is tender and fleshy, spring a large number of flexible branches, interlaced, and as- sembled in tufts, bearing upon the summit of each of their divisions an expansion of long points or projections, at first straight, then pendent, and even curved under and terminating in layers. Cordier says it is a delicate food. Hydnum repandum, L.-Doe-skin mushroom ; common hydnum ; woods ; II. W. R. has seen specimens from Ga. to Penn. It is scattered, or grows together, in a series, long or even circular, and entirely of a chamois leather, or pale flesh color, of middle height. The cap is fleshy, compact, irregular, sinuous, not zoned ; the spines un- equal, tubular, fragile, some advancing even to the top of a stem, full, irregular, and almost always eccentric. The flesh is firm, fragile ; taste slightly bitter and a little acid. The awl-shaped spines on the under surface are a charac- teristic feature of the genus, so Smith states, and there is little fear of mistake, and it " affords a charming addition to the table." Much used for food on the Continent, and often dried for winter use. II. coralloides, cyathiforme and caput medusae, all grow in the Atlantic States and are ed- ible (Curtis). See our Report, "Trans. Am. Med. Asso- ciation," vol. vii. Clavaria formosa, Pers.-Coral mushroom, N. C.; Cur- tis, edible. (See Plate XII., Fig. 1.) The elegant clavaria, as it is entitled, has a trunk thick, fleshy, white, divided into thick branches, round, lengthened out, close, orange yellow, or orange rose color, subdivided into little branches, obtuse, yellowish, collected in bundles, and ending in two or three teeth either pointed or obtuse. Cordier says it is found in the markets at Nice, the flesh being eatable, very white, and of a delicate taste. Clavaria fastigiata, L.-N. C.; Curtis, edible. This clavaria, of a yellow color, is very branching and scarcely three centimetres in height. The branches spring from a very short stem which is thin, divaricate, glabrous, dis- posed in obtuse bundles and terminate at the same height. Cordier places it among the edible mushrooms. Much used in Europe. C. botrytis also grows in South Caro- lina and is commonly used as an article of food in Ger- many. Clavaria coralloides, L., Hydnum coralloides Scop.- Goat's beard; N. C.; edible, Curtis. (See Fig. 1360). This is of a white color, inclining to gray, sub-fragile, having a stem hollow within, quite thick, irregularly branched ; the branches very numerous, forming bundles which are unequal, close together, sharp. Cordier says it is eatable, even raw. The flesh is white, coriaceous and nourishing ; all the varieties are used as articles of food ; the plant bears no resemblance to the poisonous fungi. Dr. Curtis cites thirteen edible native species, Clavaria rugosa, Bull.-Damp wood; N. C.; Curtis, edible. W. G. Smith recommends this, and adds, " all the white-spored species are believed to be esculent." Cordier cites it as edible. Morchella esculenta, L.-Common morel; earth in woods, S. C.; II. W. R. The stem is often cylindric, almost al- ways hollow within, four to five centimetres long, of a pale white, polished, quite thick ; the cap of a rounded shape, ovoid, and even conical, hollowed out at the top by irregular polygonal cellules, of which the borders are ad- herent to the stem. The cap, white or grayish in its young state, becomes of a dirty white, then a dark bistre, afterward blackish, which make many varieties. Esteemed everywhere as a valuable article of food, fresh or dried ; dried it will keep for many years. W. G. Smith speaks of the truly exquisite flavor which it im- parts to gravies, and being readily dried it can be kept 280 Reference Handbook of THE Medical Sciences. PLATE XHI 4 6 1 3 POISONOUS FUNGI. ( FROM ORIGINAL DRAWINGS MADE BY THE REV. CHARLES I. CURTIS OF NORTH CAROLINA.) H. BENCH E, LITK N .Y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi, for immediate use. " It yields a delicious ketchup." Cordier says " C'est un aliment delicat, et generalement recherche." M. caroliniana is also edible (Curtis). Helvetia crispa, Fr.-Pallid Helvetia ; S. C.; woods ; edible, Curtis. This species, one of the largest, has the cap free, that is not adherent to the stem by its borders, bent on different sides, lobed, and sometimes even contracted, the color pale-white above, becoming reddish upon dry- ing, and very slightly brown below. The stem is gla- brous, white, fistulous, hollowed or channelled, the la- cunes being deep and complicated. Smith says that if stewed slowly and with care, it will exude a delicious gravy; and that it is often dried and threaded on strings for future use. The flesh is firm and white, and resembles the morel. Cordier places it among the edible fungi. Curtis cites four other native Helvel- las as eatable. Lycoperdon bo vista, L.; Bovista gigantea, Nees.-Com- mon puff ball; pastures ; S. C. to Pa. (See Fig. 1373.) This species which acquires enormous dimensions, is al- ways rounded and sub-sessile. Its receptacle or peridium is white, fragile, often polished, but oftener hairy or cot- tony, whitish when young, then pale ochre, and finally brown-gray. Its flesh, at first white, passes little by little to a greenish-yellow, then to a gray-brown, and ends by being converted into a mass of brown fuliginous powder ; after which the peridium opens and expands at its summit into irregular colored circles, and soon only the base re- mains, of which the consistence and the lightness recalls that of sponge. The root, springing from the ground, is extremely small. It possesses the odor and taste of the meadow-mush- room when young, but becomes disagreeable when old. Cordier says it furnishes an excellent food, much sought after in Italy ; and that when the flesh is gray an ex- cellent amadou can be made from it. In Finland they give the dust, mixed with milk, to cattle suffering from diarrhoea ; and by the aid of precipitates different shades of brown color useful in staining are prepared. The puff-balls were formerly used as styptics to arrest ha?mor- rhage-sometimes inhaled. They possess also a narcotic quality ; and hence the smoke was used for stupefying bees. The Bovista nigrescens, Pers., and B. plumbea, Pers., common in grassy fields, are cited by Curtis as edible. Cordier says that Hussey and Bolton both declared them eatable when young. He says they differ very slightly. Dr. Curtis also states that L. giganteum is a great favorite with him. " It has not the high aroma of some ■others, but it has a delicacy of flavor that makes it superior to any omelette I have ever eaten. It seems, furthermore, to be so digestible as to adapt it to the most delicate stomach. This is the Southdown of mush- rooms." W. G. Smith says it should be cut up in slices, dipped into yolk of egg, and fried in fresh butter. The L. j)roteus offers itself under a variety of aspects, and is probably to be classed with L. pyriforme, which is a native. Cordier says it is edible. The powder of B. nigrescens is used in England to stanch blood. Dr. B. W. Richardson, of London, experimented on dogs, cats and rabbits with the powder of L. proteus which acted as an anaesthetic when inhaled-a tumor being removed from the dog which remained insensible {London Medical Times and Gazette, June, 1853). Mr. T. Herepath thinks the anaesthesia due to the carbonic oxide gas generated. Dr. Adinel Hewson, of Philadelphia, used a tincture in doses of a teaspoonful in nervous diseases (" U. S. Disp."). The "Nat. Dispensatory," second edi- tion, 1879, quotes as follows, p. 882 : In 1869 Dr. Porcher stated, concerning L. giganteum, that it is found in abundance near Charleston, particularly where the cattle are driven to graze. It is used sliced and fried in butter, or stewed in milk, like the common mushroom. A cor- respondent (Mr. II. W. Ravenel) wrote to him : "I, and a number of others have made several meals on lycoperdon, and I think I have discovered in myself well-marked evidences of its narcotic influence, and two other experi- menters have described similar sensations to me." A case also is referred to iu which a person "had been seriously affected in this way by too large a meal of lycoperdon." Lycoperdon coelatum, Bull.-N. C.; earth and stumps ; Curtis. Dr. Curtis does not mention this as edible, but Cordier says it has the same properties, and may serve the same purposes as L. giganteum. Lycoperdon gemmatum, Batsch.-Common ; woods and fields; N. C. Dr. Curtis does not cite this as edible. Cordier says that it is probable that the greater number of these plants (vesseloups) properly speaking, are edible when young; Micheli indicated eleven species which were eaten in Florence. We should distrust them, he adds, when old, for it is certain that their powder thrown into the eye, occasions grave ophthalmias ; and that, breathed through the nose, they provoke violent sneezing and even haemorrhage. Pachyma cocos, Schwein.; Lycoperdon (?).-Tuckahoe ; Indian bread ; underground ; 8. C. and N. C. ; edible, Curtis. It resembles bread when broken.- The Indians used it as food, and according to Clayton it was employed as such in Virginia. (See report of the writer in "Am. Med. Assoc. Trans.," vol. vii.) Dr. McBride, of S. C., made a communication on this curious plant to the New York Philosoph. Soc. ; for other references, see, also, our volume of " Resources of the Southern Fields and For- ests," p. 699, Charleston, 1869. Tuber cibarium, Sibth. ; Lycoperdon tuber, L.-Truffle ; subterranean. Mr. Ravenel has not seen this celebrated plant in S. C.; though in a letter to us, he states that Schweinitz inserts it in his Syn. U. S. Fungorum, upon the authority of Dr. Muhlenberg : " He says he was told there was an old hunter who had a dog trained to find them in the neighborhood of Narraganset, Pa." It is not cited in Curtis' catalogue. III. Poisonous Fungi.-Agaricus pb alloides, Fr.; A. bulbosus, Bull.-Phallus-like agaric ; common in woods ; August to November ; Carolina to Pa.; Curtis and Ra- venel. (See Plate XIII., Fig. 4.) Very handsome, all parts nearly white, except the top, which may be a pale shade of yellow or green. When fresh it has a powerful, but not disagreeable smell; when past maturity, its odor be- comes almost insupportable. Accounted highly poisonous, especially the yellow variety. Orfila administered portions of A. bulbosus, of Bull, to a dog. In six hours, it made efforts to vomit, be- came extremely weak, lay down and died with convul- sive movements. Upon post-mortem examination the stomach and duodenum had livid spots on their coats. The tincture made by placing one plant in § jss. of al- cohol was likewise equally destructive. Exposed to in- tense heat the plant did not give out oxygen, as other vegetables do, but azote and hydrogen; "thus confirm- ing the almost animal nature of this species of produc- tion" (M. and de L., "Diet, de Mat. Med.," ii., 204). Smith represents it in his chart, and says that it is known to be highly dangerous. Agaricus muscarius, L. Fl. Suec.; Amanita muscaria, Grev.-Fly agaric, Fausse orange, Amanita; N. C.; Curtis. Sent to us from St. Johns, S. C., by Mr. Ravenel. (See Plate XIII., Figs. 1 and 5.) The top of this handsome species is more or less covered with white warts or excrescences, the debris of the volva, and on the under side with white lamellate gills ; it is of a deep yellow, or orange, but usually brilliant scarlet. If the skin of the top is stripped off, the flesh just beneath is seen to be a bright yellow, and the rest of the flesh white. The volva is incomplete, stem full, scaly, bulbous, white, with a collar ; leaflets white. It has a burning acrid taste, and a disagreeable odor ("Nat. Disp."), but this has been denied (Merat, in Diet, de Mat. Med.). The flesh of the edible, red-fleshed mushroom {Agaricus rubescens), turns reddish when bruised (Smith). This species derives its name from its killing flies when dissolved in milk ; dogs and cats also are destroyed in two or three hours by large doses. It is highly narcotic, producing in small doses intoxi- cation and delirium, for which purpose it is used in Kam- schatka ; and in larger death. For a detailed account of its poisonous effects, see Roques, "Hist, des Champ. 281 Fungi. Fungi, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Comest. et Veneneux," and for some curious particulars a paper by Dr. Greville, in the fourth volume Wernerian Trans. From the account of Dr. Langsdorff, it appears that the inhabitants of the northeastern part of Asia use this species in the same manner as wine, arrack, brandy, opium, etc., are by other nations. They are collected in the hottest months, and hung up in the air by a string to dry ; some dry of themselves on the ground, and are far more narcotic. The usual mode of taking the fungus is to roll it up like a bolus, and swallow it without chew- ing ; which the natives say would disorder the stomach. It is sometimes eaten fresh in soups and sauces, and then loses much of its intoxicating property. One large or two small fungi is a common dose, to produce a pleasant in- toxication for a whole day, particularly if water be drunk after it, which augments the narcotic principle. The de- sired effect comes on from one or two hours after taking the fungus. Giddiness and drunkenness result in the same manner as from wine or spirits ; cheerful emotions of the mind are first produced, involuntary words and actions follow, and sometimes at last, an entire loss of con- sciousness. It renders some remarkably active, and proves highly stimulant to muscular exertion ; by too large a dose, violent spasmodic effects are produced. So very exciting to the nervous system, in many individuals is this fungus, that the effects are often very ludicrous : a person under its influence wishing to step over a straw, takes a stride or a jump sufficient to clear the trunk of a tree ; a talkative person cannot keep silence or secrets ; and one fond of music is perpetually singing. The most singular effect of the amanita, is the influence it possesses over the urine. It is said that from time immemorial the inhabitants have known that the fungus imparts an in- toxicating quality to that secretion, which continues for a considerable time after taking it. For instance, a man moderately intoxicated to-day, will, by the next morning, have slept himself sober ; but (as is the custom) by taking a teacupful of his urine, he will be more powerfully in- toxicated than he was the preceding day. It is, there- fore, not uncommon for confirmed drunkards to preserve their urine as a precious liquor, against a scarcity of the fungus. This intoxicating property of the urine is capa- ble of being propagated ; for every one who partakes of it has his urine similarly affected. Thus with a very few amanitas, a party of drunkards may keep up their de- bauch for a week. Dr. Langsdorff mentions, that by means of the second person taking the urine of the first, the third that of the second, and so on, the intoxication may be propagated through five individuals. Merat states that in a certain dose it is not fatal, since Bulliard said that he had eaten more than two ounces without injury. Dogs and cats, however, died after taking a quantity very little larger. Dr. Pouchet, of Rouen, seems to have clearly proved that the poisonous property of this and the A. venenata " may be entirely removed by boiling them in water." A quart of water in which five plants had been boiled for fifteen minutes, killed a dog in eight hours; but the boiled fungi had no effect on two other dogs ; and a third which had been fed for two months on little else than boiled amanita?, sustained no harm (Journ. de Chem. Med., 322, 1839). See our paper in vol. vii. of "Trans, of Am. Med. Assoc.," where we have quoted from several authorities, experiments more in detail regarding the poisonous prop- erties of these plants. Bulliard says he ate two ounces without accident; but M. Roques states distinctly that this plant has not its poi- sonous properties modified by any climate. The Czar Alexis lost his life by eating this mushroom, and numer- ous examples of its poisonous effects on man could be ad- duced. The acetate of ammonia presents the best means of relief. This plant possesses properties allied to those of opium -causing stupor and prostration. The tincture, in doses of forty drops, has been employed in diseases of the skin, and the powdered plant for dressing cancerous ulcers (see our Report on the Medic, and Toxicol. Properties of the Cryptog. Plants, cit. sup.). Amanitine, the active principle, was obtained by Letellier. It is stated in the recent work of I. Mitchell Bruce ("Mat. Med. and Therap.," 1884) that the nitrate of muscarin, the liquid alkaloid, may be given in doses of one-thirtieth to one- third of a grain. Schmiedeberg and Koppe (1869) sepa- rated a poisonous alkaloid, muscarina, and examined it carefully. J. Lauder Brunton ("Pharmac., Therap. and Mat. Med.," Philadelphia, 1885), Sidney Ringer ("Hand- book of Therap.," sixth edition, 1878), and others, have also investigated its action. Great interest attaches to its action, says Ringer, on account of its close similarity with pilocarpine, and its almost complete antagonism to atro- pia ; it is a myotic and contracts the pupil; it excites co- pious emesis, perspiration, salivation and a flow of tears ; it increases the intestinal mucus and the biliary and pan- creatic secretions. Brunton found that applied to the heart, it would stop its pulsations completely. Atropine antagonizes muscarine. ' ' When the heart has been stopped by digitalin, muscarin and aconite will restore its move- ments." It diminishes the activity of the respiratory cen- tre by an action on the medulla, like chloral, physos- tigmin, gelsemin, and veratrine. "When atropine is applied to the heart, it completely removes the effects of muscarine " (Brunton). There seems to be some discord- ancy in the opinions of Ringer and Brunton as to its local action on the eye. Agaricut pantherinus, De C.-Panther agaric; borders of woods; S. C. to Pa. (See Plate XIII., Fig. 6.) Christison reports from the " Annali Univ, de Med.," 1842, a singular form of the narcotic effects of this fun- gus. A boy, near Bologna, having eaten it, was seized with delirium, a maniacal disposition to rave, and con- vulsive movements. These were succeeded by a state re- sembling coma, in every way, except that he looked as if he understood what was going on ; and in point of fact really did so. He recovered under the use of emetics. Agaricus asper, Pers.-Rough-warted agaric ; woods ; June to October (A. asper of Fries); N. C. Odor strong; taste not unpleasant, though saltish ; poisonous according to Roques (" Hist, des Champ. Ven.," 319). Agaricus purus, Pers.; Agaricus roseus, Bull.-Rose agaric; N. and S. C. According to Krapf it is ex- tremely dangerous. It is distinguishable by its taste and odor which is like that of radishes. (" Crypt, of Eng- land.") Paulet did not discover any sensible effect when experimenting with it. Agaricus ternus, I). C.,Fr.; Agaricus bulbosus vernus, Bull.-Spring Agaric, Orange cigue ; August and Sep- tember ; N. C.; common in woods; Curtis. Its resem- blance to the edible mushrooms has been the cause of the most unfortunate results. It is white in every part. Instead of having a simple collar extending from the borders of the cap to the upper part of the stem, when young it has a complete volva, of the same color, which envelops it from the root and covering the cap. The trace of the volva also distinguishes it from the edible species. The stem is swollen and hollow ; not so in the edible. The poisonous plant exhales a disagreeable odor, and has an acrid taste, which is not observed in the edible. The lames or leaflets of the poisonous plant are always white, while those of the other are slightly rose, or violet colored. The skin peels with difficulty, while in the edible (Boletus edulis) it peels easily. All the varieties of the bulbous agaric of Bulliard contain a very deleterious fatty matter. Paulet administered to a vigorous dog a pate of this plant in doses of three drachms. In six hours he made efforts to vomit, his limbs became feeble, lay down, and after some convulsive movements, died. The stomach and duodenum exhibited livid spots, and the whole in- testinal canal was filled with yellow mucus. The oesopha- gus and kidneys were in a natural state. Roques quotes from Paulet, his report of the case of M. Benoit, his wife, her daughter and infant, which we think interesting enough to insert. At six o'clock in the evening they ate of this plant (Amanita printanier), which was gathered in the woods near Boulogne. On the next day they suf- fered from nausea, anxiety, and frequent faintings. On giving to the father and the child milk, ether, and a strong 282 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungi, dose of an emetic, abundant vomiting was induced. They were upon the point of giving the same to the mother, when she suffered from a flow of blood and continued prostration. The child was nearly dead when Dr. Paulet arrived. The father was found in a state of permanent anxiety and stupor; his stomach was tense, extremities cold, and pulse weak and intermitting. His whole body was livid, and he died a few minutes after. The mother vomited abundantly ; her complexion was pale and ca- daverous, and there was constant weakness and anxiety. Upon giving an ordinary purgative, after two or three hours she evacuated portions of the plant, and an abun- dance of yellow mucus. She took the milk with orange- flower water and a few drops of ether, which gave much relief. The next day she was purged and the uterine flow was arrested. There was weakness and oppression existing for some time, and she suffered from pains in the head for six months. Other cases we have translated from Roques and inserted in the "Report to the Am. Med. Assoc.," vol. vii. Cases related by Paulet, in which there was stupor and dilatation of pupil, were much benefited by the pur- gative treatment. Roques thinks the indication is to relieve the gastro-intestinal inflammation by leeching, mucilaginous and oily drinks, and topical demulcents. Smith represents it in his chart. Agaricus osruginosus.-Verdigris mushroom ; earth and wood ; middle N. C.; Curtis. Represented in Smith's chart as doubtless poisonous. It is a handsome fungus, and the green slime is easily washed off. Agaricus pusilus, D. C., Fr.-N. C. Roques says of this beautiful little mushroom, which grows in woods and gardens, that it approaches too near the poisonous species to be edible. Agaricus semiglobatus, Pers.-Slimy-dung mushroom, rich meadows and dung-hills ; rich meadow ; S. C. to Pa. De Candolle places all the coprins among the poisonous fungi. Their characteristics, tenuity, and rapid alteration are sufficient to proscribe them. Smith figures it in his chart among the poisonous species. Agaricus fascicularis. -Bundled stump-mushroom; com- moninN. C.; Curtis. Occurs in groups around old stumps; stem hollow, gills greenish ; taste bitter. Smith's chart. Agaricus emeticus, Schoeff; Agaricuspectinaceus, Bull.- Common gilled agaric ; very common ; woods; H. W. R.; S. C. All the varieties are poisonous. Agaricus sanguineus, Fr.-Common ; damp woods ; Curtis. It is even more poisonous than the A. emeticus, hence requires attention so as not to confound it with the eatable russules. Agaricus sulphureus, Bull.-Brimstone agaric ; woods ; N. C. Included in Smith's chart. Has a disagreeable, penetrating smell like "gas tar." Poisonous. Agaricus rolvaceus, Bull.-N. C. ; Schw. Braconnot found in this, gelatine, albumen, a large quantity of phosphate of potash, and adipocire, which show some- thing of an animal nature. Polyporusfomentarius andignarius, L.-Amadou-tinder; N. C., S. C., and elsewhere; H. W. R. These plants grow on oak, birch, willow, cherry, and plum trees, and both are used to make amadou. See our Report, vol. vii., Am. Med. Assoc. Agaricus sublateritius.-Olive-gilled mushroom ; com- mon on and around stumps; N. C. ; Curtis. W. G. Smith includes this in his chart of poisonous species, but only charges it with having a disagreeable smell. Russula fastens.-Fetid mushroom ; N. C. ; Curtis. Smith says it is much eaten by slugs, and has an in- sufferable odor, and must be deleterious. Russula emetica.-Emetic mushroom ; common in all parts of N. C. ; woods ; Curtis. Included in Smith's chart. He describes the skin as scarlet, and easily peeled off, the pink flesh displayed beneath is its great charac- teristic ; the gills are pure white and do not reach the stem ; the top is highly polished, and varies from scarlet and crimson to a faint rose color, and may be shaded with purple ; supposed to be very dangerous. Cantharellus aurantiacus.-False chantarelle ; woods ; N. C. ; Curtis. Smith includes this in his chart, and says it is known by its smaller size, its gills being far thinner and more crowded than in the true chantarelle ; the stem frequently deep amber at the base, and the gills, or veins, darker than the top. Hygrophorus conicus. - Red-juice mushroom ; grassy lands ; N. C.; Curtis. It turns purple-black when bruised, broken or old, with a strong and forbidding odor. It is not infrequently a brilliant yellow or deep orange, in place of crimson or scarlet (Smith's chart). Clathrus cancdlatus.-Trellised clathrus, stink horn •, common on refuse heaps; N. C.; Curtis. A very beau- tiful species, but exhaling in its mature state a most of- fensive fetor (Smith's chart). Panus stypticus.-Common on stumps; N. C.; Curtis. Smith thinks it " had better be avoided." Lactarius torminosus. - Griping milk-mushroom ; in woods; N. C.; Curtis. Known by the hairy margin of the top, which is rolled inward. The milk which ex- udes when the plant is broken is acrid, and does not change color as does the edible lactarius (L. deliciosus}. Lactarius acris.-Pungent milk-mushroom ; woods ; N. C.; Curtis. An acrid and dangerous species. When cut or broken the flesh and white milk change to a dull- sienna red; this distinguishes it from all other mush- rooms ; the change is very slow. Boletus luridus, Schoeff ; Boletus perniciosus, Roques.- Poisonous boletus ; woods ; common, N. C. to Pa.; Cur- tis and Ravenel. (See Plate XIII., Fig. 2.) Very deleteri- ous. B. perniciosus of Roques is highly poisonous to cats. The dog suffers, but seems endowed with a power of overcoming the activity of these poisons. In cases where men were poisoned, Roques found opium useful. (See our Report " Trans. Am. Med. Assoc.," vol. vii., for fuller details.) Smith considers it probably poisonous, but has known it to be eaten without fatal effects. It is a very handsome species, the prevailing tint being amber, re- lieved on the under surface by bright red, sometimes ap- proaching to crimson, or even vermilion ; when bruised, it changes color to blue (Smith). Boletus satanas.-N. C.; H. W. R. Smith represents it in his chart, and as the most splendid of all the boleti. The top is nearly white, very fleshy; the stem is firm, exquisitely colored, and reticulated ; the under surface, brilliant crimson. It attains a large size, and if bruised changes to blue. It derived its name, as Mr. Ravenel informs us, to "brand its diabolical attempt on the life of the botanist who first tried its eatable qualities." Boletus feUeus. - Bitter tube mushroom ; banks and thickets, N. C.; Curtis. The bitter taste, flesh-colored tubes, flesh color of tops when broken, the reticulated stem and pink spores distinguish it. Phallus impudicus, L.-N. C. to Pa.; H. W. R. (See Fig. 1374.) Dried on an iron plate to take out the nau- seous odor it has great remedial powers to allay pain, especially in renal diseases ; given in the form of powder or tincture ; notwithstanding its indescribably loathsome odor, it has been eaten. We have thought that it would add materially to the value of this paper to introduce the names of all the spe- cies cited by Curtis in his " Catalogue," as edible ; many of which, as was stated, he had tested. He also gives the localities where found : lower, middle, and upper coun- ties, etc. Agaricus Caesarius, Scop.: Common ; in oak forests. A. strobilifarmis, Vitt.: Common; in woods. A. rubescens, Pers.: Lower ; damp woods. These three belong to the ' ' Amanita " family. A. procerus, Scop.: Common ; woods and fields. A. rachodes, Vitt.: Middle ; base of stumps and trees. A. ercoriatus, Fr.: Middle; grassy lands. A. mastoideus, Fr.: Common; woods. A. melleus, Vahl.: Common ; about stumps and logs. A. Russula, Schaeff.: Lower ; among leaves in woods. A. frumentaceus, Bull.: Middle: pine woods. A. hypopithyus, M. A. C.: Middle ; pine logs. A. Columbetta, Fr.: Middle (Schw.); woods. A. castus, M. A. C.: Middle ; grassy old fields. A. albellus, D. C.: Middle; damp woods. 283 Fungi. Funj>tiH Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. A. consociatus, M. A. C.: Middle; pine woods. A. personatus, Fr.: Lower and middle ; near rotten logs. A. nebularis, Batsch.: Middle (Schw.); damp woods. A. odorus, Bull.: Middle (Schw.); woods. A. giganteus, Sow.: Middle (Schw.); borders of pine woods. A. cespitosus, M. A. C.: Common ; base of stumps. A. radicatus, Bull.: Common ; woods. A. esculentus, Jacq.: Middle (Schw.); dense woods. A. ulmarius, Sow.: Middle (Schw.) ; dead trunks. A. tesselatus, Bull.: Middle (Schw.); pine trunks. A. Pometi, Fr.: Middle ; carious wood. A. glandulosus, Bull.: Middle (Schw.) ; dead trunks. A. ostreatus, Jacq.: Middle (Schw.); dead trunks. A. salignus, Pers.: Common ; on trunks and stumps. A. bombicinus, Schaeff.: Lower and middle ; earth, and carious wood. A. speciosus, Fr.: Lower ; grassy land. A. Prunulus, Scop.: Lower and middle ; damp woods. A. squarrosus, Mull.: Middle (Schw.); oak stumps. A. mutabilis, Schaeff.: Middle (Schw.) ; trunks. A. campestris, L.: Common ; fields and pastures. A. arvensis, Schaeff.: Common ; fields and pastures. A. amygdulinus, M. A. C.: Common; rich grounds, woods and lanes. A. cretaceus, Fr.: Common ; earth and wood. A. sylvaticus, Schaeff.: Lower and middle ; woods. Coprinus comatus, Fr. : Lower and middle ; in stable yards. C. atramentarius, Bull.: Middle ; manured ground. Cortinarius violaceus, Fr.: Middle (Schw.) ; woods. C. cinnamomeus, Fr.: Common ; earth and wood. C. castaneus Fr.: Common ; earth in woods. PaxiUus inrolutus, Fr. : Lower and middle; sandy woods. Ilygrophorus eburneus, Yr.: Middle (Schw.); woods. H pratensis, Fr.: Middle (Schw.); hill-sides. Lactarius insulsus, Fr.: Middle ; woods. L. piperatus, Fr.: Common ; dry woods. L. deliciosus, Fr.: Lower and middle ; pine woods. L. volemus, Fr.: Common; "woods. L. subdulcis, Fr.: Common ; damp grounds. L. angustissimus, Lasch.: Common ; thin woods. Russula lepida, Fr.: Lower ; pine woods. R. virescens, Fr.: Middle (Schw.) ; woods. R. alutacea, Fr.: Common ; woods. Cantha.reUus cibarius, Fr.: Common ; woods. Marasmius oreades, Fr.: Middle (Schw.) ; hill-sides. M. scorodoneus, Fr.: Middle (Schw.); decaying vegeta- tion. Boletus luteus, L.: Middle (Schw.); pine woods. B. elegans, Fr.; Lower ; earth in W'oods. B. flavidus, Fr.: Common ; damp woods. B. collinitus, Fr.: Middle and upper ; pine woods. B. granulatus, L.: Common ; woodsand fields. B. bovinus, L.: Common ; pine woods. B. subtomentosus, L.: Common ; earth in woods. B. edulis, Bull.: Middle (Schw.); woods. B. versipellis, Fr.: Middle; woods. B. scaber, Bull.: Middle and lower; sandy woods. B. castaneus, Bull.: Middle (Schw.); woods. Polyporus leucomelas, Fr.: Middle ; woods. P. ovinus, Schaeff.: Lower and middle; earth in woods. P. poripes, Fr.: Middle and upper ; wooded ravines. P. frondosus, Fr.: Common ; earth and base of stumps. P. cristatus, Fr.: Middle (Schw.); pine woods. P. confluens, Fr.: Lower and middle ; pine woods. P. giganteus, Fr.: Lower and middle ; base of stumps. • P. sulphurous, Fr.: Common ; trunks and logs. P. Berkeleii, Fr.: Middle and upper; woods. Fistulina hepatica, Fr.: Upper; base of trunks and stumps. Hydnum imbricatum, L.: Middle and upper; earth in woods. II subsquamosum, Batsch.: Common ; damp wroods. H. lacigatum, Swartz.: Lower ; pine woods. H repandum, L.: Common ; woods. H. rufescens, Schaeff.; Middle (Schw.); woods. H. coralloides, Scop.: Common ; side of trunks. H. Caput-Medusa, Bull.: Common ; trunks and logs. Sparassis crispa, Fr.: Upper; earth. S. laminosa, Fr.: Lower ; oak log. Clavaria flava, Fr.: Common ; earth in woods. C. botritis, Pers.: Common ; earth in woods. C. fastigiata, L.: Middle (Schw.); grassy places. C. muscoides, L.: Middle (Schw.); grassy places. C. tetragona, Schw.: Middle (Schw.); damp woods. C. cristata, Holmsk.: Middle and upper ; damp woods. C. rugosa, Bull.: Middle (Schw.); damp woods. C. fuliginea, Pers.: Lower and middle ; shady woods. C. macropus, Pers.: Middle (Schw.); earth. C. subtilis, Pers.: Middle (Schw.) ; shaded banks. C. pyxidata, Pers.: Common; rotten wood. C. aurea, Schaeff.: Common ; earth in woods. C. formosa, Pers.: Common; earth in woods. I'remeUa mesenterica, Betz.: Common ; on bark. LycoperdonBovista, L.: Common; grassy lands. Bovista nigrescens, Pers.: Common ; grassy fields. B. plumbea, Pers.: Common ; grassy fields. Morchella esculenta, Pers.: (Morel.) Common; earth in woods. M. Caroliniana, Bose.: Middle ; .earth in woods. Helvetia crispa, Fr.: Lower ; pine woods. H. lacunosa, Afz.: Lower ; near rotten logs. H. sulcata, Afz.: Middle (Schw.) ; shady wroods. H. Infula, Schaeff.: Middle (Schw.); earth and pine logs. Pachyma cocos, Fr. (Tuckahoe).: Lower and middle ; under ground. Bibliography. We insert references to a few only of the many books and pamphlets which may prove useful to the reader. In the catalogue of the library of the Surgeon-General, Washington, can be found numerous references. Precis de Botanique et de Physiologie Vegdtale, or tie de vignettes, etc. Par A. Richard, Membre de 1'Institut. etc. Paris, 1852. Plantes Usuelles, par Joseph Roques. Paris, 1838, vol. iv., containing the Edible and Poisonous Fungi ; also his Histoire des Champignons Comes- tibles et VenGneux. Elegantly illustrated. Les Champignons : Histoire-Description-Culture-Usages des Espdces Comestibles-Vcneneuses-Suspectes, etc. Par F. S. Cordier. With sixty chromo-lithographs. 4th edition. Paris, 1876. Botanique Cryptogamique, ou Histoire des Families Naturelies des Plantes Infdrieures. Par I. Payer, Docteur is-sciences. etc. Avec 1,105 gra- vures sur bois. Paris, 1850. Victor Masson. Des Champignons: guide indispensable, leur culture artificielle, etc. Pamphlet with woodcuts. Pp. 75. Par Lamy. Chambery, 1866. Mushrooms and Toadstools : How to distinguish easily the differences be- tween edible and poisonous fungi. With two large sheets containing figures of twenty-nine edible, and thirty-one poisonous, species, drawn the natural size, and colored from living specimens. By Worthington G. Smith, F.L.S. 2d edition. London : R. Hardwick, 192 Piccadilly. 1875. Mushrooms of America, Edible and Poisonous. Edited by Julius A. Palmer, Jr. Published by L. Prang & Co., Boston, 1885. Colored plates. Geological & Natural History Survey of North Carolina. Part III., Botany, containing a catalogue of the indigenous and naturalized plants of the State. By Rev. M. A. Curtis, D.D., etc. Raleigh, 1867. Fungi Caroliniani Exsiccati. Five Fasciculi, one hundred specimens each. By H. W. Ravenel, of Aiken, S. C. John Russell, Charleston. The Medicinal, Poisonous, and Dietetic Properties of the Cryptogamic Plants of the United States. A report made to the American Medi- cal Association (also reprint from its Transactions, vol. vii.). By F. Peyre Porcher, M.D. New York : Baker, Godwin & Co., 1854. Edible Mushrooms of this Country. Read before Aiken Vine Growing and Horticultural Association, South Carolina. By H. W. Ravenel. Robinson : On Mushroom Culture. London, 1870. Cuthill: On the Cultivation of the Mushroom, 1861. Abercrombie : The Garden Mushroom ; its culture etc. 1802. 'The Patent Office Reports, 1854, contain papers on the cultivation of the garden mushroom from Armstrong, Loudon, and others. Paper by the writer, on Cultivation of Fungi, in Resources of the Southern Fields and Forests. 2d edition. Charleston, 1869. F. Peyre Porcher. FUNGUS FOOT OF INDIA. This name lias been given to a peculiar endemic disease, called also " Madura Foot," " Podelcdma," " Mycetoma," etc., which prevails to a considerable extent in India, and of which cases have been reported as occurring in Mexico and in the United States. It appears to be unknown in Europe. The disease is characterized by a tumor-like swelling, occurring usually in one foot, more rarely in the hand or arm, and in one case in the shoulder, together with the formation of blebs or tubercles upon the surface, which become the point of exit of sinuses penetrating to the 284 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungi. Fungus Foot. deeper tissues, and giving exit to whitish granules or black roe-like masses, mingled with a sanious discharge. It may attack individual segments of either hand or foot, as the toe or the finger ; in fact, the palmar surface of the finger or thumb, and the plantar surface of the toe, or the interspace between the toes, are often the first local- ties to be attacked. The earliest signs of the disease are variously described as discoloration or induration of the skin in places, or as swellings, tubercles, knots, and lumps of various sizes; which are sometimes compared to boils, but are usually larger, non-sensitive, and either movable or apparently limited to the integument, or deep-seated and fixed. They are firm, indolent, and very slow in progress. Sometimes the swelling, even when superficial, is by no means promi- nent or defined, and when deep-seated it may be more perceptible to touch than to sight. Sooner or later vesi- cles or pustules appear, or more limited elevated points, and the former burst or the latter ulcerate ; then there oc- curs a thin and scanty discharge in which the supposed fungous particles are at once to be found, and a fistulous opening remains, whence the latter continue to issue. The origin of the disease is commonly attributed to the entrance of a thorn or splinter, or to a bruise inflicted upon the part. Investigation, however, has failed to dem- onstrate the origin of the affection, as from without it seems on examination to have invariably first shown itself at some little distance under the skin. The inoculation of the foot, however, does not in any case seem to have a strictly-defined local mark. The first sign of the disease is revealed by its consequen- ces, that is to say, com- monly by a tumor which sooner or later communicates with the exteri- or, and then for the first time In the early stages of the disease the appearances in fungus foot are various. There may be swelling, or there may be only a slight thickening or induration of the skin, attended or not with a dark mottled appearance which has been compared to tattoo marks. At this stage, con- sideration of the patient's history, place of residence, and the position of these marks might aid the diagnosis, but the appearances are really only those which might attend the presence of a foreign body of small dimensions with- in the substance of the skin, excepting that the point of entrance is imperceptible. So soon, however, as an open- ing (of exit) is once formed, the characteristic fungus par- ticles at once appear, and the diagnosis can be made with- out question. Occasionally the first lesion is a vesicle or bleb, and in this case the disease might be confounded with filaria disease. After an interval, however, a tumor and a sinus follow, and then the diagnosis is established. When an abscess is the first sign, it is observed that it persists instead of healing up as other abscesses do. When a finger or toe is first affected, the lesion may first be a pimple or small lump, and may look as if caused by a thorn lodging in the part. In this case the history and traces of an opening made by the entering foreign body would aid the diagnosis. When a sinus has once formed and a discharge has com- menced, there are almost invariably present certain char- acteristic brownish granular particles. These should al- ways be sought for, even with the aid of a lens if necessary, and having been found should be transferred to a micro- scope slide, washed with distilled water, and examined with a low power (a half-inch objective will usually serve). In the advanced stage, tumefaction of the foot may cause the disease to be mistaken for elephantiasis of the same parts; but fungus foot is not cedematous nor puffy; it may extend to the sole of the foot, or it may be con- fined to one region only ; it rarely passes above the ankle- joint ; it is hard, nodulated, and irregular, and is per- meated by sinuses whose apertures are peculiar and whose discharge is characteristic. Elephantiasis, on the contrary, shows occasionally weeping fissures, but no sinuses ; the skin is thrown into broad and characteristic folds ; almost always the leg is implicated. Feverish ex- acerbations also are apt to occur with implication of the lymphatic system, which never occurs in fungus foot. In caries the form of the swelling may at first be simi- lar, but its mode of origin is different, its progress quicker, and its ultimate size and shape never equal to or resembling those of fungus foot. The sinuses are less numerous, and characteristic particles are absent from the discharge ; this is diagnostic. Marked local inflam- mation and pain usually precede the advent of abscesses. Before carious disease has advanced far the patient be- comes lame, while in fungus foot lameness occurs only in a very late stage of the disease. Strumous bone disease is not likely to be confounded with fungus foot, because the latter only occurs in stru- mous subjects by chance, and the tubercular deposits and discharge in no way resemble those of fungus foot. Enchondroma of the foot may resemble certain forms of fungus foot when the latter is deep-seated, circum- scribed, firm, and hard. Fungus foot, however, soon shows a tendency to work its way toward the surface, with the formation of sinuses, and, moreover, is at no time so hard and firm as a cartilaginous growth is apt to be. . Myeloid disease, malignant growths, leprosy, chronic abscess, the entrance of foreign bodies, and Guinea-worm disease, may all possibly be taken for fungus foot under circumstances in which either is apt to occur; but a ref- erence to the diagnostic points given above, with a com- parison of the general characteristics of the other diseases mentioned, will usually make the diagnosis plain. In conclusion, it may be remarked that aching, wear- ing pains in the foot, starting of the limb, nocturnal ex- acerbations of suffering and hectic fever, rigors, sweat- ing, emaciation, etc., are less evident in this affection than in those considered to be of a constitutional origin or nature. Fig. 1377.-Fungus Foot of India; Mode of Invasion of the Growth. (After Vandyke Carter.) the so-called fungus particles or roe-like bodies appear. The course of the disease is essentially chronic, the history of a case covering years rather than months, but occasionally, within even one year after its first outward sign, the growth may spread over a great part of the foot. It appears to spread by the prolongation of sinuses in the direction of least resistance (though no tissue, not even bone, can resist the onset of the disease). At various points in these sinuses certain globular foci, containing peculiar gelatinous and granular constituents, form, and these sinuses and nodes multiply until the foot seems to be one mass riddled with holes. The disease is always protracted in duration ; four, six, or even twenty or more years may elapse before the foot becomes so entirely disorganized as to demand amputa- tion. The affected foot may, in some protracted cases, exceed its fellow four or five times in bulk, and attain a weight of a dozen pounds or more. Although the possibility of a spontaneous cure cannot be denied, yet no case of such a termination is on record. The tendency of the disease is to increase progressively. Unless it is destroyed by caustics or other destructive agents, or cut off by amputation, it tends to spread until the patient dies of exhaustion, or from some complication, as diarrhoea, dysentery, or anasarca. Irritation, as shown by inflammation of the lymphatics, or enlargement of the inguinal glands, has not been observed, nor has anything like septic infection of the system been recorded. Fungus foot may be confounded with Guinea-worm disease, Elephantiasis, Caries, Struma, Enchondroma, Malignant Tumors, Articular Leprosy, or with a con- junction of such diseases. 285 Fungus Foot. Gall-Bladder. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. As regards the exciting cause of fungus foot, Dr. Car- ter regards it as beyond doubt the entry of fungus spores or other living germs, into and beneath the skin of some part of the living foot. There the materials and stimulus favorable to their subsequent growth and development are abundant, continuous, and uniform ; the near soft textures, at least, present no obstacle to increase of size and luxuriancy of ramification. Respecting the actual introduction of such spore or germ, however, there are no other than presumptive data. It is quite possible, says Carter, that the fungus may be introduced into the system by means of a bruise, or a thorn or splinter. Since, however, in many cases the affection first show's itself in the interior of the limb, and only later emerges to the sur- face, Carter supposes that the fungus may penetrate the system through the sweat and sebaceous ducts, and the hair-follicles. As regards the proximate or immediate cause of the swelling of the foot or hand, and of all the hurtful results of the disease in question, Carter asserts that this is due to the growth within the textures of these parts, of a vege- table parasite. How' far this parasite may be regarded as essential to the disease is a matter of question. Carter re- gards it as essential. Fox, Lewis, and Cunningham, and others, do not regard the disease as necessarily of a fun- gous origin, though they admit the presence of fungus. The prognosis of fungus foot is favorable, insomuch that destruction of the disease, if complete, is not followed by relapse. The treatment of fungus foot should include cleanli- ness and protection as prophylactic measures, with re- moval of the growth by scraping and cauterizing when localized, or by amputation when this is required. As there is no necessary limit to this disease, the stump should always be carefully examined after an amputa- tion, to see that the affection has not penetrated to a point beyond that indicated by external appearances. may afford ample nourishment for her babe, while the other falls far short of supplying the necessary quantity. In other words, good wet-nurses are, like poets, born, not made. It is a common practice to advise the use of alco- holic beverages with a view to stimulating the lacteal secretion, and in carefully selected cases such beverages may, no doubt, be employed with excellent effect; but their indiscriminate use, as so often practised in the con- sumption of large quantities of beer, is not only demoral- izing to the nurse, but, as I have often observed, very in- jurious to the child. When the general nutrition of a nurse may be improved by alcoholics, her appetite in- creased, or her digestion and assimilation improved, then, and then only, should their use be sanctioned. When, however, we turn from alimentation in nursing -unsatisfactory as it is in its influence to combat personal peculiarity-to medication pure and simple, we find the subject still more unsatisfactory. Here all is uncertainty. Though there are many drugs on which we may rely for suspending lacteal secretion, none are known possessing a certainty of action in increasing it. Hence it may well be doubted whether the word galactagogue is longer worthy a place in our literature. Laurence Johnson. GALBANUM, U. S. Ph., Br. Ph., Ph. G., Codex Med., is reputed to be mostly produced by the two following plants : 1. Ferula galbaniflora Boissier and Buhse, a medium- sized perennial umbellifer with a large, branched, thick- ened, moderately resinous root, and an erect, solid, branched stem about one and a half metre high, and two or three centimetres in diameter (4 or 5 feet x 1 inch). The root leaves are large, several times divided, with remote pinn®, and very small, clustered leaflets. The stem leaves are inconspicuous. The flowers are polygamous, the mostly fertile borne on a large, many-rayed, compound, almost naked terminal umbel; the stammate ones in smaller lateral umbels, arising just below the former and over-top- ping it by the greater length of their peduncles. Flowers small, yellow ; seeds very flat, oblong, winged, and one or two centimetres long. Vitt® four dorsal, and none, or two, small, narrow, ventral ones. This plant was first col- lected by Dr. Buhse, in 1847 or 1848, in Northern Persia. 2. F. rubricaulis Boissier, a similar plant, with inflated leaf-sheaths, larger and more divided leaflets, and reddish- brown fruit having numerous vitt®. It is a native of Persia and adjacent regions. F. Schair Borsc. is also reputed to furnish some of the drug, and it is probable that other species of this large and eminently Asiatic, resiniferous genus also contribute. Galbanum exists, like other gum-resins, in the plant as a fragrant creamy latex, and exudes spontaneously from the crown and stem, or flows upon puncture, in white drops that soon become thick and sticky, and finally hard and brittle, by the action of the air. As they dry they also turn to a light yellow-brown or buff-color. These drops or tears, collected when nearly dry and not stick- ing together, compose the " Galbanum in tears; " when collected softer, and running more or less completely into a granular or even homogeneous mass, they are the more common Galbanum in mass. The pharmacopceial de- scription is as follows : "In tears from the size of a pin's head to that of a pea, and larger ; mostly agglutinated, forming a more or less hard mass ; externally yellowish, or pale brown; internally milk-white, bluish-white, or yellowish, with a waxy lustre ; odor peculiar, balsamic ; taste bitter and acrid. When moistened with alcohol, Galbanum acquires a purple color on the addition of a little hydrochloric acid." Composition.-Like other substances of its class, Gal- banum makes a yellowish emulsion with water, and con- tains a varying amount of essential oil (six per cent., more or less) according to its freshness and softness. It con- sists besides of about three-fourths resin and one-fourth gum, excluding a variable amount of coarse impurities. The oil is a colorless, pleasant-smelling hydrocarbon of the turpentine type, the resin a yellowish-white amor- phous substance, soluble in alcohol, and remarkable for yielding by dry distillation a brilliant blue, rather thick Carter, H. Vandyke : On Mycetoma, or The Fungus Disease of India. London: J. & A. Churchill, 1874. Quarto (illustrated). (The above ar- ticle is based upon Dr. Carter's exhaustive monograph, corrected by references to the other authorities mentioned.) Lewis, T. R., and Cunningham, D. D. : The Fungus Disease of India. Calcutta : Office of the Superintendent of Public Printing, 1875. Oc- tavo. Cuts. Fox, Tilbury, and Farquhar, T. : On Certain Endemic Skin and other Diseases of India and Hot Climates Generally. London: J. and A. Churchill, 1876. Octavo. Illustrated. Questin, M.: Fungus Foot of India. Pacific Med. and Surg. Jour., vol. vii., 1873, p. 552. Kemper: A Case of Podelcoma, with Microscopic Examination of the Diseased Skin. Am. Practitioner, vol. xiv., 1876. Arthur Van Harlingen. Bibliography. FUSCH. A hospital and bathing establishment, "St. Wolfgang," two hours by stage from the railroad station, Bruck, in the Fusch valley, nearly four thousand feet above the level of the sea. As a resort Fusch affords all the advantages of an Alpine climate. It has also a cold water institution. J. M. F. GALACTAGOGUES (yaAa. milk, and aya>, to lead) is a term applied to agents believed to possess the power of increasing the flow of milk. It is barely possible that agents possessing this power do really exist among drugs, but if so the fact does not seem to have been clearly demonstrated. The statement that such and such drugs will increase the flow of milk has been made from time to time, but with a degree of looseness that has failed to carry conviction. That a generous and properly-regu- lated diet may increase the quantity and improve the quality of milk yielded by a nursing woman within cer- tain narrow limits, is as well established as that starvation will produce the opposite effect ; but even here the limits are very narrow indeed. No special dietetic rules can be formulated of general application, and no special articles seem of paramount importance. If her diet be generous in quality and quantity, and contain no positively dele- terious articles, a nursing woman will yield as much and as rich milk as is possible for her. But, of two women placed under similar circumstances in this respect, the one 286 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fungus Foot. Gall-Bladder. essential oil (see German Chamomile for a similar sub- stance), and the crystalline substance called Umbelliferous, which, in its turn, melted with potash, yields the deriva- tive resorcin, which has had some recent employment (ob- tained, however, from other sources) in medicine as an antipyretic and antiseptic. Galbanum is an old article of commerce, having been used by the ancient Hebrews as an ingredient of some in- censes, and by many peoples since for various purposes, including medical. It has had in its day, with other gum-resins, reputation as an emmenagogue and antispas- modic, and is occasionally still given with these qualities in view. Somewhat more often it is administered in chronic bronchitis or laryngitis as an expectorant or cough mixture. Rarely it is given in rheumatism, with probably no benefit. The principal present employment of this antiquated medicine is as an ingredient of stim- ulating plasters, of which two are officinal. It is extremely doubtful if in any of these directions it is not physio- logically a mere duplicate of numerous other turpentines and resins. Administration.-It should be heated and strained to separate dirt and refuse before employment in pharmacy ; a gram (ten to twenty grains) may be considered a full dose, and can be administered in pill form or as an emul- sion. The compound pills (Pilule Galbani Composita, U. S. Ph.): "Galbanum, 150 grains; myrrh, 150 grains; asafoetida, 50 grains; and syrup enough to soften the mass, made into 100 pills, are an improvement on simple galbanum as an antispasmodic, etc. Besides these, Gal- banum appears as a plaster {Emplastrum Galbani, U. S. Ph.): Galbanum, 16 parts; turpentine, 2 parts; Bur- gundy pitch, 6 parts; and lead plaster, 76 parts ; rubbed together and spread upon cloth or leather. It is also an ingredient of asafoetida plaster (Emplastrum Asafatida, U. S. Ph.), of which it comprises about fifteen per cent. Allied Plants.-The genus Ferula supplies a number of odorous gum-resins of peculiar composition and anti- spasmodic action (see Asafcetida). For the order see Anise. Allied Drugs.-Ammoniac, Myrrh, etc.; also the Turpentines in general. IP. P. Bolles. Icterus catarrhalis ; Icterus gastro-duodenalis ; Catarrh der Gallenwege ; Inflammation des voies biliaires.) Since the investigations of Wyss, Charcot, Legg, and others, a broader significance has been given to catarrh of the bile- ducts than formerly ; and, at the present time, pathologists are wont to include in the term all forms of jaundice save that due to stenosis and non-inflammatory occlusion of the ducts (by foreign bodies, growths, external pressure, etc.), or to a narrowing occurring as a sequence of a previous inflammation-catarrhal, suppurative, or ex- udative. (See Stenosis, etc.) For a full discussion of these questions, see Jaundice ; suffice it to say that to a catarrh of the finer bile-ducts has been attributed the jaundice of acute yellow atrophy of the liver, of phos- phorus and other poisons, and of the various fevers, thus narrowing the limits of haematogenous jaundice. This section will be devoted only to an account of catar- rhal inflammation of the bile-ducts in the common ac- ceptation of the term. Etiology.-A predisposition to catarrh of the bile- ducts is said to exist in persons of a bilious temperament. Persons liable to catarrh of other mucous membranes are prone to this affection. It arises very frequently from an extension of catarrhal inflammation from the stomach and duodenum, and thecauses which excite the latter con- dition are prominent in the etiology of the former. Hence, an attack may occur as the result of exposure to cold and dampness, of checking of the perspiration, of errors in diet, of over-eating, and of the ingestion of rich or fatty food, and of acrid substances, as well as of certain drugs and stimulants. A debauch is often followed by an attack, and the inhalation of noxious vapors and foul gases has been known to excite the disease. The so-called ' ' epi- demic " jaundice is thought to be due to a poison intro- duced from without through the food, drink, or air. I have had an unusual number of cases of mild catarrhal jaundice in children, in private practice, during the past season (autumn, 1885), and I learn that many cases have been observed by others. Hughes had about twenty at the Children's Hospital. The season has been unusually mild, epidemic diseases have not prevailed extensively, and the city mortality has been less than the average. The drinking-water has been poor, and doubtless may have been the cause of this widespread epidemic. A few authorities believe that in epidemic jaundice the duode- num is not involved; the ducts alone are inflamed. In addition to the causes which set up the catarrh of the bile-ducts, either coincidently with, or secondarily to, the gastro-duodenal catarrh, there are other local causal conditions existing in disturbances of the portal circula- tion. Obstructive cardiac disease and impeded pulmo- nary circulation from lung disease or feeble heart, lead to portal congestion, and hence to a venous stasis and conse- quent catarrh of the mucous membranes. Tumors in the abdotninal cavity, enlarged glands, or the enlargement of any of the organs, by interfering with the portal circula- tion, may set up a catarrh. Catarrhal inflammation of the bile-ducts, with or with- out gastro-duodenal catarrh, is frequently caused by ma- laria, by syphilis (in the secondary stage), and by gout (Murchison). Acute phosphorus-poisoning and lead- poisoning are often attended with gastro-hepatic catarrh. The jaundice that accompanies cholera, typhus, typhoid, and other fevers, pneumonia, pyaemia, and septicaemia, is due to a catarrh of the bile-ducts. Direct irritation of the mucous membrane of the ducts by mechanical causes, as by the passage of gall-stones or the presence of parasites, frequently causes a catarrh which may be local or diffused. Finally, it is said that pathological states of the bile itself irritate and excite in- flammation of the ducts. In persons who are starving, from choice or necessity, it is said that the bile, which is re- tained in the gall-bladder, becomes acrid and sets up an active inflammation. The jaundice that in rare cases ac- companies cirrhosis, amyloid and fatty liver, is due to a catarrh of the ducts. The season of the year is believed to have some influ- ence on the production of biliary catarrh-spring and autumn being the favorable periods ; hence the terms ic- GALANGA ; GALANGAL (Rhizoma Galanga, Ph. G.). Lesser Galangal. The source of tins article, Alpinia oflicinarum Hance, order Zingiberacece, is a perennial herb of flag-like habit, and the floral peculiarities of ginger and cardamon plants, viz., a trimerous flower with a three-lobed calyx, a three-parted, slightly irregular corolla, and six remarkable stamens in two rows, of which four are variously small and abortive, one is a large showy " lip," and one bears a perfect anther ; pistil inferior, with a three celled, many-ovuled ovary ; leaves lanceolate, ligulate, alternate, in two rows; rhizome fleshy, cylindrical, long, and creeping; nodes and scales conspicuous. It is an inhabitant of Hainan and other parts of Southern China, where it is also cultivated as an article of commerce. Galanga has been long known in Europe, as well as Asia, and was formerly esteemed as a domestic spice or flavor. The dried rhizome is cylindrical, often branched, about as large as the little finger, and in pieces two or three inches in length. The nodes are close together and very prominent. Texture hard, tough; color deep brown ; odor aromatic, curcuma-like; taste pungent. It con- tains an essential oil to which its odor is due, and prob- ably some pungent resin. Its qualities as a medicine are essentially those of ginger, q.v. As a medicine galanga is obsolete in Europe, and nearly so as a spice, although it is said to be used with other things in flavoring cordials, and in veterinary mixtures, etc. Allied Plants and Drugs.-See Ginger. W. P. Bolles. GALL-BLADDER AND GALL-DUCTS, DISEASES OF. (Krankheiten der Gallenwege; Maladies des roies biliaires). I. Catarrhal Inflammation of the Gall-bladder and Gall-ducts.-(Catarrhal jaundice ; Icterus simplex ; 287 Gall-Bladder. Gall-Bladder. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. terns vernalis, autumnalis, etc. Sex exercises no influ- ence on the frequency (Ewald, Von Schiippel); yet, in my cases, excluding "epidemic" jaundice, the males were largely in preponderance. The disease is most fre- quently seen in the early period of life, and after forty a jaundice is not likely to be due to primary catarrh, al- though one of my patients was seventy years of age. Firemen, puddlers, stokers, and laborers who are exposed to extremes of temperature, are liable to the affection. Morbid Anatomy.-In the milder forms post-mortem inspection reveals nothing, for, as we often find in a laryngitis so severe as to cause stenosis, the congestion and oedema subside after death. In the more severe va- rieties, redness, swelling, succulence, and often ecchymo- sis of the mucous membrane, are observed. The lumen of the ducts, if not occluded by the flaccid lining mem- brane, is filled with proliferated epithelium and mucus. The latter may be bile-stained, especially at first, or may be clear and viscid. A plug of firm mucus often stops the orifice. The papilla stands out prominently on the duodenal mucous membrane and is red and softened, but a probe readily penetrates the duct, and bile may be forced out by pressure of the hand on the gall-bladder, although the feeble " vis a tergo" of the biliary secretion during life is not sufficient to overcome the obstruction. The duct, beyond the seat of the catarrh, is stained with bile. In the more advanced or prolonged cases the ducts are completely blocked by a somewhat firm, gray mucus, intermingled with proliferated epithelium and leucocytes. The congestion is more intense, ecchymoses are more common, and a more marked thickening of the mucous membrane is observed, due to cellular infiltration. Now it is that denudation of the epithelial surface takes place, ulcerations develop, and the terminal ducts undergo in- flammation and dilatation from retention and irritation of the imprisoned bile. Anatomically, catarrhal inflam- mation of the ducts may be divided into an acute form of ten days' duration (no lesions after death, or only con- gestion and oedema), a subacute form, lasting from two to six weeks (with the above lesions, cell proliferation and mucus formation in abundance), and a chronic form, continuing from two to six or eight months (excessive ca- tarrh, abrasion, ulceration, dilatation, stricture, and re- tention abscesses or cysts). Catarrhal inflammation results either in the return of the parts to a normal condition, or in a stricture of the ducts (see Stenosis, etc., of the Ducts) and its sequences, or in a " biliary " or " hypertrophic " cirrhosis of the liver.1 Dropsy of the gall-bladder occurs also as a sequence of catarrh of the cystic or common duct, with occlusion. The seat of the catarrhal inflammation may be limited to the finer ducts, to the common duct, or to the cystic duct and gall-bladder. The pars intestinalis was formerly considered to be the only portion of the common duct in- volved in catarrhal icterus. If the finer ducts are the seat of catarrh, as in phosphorus-poisoning, the larger ducts are pale and covered with a film of mucus or a small amount of thin bile. If the gall-bladder be the exclusive seat, its mucous membrane undergoes changes similar to that of the duct ; its contents are a dark-colored inspis- sated bile, and mucus in abundance, or a thin, watery mu- cus or muco-pus fills the bladder. The histological changes in the parenchyma of the liver vary. Either the appearances of a liver long stained with bile are found, or the atrophic and degenerative alterations seen in stenosis of the ducts are observed, or a " biliary " cirrhosis develops. (Consult these sections.) Symptoms, Course, and Duration.-These depend upon the cause; if this be one that is readily removed or that passes off quickly, the symptoms are mild and the dura- tion brief, as in the catarrh that succeeds the passage of a gall-stone. If the affection arise from obstructive heart- or lung-diseases, the symptoms are mild, but the duration is long. The catarrh that accompanies malaria or a gastro-duodenitis is the most severe and protracted. The mode of onset, also, varies with the cause. The gastro- duodeno-hepatic form is usually preceded by gastric symp- toms for three or four days; while that due to other causes follows the usual manifestations of that cause. The description which follows is that of a catarrhal in- flammation of the ducts supervening upon duodenal ca- tarrh, which may be regarded as a type of the disease un der consideration. The affection may begin in any of several different ways: The gastro-duodenal symptoms may precede the hepat- ic by three or four days ; or the first" observed symptom may be jaundice; or the attack may be ushered in by a chill, followed by fever with gastric symptoms, and in a few days, by jaundice. Loss of appetite, a tongue cov- ered with a heavy yellow fur, pasty and bitter buccal se- cretions, and an offensive breath, are prominent. Nausea in the mornings, or at the sight of food, and vomiting of a glairy mucus, or, early in the attack, of a bitter, bile- stained, acrid fluid, may occur. At the same time there is epigastric distress, weight and fulness, some tender- ness on pressure, soreness, or even marked pain. Later there is pain and tenderness in the right hypochondrium and over the liver. It is denied by some authorities that the liver and gall-bladder are enlarged, but I have observed enlargement of the former constantly in chronic cases. The abdomen is usually distended with gas, and eructations of gas and the imperfect products of di- gestion occur. The bowels are constipated, or a diar- rhoea from indigestion may occur in the early stage. In a few days jaundice appears; first the conjunctiva, then the face, and in a short time the entire body is dis- colored. The icterus varies in extent and degree. The conjunctiva alone may be affected, and it may be merely of a faint yellow tinge, or, in chronic cases, of a deep bronze. The fever, which is from 100° to 103° F., gen- erally subsides with the advent of the jaundice, but it may continue, for ten days or two weeks, as a simple continued fever, the so-called "gastric" or catarrhal fever. The well-known symptoms and effects of obstruc- tive jaundice are present. (See article on Jaundice.) It is important, however, to remark the uniform per- sistence of the jaundice. Probably the most characteris- tic symptom is the slow pulse, which often distinguishes this form from other varieties of jaundice. Fagge calls particular attention to this symptom. Headache is present often in the beginning, with or without vertigo. After the jaundice becomes developed, the usual nervous symp- toms of the disease are manifested. If the case be a mild one, the gastric symptoms first subside, and then the jaundice gradually disappears, without any serious disturbances of nutrition. In the more protracted cases, however, anaemia, emaciation, and prostration are marked, the degree depending on the dura- tion of the disease. The mild idiopathic cases continue from ten days to three weeks, the more severe ones from six to ten weeks, and the more obstinate cases as long as five or six months. Should stricture of the duct take place as a sequence of the catarrh, and should suppuration of the ducts occur, and abscesses form, fever of an irregular type, often with chills, and with exhaustive sweats, will usually be present. A similar fever, or one of an intermitting character, also accompanies the development of secondary cirrhosis. In these instances the liver and gall-bladder are enlarged. Inflammation of the gall-bladder alone is characterized by pain and tenderness in the right hypochondrium, by enlargement of the gall-bladder, and by slight fever, with, at times, nausea. Jaundice, manifestly, is not present. Diagnosis.-The presence of one of the causes or ante- cedent pathological conditions just noted, the early age and previous good health of the patient, the sudden and uniform development and persistence of the jaundice, and the absence of the physical signs of organic disease of the liver, clearly indicate simple catarrhal icterus. Care must be taken not to confound it with the jaundice of acute yellow atrophy, and it must not be forgotten that, in apparently the most simple jaundice, grave cerebral and other symptoms due to acute atrophy may arise. Acute yellow atrophy may occur at an early age in the pregnant female ; the more marked epigastric pain, the jaundice of the upper portion of the body, the vomiting of blood, the cerebral symptoms, and the alterations in the size of the liver and spleen, serve to distinguish it. 288 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gall-Bladder. Gall-Bladder. The jaundice due to obstruction by gall-stones devel- ops quickly, is quite marked, and varies in its intensity from time to time ; paroxysmal and persistent pain is more pronounced than in the simple form ; the patient is usually a female, and the attacks occur late in life. The diagnosis must be made between jaundice from simple obstruction and that caused by pressure on the ducts. The physical signs and clinical history of the many forms of external pressure must be considered (see Stenosis, etc.). Pain, fever, sweats, increase in size and tenderness of the liver and gall-bladder, with prostration and emaci- ation, occurring late in the disease, indicate stricture and the formation of abscesses, or purulent inflammation of the ducts. If the jaundice continues longer than two months, if the pulse is frequent from the first, if sweats are marked, if emaciation rapidly ensues, and if the pa- tient is over thirty years of age, it is more than possible that some affection other than simple catarrh, and not re- vealed by physical signs, is present. It has occurred to the writer that the existence of a diarrhoea in the course of catarrh of the bile-ducts would indicate closure at the orifice ; for then the pancreatic duct would likewise be occluded, and diarrhoea, a well-known symptom of pan- creatic disease, would ensue. The presence of fat and blood in the stools would also point to this conclu- sion. Prognosis.-This is usually favorable, but depends more or less on the cause. Gastro-hepatic catarrh terminates favorably. The presence of symptoms indicating puru- lent inflammation of the duct renders the prognosis grave. Prolonged jaundice, with the advent of marked cerebral symptoms, is very serious. The possibility of the devel- opment of icterus gravis should not be forgotten. I re- call a case of jaundice in a man, aged thirty-five, whose habits and occupation, and the mode of development of the disease, clearly indicated simple jaundice. He was an excessive beer-drinker, and labored in a malt house. Ten days after the symptoms of gastro-duodeno-hepatic catarrh developed, "black vomit" set in, followed by cerebral symptoms and death in five days. The autopsy revealed an intense gastritis, with ecchymoses ; a catarrh of the bile-ducts, and a diffuse hepatitis. A simple pro- longed jaundice, that supervenes in the course of Bright's disease, is very serious ; the latter affection was so aggra- vated by an intercurrent jaundice, in one of my cases, as to result in death. I am inclined to think that the prog- nosis is seriously modified by inactivity of the kidneys, and that cerebral symptoms are not so liable to occur if the renal secretion is abundant. Htemorrhage, in any of its forms, is of bad omen. Treatment.-The line of treatment to be adopted de- pends entirely on the cause of the catarrhal inflammation. If it arise from cold and exposure and is seen early, a warm bath or a vapor bath, and the use of saline cathar- tics, or of small doses of tartar emetic, are of service. Full doses of quinine and Dover's powder at bed-time, with a light purge in the morning, will often relieve the general symptoms of " cold," and exert a favorable influ- ence upon the local catarrh. If the cause of the disease is a co-existing gastro-duodenal catarrh, a mechanical emetic, repeated twice on each of the first two days, is often of service. Large draughts of hot water, either at bed-time or repeated throughout the day, are grateful and beneficial. They are made more palatable by the addi- tion of some one of the alkaline citrates. At the same time an alkaline purgative, largely diluted, should be em- ployed, and then gastric sedatives or the mineral acids. Patients with catarrhal jaundice rarely apply for treat- ment until some time after the jaundice has appeared, and as this is generally due to a gastro-intestinal catarrh, a system of treatment that has usually been successful in these cases may here be presented. First, in the acute form : A mercurial purgative is first administered. I usually prescribe one-twelfth to one-third of a grain of calomel, in combination with from three to ten grains of bicarbonate of soda every two hours, until eight or twelve powders are taken. If the bowels are not acted on freely by this combination, it should be followed by a saline lax- ative. At the same time light sinapisms are applied to the epigastrium. After the bowels are freely opened, it will often be found that the tongue has already cleaned somewhat, and the bad taste, the nausea, and the vomit- ing have been relieved. If this happy effect has been produced, a weak acid or an alkali and bitter may be used. On the other hand, if the symptoms are not re- lieved, and the tongue is clean, denuded of epithelium, or pointed, red at the tip, heavily furred, and the epithelium rapidly shed, a sedative is indicated. This is especially called for if the following symptoms are associated : pain, a sinking sensation in the epigastrium, and nausea, when the stomach is empty, with weight and fulness after eat- ing, and vomiting with or without diarrhoea. Of the sed- atives, the salts of silver stand first; preferably the ni- trate, administered in pill form, or, to children, dissolved in thin, strained mucilage. If diarrhoea be present, opium may be added, or if the bowels are confined, extract of belladonna. One-eighth to one-fourth of a grain of ni- trate of silver, and an equal amount of extract of bella- donna, or one-sixteenth to one-eighth of a grain of pow- dered opium, may be combined in one pill, which should be given half an hour before meals. Bismuth, small doses of calomel, in combination with morphia, if pain and diarrhoea be present, and other sedatives (liq. potas. arsen., creasote) may be used. If the tongue is flat, some- what flabby and coated, but the epithelium is sluggishly removed, then an acid is; indicated. The continuance of the sedative or acid for some time usually suffices, al- though often the occurrence of flatulence and other ef- fects of putrefaction demand the use of alkalies, carmin- atives, absorbents, and anti-fermentatives. In the more chronic cases, however, in which the gastro-duodenal catarrh has subsided, w'e have other conditions to deal with, and the indications are to remove the obstructing mucus and reduce the inflammation and thickening of the ducts. These indications may be met by remedies that in a measure increase the secretion of bile and thereby drive away the obstruction, or by drugs that render the mucus less viscid and that relieve the congestion. Among the remedies of this latter class the alkalies are of great service, and may be given in the form of the alkaline ef- fervescing waters, as the Carlsbad, Vichy, or Hathorn wa- ters, or the salts of ammonium, sodium, or potassium, may be used. Bartholow advocates the phosphate of so- dium in drachm doses ; Guiteras, iodide of potassium in small doses freely diluted, and taken fasting. The muri- ate of ammonium is one of the most reliable alkalies ; it may be given in ten- or twenty-grain doses, three or four times daily, combined with an equal quantity of powdered licorice, and dissolved in water. Ipecacuanha has been advocated in small doses, as one-half to one grain, fre- quently repeated, for the same purpose. To increase the secretion, nitro-hydrochloric acid, the vegetable hepatic stimulants, benzoate and salicylate of soda, and alkaline waters are of service. The alkalies should be taken in a large amount of water, preferably hot, on an empty stomach, and by slowly sipping the fluid. Emetics are also used for their mechanical effect. These measures have rendered good service on two occasions in the writer's practice, but care must be ob- served lest the too free use of the remedies here mentioned (emetics) incite a fresh catarrh or aggravate the one already existing. Mosier and afterward Krull have successfully treated catarrhal jaundice with enemas of cold water. They in- ject, once in twenty-four hours, from one to four pints of cold water (59° F.) slowly into the rectum, and require the patient to retain it as long as possible. With each in- jection the temperature of the water is gradually raised, otherwise it will not be retained. By pressure on the fundus of the gall-bladder, if it be readily grasped, directing the force toward the vertebral column, Gerhardt has succeeded in overcoming the ob- struction and relieving the jaundice. The same author recommends the application of electricity. A strong in- duced current with slow interruptions is used ; one elec- trode is placed over the gall-bladder, the other on the back at a point directly opposite, and close to the spinal column. No doubt Kussmaul's treatment of intestinal obstruction, 289 Gall-Bladder. Gall-Bladder. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by washing out the stomach, would be of service in this affection. The diet should be bland and non-irritating. Fats, sugars, and, as a rule, starches, should be excluded, as well as spirituous or malt liquors. Light broths, beef-tea, milk, and later, meats, fish, eggs, and oysters should be the chief articles of diet. Afterward tomatoes, lettuce, spinach, celery, and the like may be used. The troublesome, and at times serious, effects of the jaundice will be treated of under that heading. II. Purulent, Ulcerative, and Croupous In- flammation of the Gall-bladder and Gall-ducts (Cholecystitis et Cholangitis Suppurativa, diphtherica, exul- cerans, and crouposa (Schiippel); Exsudative Entzundung der Gadenwege (Frerichs); Cholecystite et Angeiocholeite). Etiology.-Foreign bodies in the biliary passages readily set up purulent and ulcerative inflammation. This is the most serious pathological sequence, therefore, of gall- stones and parasites. Stenosis and occlusion of the ducts in any part of their course may also frequently give rise to this form of inflammation, and it has been observed to take place in chronic catarrhal jaundice. The pent-up bile is believed to be the cause of the inflammation in these cases. In typhoid and typhus fevers, in cholera and in septic diseases generally, suppurative inflammation may occur. It is not believed to arise idiopathically, although Von Schiippel can see only a difference in degree between a catarrhal inflammation of the ducts and this variety, and believes intensified causes of the former will produce the latter. No evidence exists to prove that external in- juries have anv etiological significance. It has been held that pathological states of the bile are sufficiently irritat- ing to cause the disease, and this explanation suffices in the case of fevers. Most authors regard a lowered state of the system and a certain vulnerability of the tissues as efficient causes. Extension of purulent inflammation from adjoining veins, or from hepatic abscesses, appears to have been the cause in some instances. It is certainly true that a multiform inflammation of the ducts may oc- cur by extension of inflammation from some one localized focus, as an ulcerating gall-stone. This form of biliary in- flammation is usually met with in advanced life. Croup- ous inflammation of the biliary passages is also caused by gall-stones. Von Schiippel reports a case of apparently idiopathic origin. Morbid Anatomy.-The cases that have been observed by the writer presented nearly all the anatomical appear- ances that occur in cholangitis and cholecystitis. A de- scription of them will, therefore, indicate the morbid anatomy of this severe form of inflammation. The first case was one of chronic catarrhal jaundice, with obstruc- tion of the hepatic duct, following catarrh of the duo- denum. (See Trans. Coll. Phys., 1884, iii.) The liver was firmly adherent to the diaphragm over its entire right lobe, and over a part of the left; it was one and a half time the normal size, occupying the position de- fined in life ; its color was a dark bottle-green. The gall- bladder was about as large as the fist, with thickened walls and inflamed mucous coat, and contained bile. The cystic duct was dilated to almost the thickness of a lead- pencil ; at its junction with the gall-bladder there seemed to be a honeycombed projection of the mucous membrane, by which the duct was occluded. The common duct was enlarged, walls thickened, calibre increased enough to ad- mit forefinger ; mucous membrane inflamed ; orifice im- pervious to blowpipe and to liquid, although a small probe could be forced through with some difficulty from the duodenum ; the mouth of this, in common with the pan- creatic duct, presented a knob-like projection a little larger than a split pea in the mucous membrane of the duodenum, the walls of which were thickened ; there was no evidence of ulceration or cicatrix. The hepatic ducts were dilated and inflamed in their ramifications through the liver, some terminating in blind pouches. In the periphery of the left lobe of the liver there were several retention cysts, abscesses the size of a filbert, filled with pus and bile ; the tissue of the liver was very soft, olive- green in color, and had the appearance of disintegration. The second case was one of carcinoma of the gall-blad- der and occlusion of the ducts, and secondary exudative inflammation. (See Trans. Path. Soc., Phila.) The hepatic duct was enlarged, its walls thickened, and its calibre much increased. The branches extending into the upper half of the right lobe were greatly dilated, even almost to the periphery of the liver, terminating in saccular dila- tations. The ducts contained a thick grayish-green mat- ter ; the walls were of a slate-gray color, dotted with dark points. The liver-substance traversed by these ducts was dark and soft, not unlike gangrenous tissue. A part in the centre, about three inches square, was especially of this appearance. The remainder of the structure of the organ was slightly stained with bile, and fatty in appearance. In a third case, the inflammation was secondary to an impacted calculus, and in addition to dilatation and in- flammation of the walls, small abscesses were observed containing calculous material, and in the ducts a few small ulcers were seen. There is observed, therefore, a swollen, thickened mu- cous membrane, of a pale ashen or slate-gray color ; uni- form or saccular dilatation of the ducts, and abscesses in the periphery of the duct, or along its course. Often a gangrenous appearance of the duct-wall is seen. The dilated canals and the abscesses contain yellowish-green bile and pus, sometimes thick and ropy, and often ichor- ous. The dilatation is most frequently confined to, or most marked in, the left lobe of the liver, and Legg says the dilated pouches and ducts are lined with columnar epithelium. Ulcers are often found, superficial in char- acter, large, and irregular, or quite deep and small. From the healing of the ulcers and the contraction of the cicatrix, the ducts beyond the obstruction are obliterated. This may also occur after exudative inflammation ; and in the liver fibrous bands, the remains of the biliary chan- nels, are often seen. The tissue of the liver beyond be- comes sclerosed, and the cells proper undergo atrophy and degeneration. The abscesses of the liver may extend into a contiguous vein, or may ulcerate toward the sur- face ; hence a peri-hepatitis is often seen. Sometimes one large abscess alone is found ; rarely do they become en- capsulated. The ulcers that have formed are often cov- ered with a gray, gangrenous detritus, which is removed with difficulty. This characterizes the diphtheritic form. In the croupous inflammation of the ducts, fibrin cylin- ders, well moulded and easily removed, are found. The hepatic structure undergoes some changes: in the mild forms either a connective-tissue overgrowth lights up, or a diffuse hepatitis arises; in the chronic forms with jaundice the liver-cells are icteric, compressed into vari- ous shapes, and present the appearances of having under- gone fatty or granular degeneration. As a sequence of purulent or exudative inflammation of the gall-bladder, marked phenomena are observed. The mucous membrane undergoes the usual changes, the walls become thickened, and the cavity is filled with pus, muco-pus, or pus and bile. Ulcerations, simple or diph- theritic in nature, are formed, and may penetrate to the peritoneal cavity. Adhesions take place between the gall-bladder and neighboring structures, fistulye develop, and often the ad- jacent tissues are tilled with pus. The ulcers are single or multiform. In mild cases a fibrous thickening of the walls of the gall-bladder and its surroundings takes place, followed by contraction and obliteration of the organ. Twice the writer has found the gall-bladder firmly con- tracted around imprisoned gall-stones, and in one case numerous sacculi had been formed, each sac containing a gall-stone surrounded by bands of fibrous tissue. On the other hand, the gall-bladder may undergo extreme dila- tation and enlargement, producing an empysema. If the phlegmonous inflammation be confined to the walls, this structure may undergo calcareous degeneration (so-called " ossification "). Symptoms, Cause, Duration.-The symptoms are those of the causal condition, as one of the low fevers, gall- stones, etc., combined with the local inflammatory mani- festations. Often the condition is not recognized during life, or there may be present only an irregular fever, with rigors. In the course of a low fever, unless a marked in- 290 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gall-Bladder. Gall-Bladder. flammation of the gall-bladder be present, the disease lasts about two weeks, and may not be characterized by any symptom, or may be manifested only by an increase in the fever, and the occurrence of exhaustion. If, after an attack of hepatic colic, fever of an irregular type, chilly sensations, or sharp rigors, occur, and prostration ensues, independently of any paludal affection, we may suspect ulcerative inflammation of the bile-ducts. In these cases, the jaundice, which is usually present, deepens, pains in the hepatic region are marked, and a fixed local pain in the right hypochondrium is complained of. If the gall-blad- der is involved, the physical signs of enlargement of that organ are observed (see Enlargement of the Gall-bladder). As the inflammation proceeds, the symptoms of peri-he- patitis, local or general peritonitis, occur. In addition to pain in the region of the gall-bladder, we have pain and tenderness frequently in the epigastrium. With or with- out this local inflammation, vomiting is frequent, haemor- rhages occur from the stomach and bowel, and often a diarrhoea is started. Budd believed that many cases re- covered. If so, the burrowing of the pus must have been in the direction of the stomach or duodenum. An increase of local tenderness, and the presence of tumefaction and redness, show that the direction which the pus is taking is toward the surface. Discharge of the abscess in this position leads to the formation of cutaneous biliary fistu- la. If this fortunate termination does not occur, and in a cholangitis it is not to be expected, the fever continues, the gastro-intestinal digestion gives way completely, a typhoid state of the system arises, cholaemia frequently occurs, and finally death. A fatal result may occur from exhaustion, due to the combined influences of the fever, the suppuration, the gastro-intestinal disturbances, and the jaundice ; or a peritonitis from perforation or rupture of the gall-ducts, or a pylephlebitis, may hasten the fatal termination. Haemorrhages are also liable to occur if the jaundice is of long duration, and will add to the extreme debility. Cholecystitis, due to foreign bodies or to obstruc- tion of the cystic duct, may run its course, and the con- tents of the bladder be discharged into the neighboring hollow viscera, or externally, without the supervention of grave general symptoms ; local phenomena and physi- cal signs alone indicating its presence. The fever that attends inflammation of the bile-ducts is peculiar. It has been called intermitting hepatic fever by Charcot. Since the time of his observations, which, though they were not the first, were the most complete and conclusive, others have studied the affection carefully. It is not to be confounded with the reflex fever from the pas- sage of a gall-stone. It can be distinguished from malaria by its refusal to yield to quinine, by the diminution of the amount of urea in the urine, and by the extreme irreg- ularity in the time and character of the paroxysms.2 It is produced by the absorption of the pus and bile-products in the ducts, and is a form of septicaemia. It generally begins one or two wreeks after the inflammation has ex- isted, or after the passage of the gall-stone which pro- duced the inflammation. It continues until the death of the patient, or may cease in from one week to three months after its inception. (Charcot.) Croupous inflam- mation of the gall-ducts presents no marked symptoms, but it is of importance to note that jaundice is absent. Diagnosis and Prognosis.-The diagnosis is uncer- tain, and when the symptoms are latent it is manifestly not possible. Pain and swelling of the liver, with tender- ness on pressure, irregular chills and fever in a person who is jaundiced, or who has had an attack of gall- stones, are strong evidences of exudative inflammation. Cholecystitis may be recognized by local symptoms (see Enlargement of the Gall-bladder). The prognosis is very unfavorable on account of the many accidents that may arise. Treatment.-Stimulants, tonics, quinine, medicines to allay gastro-intestinal irritation and dyspepsia, and morphine or other preparations of opium to relieve pain, are the only means at our command to combat the dis- ease. In cholecystitis the local applications of poultices, etc., tapping of the bladder, and the performance of chole- cystotomy are important measures. III. Stenosis and Occlusion of the Gall-ducts. -The canal is occluded when it is completelyclosed ; par- tial closure, sufficient to cause obstruction, is denominated stenosis. These conditions may be congenital or acquired; the acquired forms alone are treated of in this connection. The causes of each are the same, and the results are sim- ilar. The obstruction may be due to foreign bodies within the duct, to diseases of the duct-walls, or to external pres- sure. 1.. The foreign bodies which may find lodgment within the ducts are gall-stones, parasites, or in rare cases-if the orifice of the duct is very patulous, as occurs after the passage of a gall-stone-cherry-pits, plum-stones, or raisin-seeds. The gall-stones are generally impacted in the cystic duct, or at the mouth of the common duct. The common round worm has been found in the lumen of the duct. The liver fluke also causes stenosis; but complete obstruction is not effected without the interven- tion of local inflammatory symptoms. The rupture of an echinococcus sac into the ducts, and the discharge of the vesicles, causes temporary obstruction. Complete closure is caused by multilocular echinococcus tumors, which cause infiltration, thickening, and ulceration of the wall of the duct. The hepatic and cystic ducts are chiefly in- volved. 2. Chronic catarrhal inflammation, purulent and ulcer- ative inflammation, carcinoma or other morbid growths of the ducts, and a peri-hepatitis with thickening of the investing membrane, leading to hypertrophy of the subse- rous connective tissue and occlusion of the duct. In the inflammatory forms, granulations in apposition coalesce, and the formation of a stricture ensues. When ulcera- tion has previously occurred, the stenosis is due to the contraction of the cicatrix. The causes mentioned in the sections treating of those affections are the primary causes, therefore, of the stenosis. The lumen of the duct becomes absolutely imperforate in the inflammatory vari- eties, and the occlusion may extend over a variable length, though it most frequently exists in the common duct. The lumen is not completely occluded in cicatricial stric- ture, but is impermeable, and is not unlike a urethral stricture. Local or extended thickenings of the duct causing stenosis are due to a connective-tissue hyper- plasia, which originates in a previous catarrhal inflam- mation. The cicatrix of a duodenal ulcer sometimes in- cludes in its grasp the duodenal opening of the common bile-duct. Carcinoma of the biliary passages will be treated of in a separate section. The peri-hepatitis, which includes in its course the investment membrane of the ducts, is caused by general peritonitis, by right-sided pleurisy, by affec- tions of the liver and adjacent organs, which set up irri- tation, as cancer, cirrhosis, ulceration, etc. As the peri- toneal thickening and the new inflammatory tissues grow in age, they contract and thus encroach on the lumen of the ducts. Syphilis is said to be a cause of this local in- flammation. 3. External pressure is caused by disease or displace- ment of contiguous organs. Named in their order of fre- quency, it is often found that affections of the pancreas, the lymphatic glands in the hepatic fissure, the duo- denum, the stomach, the omentum, and the kidpey are the sources of pressure. Carcinoma or hypertrophy of the pancreas, carcinoma, tuberculosis, amyloid disease or lymphosarcoma of the lymphatic glands, carcinoma of the stomach, duodenum and omentum, and tumors of the kidney (hydronephrosis or carcinoma) are the essen- tial pathological conditions which lead to the occlusion. Aneurisms of the aorta (Hatton), and of the hepatic artery (Gairdner), cause obstruction. Very rarely tumors of the ovary and uterus, and faecal tumors, are the cause of oc- clusion. The anatomical sequences of occlusion and stenosis of the biliary passages are dilatation of the ducts or gall- bladder behind the obstruction, catarrhal or suppurative inflammation of the ducts, enlargement of the liver, at first from the excessive dilatation of the canals, and then from a hypertrophic or biliary cirrhosis, and subsequent 291 Gall-Bladder. Gall-Bladder. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. atrophy of the liver from pressure of the ducts on the se- creting tissue, or destruction of the cells by the connective- tissue overgrowth. The dilatation of the ducts is often extreme. The com- mon and hepatic ducts are as large as the intestine, and their walls thin, though rupture rarely takes place. The ducts in the liver are also dilated to the size of the finger, throughout their extent, even to the surface, causing it to have a vesicular appearance. The walls are not greatly thickened, and are lined with columnar epithe- lium. The mucous membrane is pale and smooth. The ducts terminate in large pouches, and numerous recesses are seen in the course of the cylindrical canal. Retention cysts are often found. At first the biliary channels are filled with bile only, but after a time this fluid is replaced by a secretion from the glands of the mucous membrane, which is limpid, viscid, and serous in character. The chemical and microscopical examination of the fluid gives no indication of bile constituents. The reaction of the fluid is neutral; it contains albumen, and in some in- stances-as in two of the cases observed by the writer-nu- cleated corpuscles are formed after standing. When this fluid is found in the bile-ducts, bile is not secreted in them, and the mucous membrane of the ducts is in truth a cyst wall. Whatever bile is secreted is at once absorbed. 'The liver is icteric and anaemic ; flaccid at first, cir- rhotic afterward. The cells undergo atrophy, contain bile-pigment and minute oil-globules ; while cloudy swell- ing of the protoplasm is observed. The changes peculiar to "hypertrophic " cirrhosis are observed later. A description of the changes in the gall-bladder is re- served for the section on Enlargement of the Gall-blad- der. The Symptoms are complex, and include the symptoms of the primary cause and those of biliary obstruction. Aside from the physical signs and symptoms of the causal disease, jaundice3 is the first symptom. As a rule, the yellowish tinge gradually changes to a deep olive-green color, and with it the changes in the urine take place ; gastro-intestinal dyspepsia is developed, and finally, a veritable catarrh supervenes, with its full train of symp- toms. Early in the disease weight and tension in the epigastrium and hypochondriac region are complained of, and enlargement of the liver and gall-bladder are observed. After a time pruritus comes on, and in from two to four months haemorrhages ensue. Loss of flesh and strength rapidly takes place in a short time. Soon, if the orig- inal cause has not produced death, or an intercurrent disease proved fatal, the symptoms of cholaemic intoxi- cation may arise, and death results from this condition. One cannot, within the limits of this article, discuss in detail all the forms of biliary stenosis and occlusion, and their differential diagnosis; persistent jaundice, the ab- sence of bile in the stools, and its presence in the urine, clearly indicate obstructive jaundice. There are some or- ganic diseases of the liver, howrever, which give rise to jaundice, the mechanism of which is not by occlusion, which should be distinguished from other forms of ob- structive jaundice, on account of the opposite methods adopted for their treatment. Reference is made to atrophic and hypertrophic cirrhosis, to carcinoma, to simple and multiple abscesses, to simple and multiform hydatid dis-, ease, and to amyloid disease. The recognition of any of these is nbt difficult. The atrophic variety of cirrhosis is easily recognized by its wrell-known symptoms, but not so the so-called hypertrophic cirrhosis. The jaundice is in- tense, the liver enlarged and smooth, ascites is absent, paroxysmal pains occur, and irregular fever is present.4 In other forms of obstruction the liver is not so large, the gall-bladder is enlarged, while a distinct cause for the jaundice, as a tumor, may be discovered. Regarding multiple abscesses, Dr. Carrington5 analyzes a series of cases, and shows that the following group of symptoms portray the disease : The patient is extremely ill, and "the illness appears to be abdominal," with evidences of local or general peritonitis; he is emaciated ; his abdo- men is distended and the seat of pain ; the liver is en- larged, painful, and tender ; vomiting is frequent; diar- rhoea or constipation occurs in an equal proportion of cases ; jaundice in one-third of all cases ; the temperature is irregularly febrile; rigors occur occasionally; the pulse and respiration are hurried. The cause of these abscesses is either the occurrence of an ulceration at some point in the area of the portal circulation, or they occur in the course of occlusion of the ducts. There is no one sign or symptom pathognomonic of this disease, and it can be inferred only by the previous history of the patient with the grouping of the detailed symptoms. Having discussed the question of occlusion due to any one of the etiological factors previously noted, a brief reference, for diagnostic purposes, will be made to these causal conditions. 1. Foreign Bodies.-If the obstruction be due to worms, the latter may be recognized by the age of the pa- tient, and the presence of the parasite in the ejecta. Their presence is indicated by an attack of hepatic colic, but an absolute diagnosis cannot, and practically need not, be made. This, however, is not so in the case of hyda- tid cysts, bursting into the bile-ducts, with symptoms of hepatic colic. The diagnosis can be more readily made in this instance : first, by the previous history and phys- ical signs of an hydatid tumor ; second, by the disappear- ance of the tumor after the colic; third, by the subse- quent occurrence of fever and local inflammation ; and lastly, the appearance of sacs or booklets in the vomited or aspirated matter. Gall-stones.-It is of the utmost importance to deter- mine the presence of biliary calculi. The differentiation of them is sometimes very difficult, and, in fact, often im- possible. The varying symptoms of cholelithiasis are so many that it is not possible to name one of them, or to present a group of them, for the purpose of making a diagnosis, without being able to give an exception to each and every one. The only absolutely definite sign is to see or feel the calculus. If one has been passed by the rec- tum, it probably was the cause of obstruction ; if it have facets, a fellow-calculus may be the cause.6 If not detected in the stools, exploration of the gall-bladder must be re- sorted to, either by opening the abdominal cavity, or, as successfully practised by Whitaker, by the insertion of long needles into the viscus.1 Martin-Solon (Jour. des Conn. Med.-Chir., Paris, 1849, xxxiii.) reports a case in which the stones could be detected on palpation if the patient took a forcible inspiration, the hand being on the gall-bladder. He considered it a new mode of diagnosis. Aside from these positive methods, a correct conclu- sion cannot be arrived at without a study of the case in its entirety; the age and sex of the patient, the habits, the family history, the temperament, all are important elements to be considered. If these circumstances are favorable, and if, in addition, the patient has had previ- ous attacks of hepatic colic, followed by jaundice and the symptoms of duodenal catarrh ; if constipation and putty- colored stools accompany the jaundice, the diagnosis is very probable. Then, if, after impaction has taken place, the nutrition of the patient remains good for a long time, the liver enlarges only slightly, while the gall-bladder in- creases in size, it is scarcely possible to name any other affection. Campbell (Brooklyn Annals) suggests that, if after as- piration of the gall-bladder bilious stools are present, cal- culi are the cause of the obstruction. The relief of the tension allows the stone to recede, and the bile to escape. 2. Diseases of the Ducts.-a. Congenital closure. Jaundice in an infant, continuing over four weeks, with supervening cholaemia, is due most frequently to this con- dition. b. Closure of the ducts by chronic catarrh of the duodenum, adhesive inflammation of the ducts, the cica- trization of an ulcer in the duct or at the duodenal ori- fice, and by fibrous bands. The first may be recognized by exclusion, and the history of the cause, and the at- tack, of catarrhal jaundice. Adhesive inflammation of the ducts is due either to the passage of biliary calculi or to a previous catarrh. The respective symptoms of the two must be considered in such case. Ulcers in the bile-ducts are due to gall-stones, or are secondary to the low fevers. In the former case, in ad- dition to the symptoms of gall-stones, we have, accompa- 292 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gall-Bladder. Gall-Bladder. nying the ulceration, irregular chills and fever and ex- treme exhaustion, conditions not likely to be present in the early stages, at least, of simple impaction. If the symptoms of occlusion become developed after such phenomena or after a low fever, the exciting cause is probably the cicatrization of an ulcer in the duct. The well-known symptoms of duodenal ulceration precede for a long time the symptoms of obstruction of the biliary passages from this cause, and while it may be said that the gall-bladder is enlarged under such circumstances, it is not necessarily so when the seat of ulceration is in the duct. Closure of the ducts by fibrous bands may be in- ferred, if the cause (as syphilis) and the symptoms indi- cate a peri-hepatitis, and if other evidence of old lymph be present, as atrophy of the liver, or ascites, etc., due to pressure on the portal veins. 3. Diseases External to the Ducts.-a. Carcinoma and other neoplasms of the liver and surrounding organs. A recognition of these affections can be obtained by the exclusion of other causes of obstruction, by the presence of tumors or nodules, and by the physical signs on palpa- tion, etc.; also, when these are present, by the alterations of the functions of adjacent organs, and by the presence of the symptoms of malignant disease of these organs ; and finally by the duration of the disease, the stenosis from carcinomata being of shorter course than that due to other causes, b. Enlarged lymphatic glands. Ob- struction from this cause is probable, if there be else- where present any of the well-known causes of hyper- trophy of these glands, as carcinoma, tuberculosis, amy- loid disease, etc. Amyloid disease but rarely causes jaundice, except in this way ; its symptoms are too w ell known to be detailed in this article, c. Aneurism. This rare form of occlusion may be recognized by the pressure-symptoms of a tumor located in the region of the duodenum, and by the physical signs of aneurism. The course of the disease, in occlusion of the biliary duct, is a chronic and, most frequently, a progressive one. It is a gradual march to death, except in cases in which foreign bodies cause the occlusion. Under these circum- stances their removal by ulceration or the escape of bile around them, may be followed by recovery. Death is the result of the original cause of the disease in many cases. Exhaustion or cholsemia often brings about a fatal termination. The duration varies with the cause, and is modified by the onset of accidental complications. Com- plete occlusion may terminate in recovery even after a lapse of six years. The prognosis is unfavorable, depend- ing on the nature of the causal lesion. Haemorrhages render the prognosis very grave. The supervention of symptoms of cholesteraemia is serious. The return of color to the stools is of more favorable import than is a change in the skin discoloration. The treatment is mainly directed to the relief of symp- toms. Medicinal remedies are of but little avail, and resort must be had to surgical measures. The regula- tion of the diet is of the utmost importance to the con- servation of life. (See Catarrhal Inflammation.) Means must be taken to overcome the gastro-intestinal symptoms that result from the absence of bile in the intestines. The bowels must be regulated, the secretion of the kidneys kept active, and the activity of the cutaneous glands pro- moted. IV. Enlargement of the Gall-bladder.-Under this caption all forms of enlargement of the gall-bladder will be described, as it is by the clinical study of this mani- festation of the disease that we, to a large extent, deter- mine the nature of the ailment, and the indications for treatment. The gall-bladder is enlarged from the accumulation within it of bile, of pus, of mucus, and of gall-stones, and from disease of its walls-carcinoma. Increase in size from bile, pus, or serum is usually styled simple dilata- tion. Carcinoma of the biliary passages will be treated of in a separate section. Accumulation of the fluids just indicated is due either to obstruction of the duct, or, in rare cases, to a paralysis of the muscular coat of the gall- bladder from over-distention. The dilatation from bile or pus may be temporary, and in such a case is caused by an obstruction catarrhal in nature, or by the presence of a gall-stone, which acts as a ball-valve in the lumen of the ducts. Permanent enlargement from accumulation of bile follows an obstruction of any kind of the cystic or common duct. The walls of the gall-bladder are uniformly distended and thinner than normal, the mucous membrane is smooth, and there are no adhesions to the surrounding parts. Sometimes the dilatation is extreme. From a patient of Babington's, three wash-basins full of bile were with- drawn, and in another case the gall-bladder was so dis- tended as to resemble an ascites (Coupland). The con- tents are at first bile, but as the obstruction continues, this becomes more and more intermingled with mucus. If serum accumulates, causing enlargement (hydrops cystidis felleae), the obstruction is usually of long dura- tion. The inner surface of the mucous membrane is like a serous membrane in appearance, and the accumulated fluid is the result of secretion from this membrane. Ad- hesions are also absent in dropsy of the gall-bladder, and the walls of this organ are much attenuated. The chem- ical character of the fluid has been described when speak- ing of occlusion. Empyaema, abscess of the gall-bladder, results from an inflammation of the walls of this viscus, set up by the presence of gall-stones or accumulated bile. Cases have been reported which were apparently of idiopathic origin, and others secondary to low fevers. The same anatomi- cal changes are presented as have been described under purulent, etc., inflammation of the gall-bladder. The walls of the organ are friable and easily ruptured. Ad- hesions to the surrounding parts are usually formed, and a fistula established. Pus, or pus and bile, and almost always gall-stones, make up the contents. The accu- mulation of gall-stones in the gall-bladder causing en- largement, is not uncommon. Symptoms.-The presence of a tumor in the region of the gall-bladder is common to all forms of enlargement. The nature of a tumor observed in this region is deter- mined by its position, size and shape, by the characters revealed by palpation, and by the nature of its contents. The gall-bladder may be known to be enlarged when it is situated under the free border of the ribs, at a point where it is crossed by a line drawn from the tip of the shoulder to the symphysis pubis (Janeway). As enlarge- ment progresses, the direction it takes is usually toward the umbilicus, or into the iliac fossa. An area of reson- ance intervenes between the tumor and the liver, and the intestines are never in front of the organ. The tumor may be pyriform, oval, semi-globular, reniform, or heart- shaped. The size varies from that of a walnut to that of a child's head ; it may even distend the ribs on both sides (Coupland). On palpation, the tumor may be fixed or movable, tender on pressure, firm, elastic, and fluctuat- ing. If enlarged by gall-stones, a grating sensation may be experienced on palpation, and the mass will be hard and firm. The nature of the contents may be revealed by sounding with a fine needle, grooved needle, or an as- pirator. A chemical examination of the mucoid or serous fluid that may be withdrawn should be made. The general condition of the patient, and the symptoms presented, depend on the cause of the obstruction. (See Purulent Inflammation, etc.) Diagnosis.-A differential diagnosis must be made between enlargement of the gall-bladder and many forms of abdominal tumors-hepatic, gastric, duodenal, pan creatic, and lymphatic tumors. (See Occlusion, etc.) Abscess of the liver and hydatid disease must be ex- cluded. In the former, the cause, the general and local symptoms, the absence of jaundice, the induration, and then the softening and fluctuation of the swelling, should be noted. The painless, slow course of hydatid disease, the broad base of the cyst, the fremitus, and the result of tapping will serve, if taken with the negative symptoms of enlargement of the gall-bladder, to render the recog- nition of this disease possible. In multilocular hydatid disease the tumor resembles an enlarged gall bladder con- taining calculi ; like the latter, it is nodulated, hard, and tender, but it is associated with early jaundice, ascites, an 293 Gall-Bladder. Gall-Bladder. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. enlarged spleen, oedema of the lower eyelids, great ema- ciation and prostration, with rapid decline of the patient's general health-conditions which, excepting jaundice, are not likely to be present in gall-stones. Floating kidney, and renal and ovarian tumors, have been mistaken for enlargement of the gall-bladder. Such an error will not often be made if it be remembered that the enlarged gall- bladder is more movable at the lower than at the upper portion ; that one end is larger and more rounded than the other; that fluctuation may be present; and that biliary symptoms generally exist; while the absolute sign of floating kidney, an abnormal area of resonance in the renal region, is absent. Tapping would also be in- valuable as an aid. In sarcoma of the kidney, hydro- nephrosis, and pyo-nephrosis, there are changes in the urine to call attention to them. Those renal tumors at first always have the intestines in front of them ; they are not influenced by respiratory movement, nor is their area of dulness on percussion continuous with that of the liver ; in hydro-nephrosis, a previous renal colic, and possibly frequent discharges of urine followed by dimi- nution in size of the tumor, occur. These questions of diagnosis arose in the study of the case of Kocher. He relied much on the results of exploratory puncture, as previously discussed. A connection between the tumor, and the uterine appendages, and the seat of origin and direction of development of the growth, are the pointe in favor of ovarian tumor ; in addition to which, if the fluid be characteristic, the diagnosis of such a tumor would be doubtless correct. A recognition of the various forms of enlargement of the gall-bladder can be made by attention to the results of palpation and exploratory puncture, and by a consideration of the history of the case. A cancer- ous tumor of the gall-bladder is fixed, painful, not very large, attended by gastric symptoms and cachexia. Course, Duration, Prognosis.-These all depend upon the cause. Abscess of the gall-bladder is manifested by active symptoms and runs a rapid course. It may termi- nate favorably by communicating with the exterior, or the stomach, or intestines, although long-continued dis- charge from the fistula might be serious. The prognosis of this condition depends on the direction in which the pus may burrow. Accumulations of bile are serious, on account of the cause of the collection, and the course and prognosis depend upon the concomitant pathological phenomena. Dropsy of the gall-bladder is latent and chronic ; the prognosis is not unfavorable. Treatment.-Tapping of the gall-bladder is indicated in cases of accumulation of bile or serum. Either aspira- tion or free incisions should be practised in abscess of the gall-bladder, after rest, the usual local applications, and opiates have been used. At the same time a supporting and stimulating line of treatment must be carried out. The same indications are to be met in accumulations of bile in the gall-bladder, as in occlusion of the biliary pas- sages. V. Morbid Growths of the Gall-bladder and Gall-duct.-Here and there may be found an isolated re- port of a case of polypus, fibroma (submucous), myxoma, or tuberculosis of the biliary channels, but they are uncom- mon. It is not so with the carcinomata. Primary cancer is more frequent than is generally supposed, while the sec- ondary form is very common. The writer has tabulated seventy-eight cases of primary cancer of the gall-bladder, and ten cases of cancer of the bile-ducts. Primary Cancer of the Gall-bladder.-Etiology.-The age was not recorded in eight cases. Two cases oc- curred under thirty; 13 between forty and fifty; 19 be- tween fifty and sixty ; 14 between sixty and seventy ; 13 between seventy and eighty, and one in a patient over eighty years of age. The variety of carcinoma was not recorded in twenty-eight instances. In the remainder, at no period of life was there any remarkable tendency to one variety rather than to another. The extreme age at which the growths were found is noteworthy. The sex was recorded in 75 cases, of wThich 61 were females, and 14 males. The varieties were equally distributed among the men. Among the women, 18 had ence- phaloid, 8 scirrhus, 6 epithelioma, 5 colloid, and 2 villous, carcinomata. Two others had sarcomata. Occupation, heredity, and habits played no part in the etiology. Nor did previous health, mental states, or accidents in any way predispose to the disease. Four cases were recorded with antecedent history of gall-stones. In the reports of the autopsies, however, it is noted that in 52 of the 78 cases gall-stones were found. Symptoms.-Jaundice was present in 51 cases. It de- veloped rapidly in 1, was slight in 6, recurring in 1, and continued for periods varying from one week to three months. The cancerous cachexia was observed in 12 cases. Pain was present in 39 instances. It was seated in the right hypochondrium in 22 cases. Nine suffered from epigastric pain. It was described as colicky (8 cases), as lancinating, as paroxysmal, as wandering, as- constant, and as severe. Tenderness on pressure was elicited in a few instances. Fever was present in a large number, 13 cases. It was intermittent in 2, continued in the others. The gastro-intestinal symptoms were marked. Nausea was noted in 5 cases, and vomiting in 30. The appetite was lost in 14 ; constipation was present in 19 cases, di- arrhoea in 11. Ascites developed in 16 cases; oedema, appearing late in the disease, in 9. Exhaustion ensued in 15 ; emaciation continued and became excessive in 36 instances. Haemorrhages occurred, late in the disease, in 5 cases, and gave cerebral symptoms in 7. Physical signs: A tumor was observed in thirty-four instances; hard and firm, nineteen times; irregular and nodular, eight8; round, oval, pyriform, cylindrical, and smooth, were terms used to describe it. In 8 it was movable, in 6 fixed. It disappeared on pressure in one instance. It varied in size from a hazel-nut to a child's head. Ten times a record of pain in the tumor was made; 4 times the tenderness was marked. The tumor was said to be situated in the region of the gall-bladder (10), in the um- bilical region (7), in the right hypochondrium (10), or in close proximity to these situations. The liver was en- larged (21), atrophied (1), hard (2), irregular (2), nodular (3), or tender (2). The veins over the surface were en- larged in two instances. In tine, emaciation jaundice, cachexia, pain in the re- gion of the gall-bladder, with fever, nausea, vomiting, and loss of appetite, with or without diarrhoea, are the prominent symptoms of cancer of the gall-bladder. To corroborate the surmise of its presence, a tumor in the right hypochondrium, tender on pressure, and the seat of pain, and nodular in character, would usually be found. Morbid Anatomy.-The encephaloid variety is found most frequently, the scirrhous next, and then the epithelio- matous, colloid, and villous. The growth begins at the junction of the cystic duct with the bladder and involves the entire organ, leaving scarcely a trace of it, or infil- trates the coats and encroaches on the cavity. Again, a few nodules are seen underneath the mucous membrane, or a dense thickening of the walls by new formations takes place, especially at the cystic duct, or finally the gall- bladder is represented by a nodular mass. The mucous membrane is destroyed entirely or ulcerated at various points over the cancer, or is the seat of intense inflamma- tion. Fungoid cauliflower or villous excrescences grow into the cavity of the bladder, or the surface of the mass may be covered with papillae with bulbous extremities. The tumor may be dense, firm, without juice, or a soft, pulpy mass. In some instances the gall-bladder is re- duced in size, very often it is enlarged, even enormously dis- tended. The peritoneal investment is intimately adherent and thickened ; sub-peritoneal nodules are seen, or the ex- ternal surface in the colloid variety partakes of its peculiar characters. Adhesions are formed between the diseased gall-bladder and the adjacent organs ; degeneration of the walls, and at times rupture, takes place. Ulceration and perforation is very common. Fistulous communication is thus established between the gall-bladder and the duo- denum, the colon, or the stomach. In the course of the disease gall-stones are often discharged in this -way. The centre of the carcinomatous mass is made up of soft, pulpy detritus, or of a thick, creamy matter. In it gall- stones are also found, sometimes firmly encapsulated by 294 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gall-Bladder. Gall-Bladder. the growth ; or, if the cavity of the gall-bladder remains, it is filled with calculi, with pus, ichor, bile, blood, or mucus, singly or combined. In fifty-two instances out of seventy-eight, gall-stones were present. The new forma- tion spreads to contiguous structures-thus the liver, colon, stomach, etc., may be involved. Changes are found in the liver and in the ducts, due to obstruction of the large bile-ducts. (See Occlusion or Purulent Inflammation, for description.) Peritonitis (local) is usually present; an acute inflammation is set up by rupture. Secondary de- posits may also be found in the abdominal lymphatic glands, the omentum, the supra-renal bodies, and the pleura. Diagnosis.-The marked symptoms detailed in the clini- cal history are to be borne in mind. The character of the tumor, its seat, its immobility, pain, and tender- ness, and its growth, are important. The occurrence of jaundice and vomiting, the passage of calculi (by a fistula leading to the colon) per rectum, without relief to ob- struction, and the occurrence of emaciation, make a diagnosis almost positive. The age and the sex are im- portant factors, and a history of the jaundice is of aid in the diagnosis. Relation of Gall-stones to Carcinoma.-This is believed to be causal. The frequent occurrence of this disease in the same sex in which biliary calculi are most com- mon, is strong evidence. But a case of Quetsch's {Berl, klin. Wochenschrift, 1885, No. 42, p. 672) confirms this opinion more decidedly than any previous clinical evi- dence. The patient, a female, was subject to biliary cal- culi, and a biliary cutaneous fistula had been formed. Subsequently, a carcinoma of the gall-bladder developed in the presence of the calculi which did not pass, and, no doubt, were the cause of the local irritation. Others believe that the calculi develop secondarily from stagna- tion of the bile and precipitation of its constituents. Duration.-This has been placed at several years by Villard; in other cases death occurred within three months after the first symptoms developed. The prophylactic treatment consists in the removal or prevention of formation of the calculi, and the treatment of the disease, after it is once manifested, is purely symp- tomatic. VI. Primary Cancer of the Gall-ducts.-It may develop within the liver or in the larger ducts. The most common point of origin is at the mouth of the common duct or at the junction of the cystic and hepatic ducts. A firm mass of newly-formed tissue surrounds the duct or invades its walls. The lumen is almost or completely ob- literated ; its inner surface is the seat of ulceration, at cer- tain points, or of papillary growths. A fungous growth projected from the mouth of the common duct in a case of Stokes. The anatomical changes of occlusion and stenosis are seen in the liver and ducts. Secondary de- posits are found generally in the liver only, along the ducts. The symptoms common to carcinoma and to biliary obstruction are present. Rarely is the growth large enough to be recognized by palpation. Death is rapid and due to occlusion of the ducts, leading to bile intoxi- cation, or purulent inflammation. VII. Congenital Defects of the Gall-bladder and Gall-ducts.-The gall-bladder may be absent en- tirely, without serious inconvenience ; a shrivelled pouch or a contracted tube takes its place. In atresia of the ducts, jaundice, umbilical haemorrhage, and marasmus are pres- ent during life. The jaundice is present at birth, or makes its appearance a few days afterward, persists, and deep- ens. The stools show an absence of bile ; the urine is bile-tinged. There is from the first a tendency to hemor- rhages, and this increases ecchymosis under the skin ; bleedings from the mouth, nose, or bowTels take place. Umbilical haemorrhage is especially marked, occurring after the separation of the cord. As the child grows older it loses in flesh, becomes extremely weakened, and dies of cholaemia or exhaustion, in spite of an ability to take much nourishment. At first the liver is normal, but if the child lives it becomes very large, and the spleen is likewise increased in size. Ascites may develop. If haemorrhages do not occur, the child lives many months. In a case reported by Lotze, the child lived seven months. R. Lomer9 reports a curious case. It was one of con- genital obliteration of the right hepatic and the cystic ducts. The whole right lobe had undergone cystic degenera- tion and was shrunken, the gall-bladder was obliterated, but the left lobe remained normal. He analyzes a series of cases, and, from the fact that usually the parents are syphilitic and several of their children are similarly dis- eased, he holds that an intra-uterine hepatitis of syphilitic origin is the cause of the disease. This is the usually ac- cepted explanation of the pathology of congenital dis- ease of the ducts. The obstruction, which is fibrous, may be in a main duct or in one of its branches. The gall-bladder may be normal, but contains a serous fluid. It may be obliterated or remain as a fibrous cord. The ducts in the liver may be dilated, or some may ap- pear like fibrous cords. Sometimes the portal fissure is the seat of local peri-hepatitis, and usually the surface of the liver is involved. The liver is icteric, the seat of connective-tissue overgrowth, or atrophied. Some parts become cystic. The jaundice due to congenital defects of the ducts is to be distinguished from that jaundice-like discoloration of the integuments, conjunctiva, etc., that is physiologi- cal. In this condition, which is common in new-born in- fants, bile is present in the stools. Jaundice of the sim- ple catarrhal variety also occurs in infants. It usually responds promptly to treatment, and has not the malig- nant aspect of disease dependent upon deficiency of the ducts. Then, again, a pylephlebitis occurs sometimes in infants. In this case fever and the usual evidences of pyaemia are present. VIII. Parasites.-They may develop within the bili- ary passages (distoma), they may emigrate from the in- testines (round worm), or they may find their way into the ducts by ulcerative action (echinococcus). Rarely the latter develop within the ducts. 1. Distoma llepaticum {large liver fluke) and Distoma Lanceolatum {small liver fluke).-Common in sheep and cows, rare in man. The large fluke is found in the gall- bladder or large bile-ducts; the small one generally in the finer ducts. Both species may occur in the same subject. The latter variety produces the most notable changes in the liver. The presence of these parasites sets up a chronic catar- rhal and suppurative inflammation of the ducts. En- largement of the gall-bladder and ducts occurs sec- ondarily. A fibrous inflammation of the walls takes place, with secondary calcareous degeneration of the prod- ucts of inflammation ; the ducts become much enlarged and thickened, and the lumen dilated. Occlusion of the ducts results on account of the inflammatory disease and the presence of tbe parasites in the canal. By necessity, therefore, we have the symptoms, previously noted in this section, of the above anatomical changes, and of ob- structive jaundice. In addition, nervous symptoms of a reflex nature-as syncope, convulsions, or aphonia-may be present. A positive diagnosis can be made only by finding the parasites in the vomited matter, or in the faeces. Death occurs sometimes on account of the in- flammatory complications, or from exhaustion. 2. Round Worms {Ascaris Lumbricoides).-They usually wander from the intestines, and are found with their head toward the liver. Rarely, after adhesive inflammation and fistulous communication between the gall-bladder or ducts and the intestine, worms are found in the biliary passages. The number of them varies-one to three or four usually. They are often found alive, on making an autopsy, or have died before the death of the patient, and are soft and macerated. Their presence excites catarrhal inflammation, causes occlusion and, secondarily, a pur- ulent cholangitis, a dilatation of the ducts, and subse- quent atrophy of the liver, or the formation of multiple abscesses. When limited to the gall-bladder, they cause enlargement and inflammation of that organ. The dilata- tion of the ducts is usually general; sometimes local sac- ulated dilatations are observed, in which worms lie rolled up. 295 Gall-Bladder. Gangrene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The symptoms are like those of hepatic colic, if the worm recently migrated into a duct. Later, the symp- toms and signs of obstructive jaundice occur, and then those of purulent cholangitis. A history of an attack of worms, the presence of the parasite in the ejecta, and the age of the patient, furnish valuable corroborative evidence. Further, intestinal and nervous symptoms due to worms are said to be present. 3. Echinococcus (Hydatid Disease of the Bile-ducts).- Either an hydatid cyst may press upon one or more of the ducts, causing occlusion of them, or complete obliteration of their lumen, or entire destruction of them (Leroux); or the sac may ulcerate into the ducts or bladder, and the vesicles pass by this route into the intestines, with symp- toms of hepatic colic; or it may cause occlusion, dilatation, and inflammation of the-biliary passages. This process may terminate in suppuration and gangrene of the cyst, and is usually fatal. The symptoms of obstructive jaun- dice of a high degree, and of the local inflammatory changes, indicate this pathological condition. The pres- ence of hydatid booklets in the ejecta from the stomach or bowels, a previous history of a painless enlargement of the liver, and the results of tapping or exploratory punct- ure, would confirm one's opinion of the presence of hy- datid disease. Finally, the gall-ducts are seriously in- vaded in that rare manifestation of hydatid disease known as multilocular echinococcus. In this instance the walls of the ducts are thickened, hard, and rigid, and the lumen effaced, by the presence of the vesicles in the tissues. Secondary inflammation, suppuration, and dila- tation, etc., may arise in these cases. The symptoms of this manifestation have been considered in the section on Occlusion of the Ducts. It is interesting to note that the bile, some authorities believe, is capable of killing these parasites. J. H. Musser. tion in the blood, it is evidently necessary for success that the charge of acid to blood shall be as great as pos sible. Full and frequent doses, therefore, are required by the indication. Gallic acid has been given without un- toward effect in dosage of 0.65 Gm. (ten grains) every three hours, unremittingly, for three weeks. It may be prescribed in pill, powder, or mixture. Unguentum Acidi Gallici, Ointment of gallic Acid, is an officinal preparation of the U. S. Pharmacopoeia, and con- sists of ten per cent, of gallic acid mixed with benzoinated lard. Edward Curtis. GAMBOGE (Cambogia, U. S. Ph., Br. Ph.; Gutti, Ph. G.; Gomms gutte, Codex Med.).-An orange-colored gum- resin making a brilliant light-yellow emulsion with water, obtained from Garcinia Hanburii Hooker (G. morella, var. pedicellata Hanbury), order Guttiferce (Clu- siacece Eichler). This genus comprises about forty spe- cies of eastern tropical trees with yellow juice, leathery, evergreen leaves, small polygamous or dioecious, clus- tered, four- or five-merous, numerous-stamened flowers, and four or more celled ovaries. The anthers (see Fig. 1 See Trans. Path. Soo., vol. viil., and Am. Jour, of the Med. Sciences, July and October, 1884, for cases of chronic catarrhal jaundice by the writer. 2 On Paroxysmal Fever, Non-malarial. J. H. Musser, M.D., Trans. Phila. Co. Med. Soc., 1883. 3 Jaundice is used in a general sense. A full discussion of symptoms and effects will be found under Jaundice. 4 See Pathological Society's Transactions, Philadelphia, 1877-78, Am. Jour, of the Med. Sciences, July, 1884. 8 Guy's Hosp. Rep., 1883. 6 In cases of cancer of the gall-bladder and ducts, calculi are often passed. 7 New York Medical Record, 1882, i., 568. 8 Numbers record frequency of the presence of a stated fact in the seventy-eight cases. 8 Lomer : Ueber einen Fall von Congenitaler partiellen Obliteration der Gallengiinge. Virchow's Arch., Band 99, p. 130. GALLIC ACID. By exposure, to the atmosphere, of galls in the presence of water, chemical conversion of the tannic acid of the galls takes place, resulting in the for- mation of gallic acid, HCMI6O6,IIaO. This body is officinal in the U. S. Pharmacopoeia under the title Addum GaUicum, Gallic Acid, and presents itself as " a nearly or quite colorless solid, crystallizing from water in long silky needles or triclinic prisms, permanent in the air, odorless, having an astringent and slightly acidulous taste and an acid reaction. Soluble in 100 parts of water and in 4.5 parts of alcohol at 15° C. (59° F.); in 3 parts of boiling water and in 1 part of boiling alcohol; also soluble in 39 parts of absolute ether ; less soluble in chloroform, benzol, and benzin. When dried at 100° C. (212° F.), the crystals lose 9.5 to 10 per cent, of combined water. At a low red heat they are completely volatil- ized" (U. S. Ph.). Gallic acid is purely but feebly astringent, and seems practically devoid of any other physiological property. Taken internally, it does not poison, nor constipate, nor even-unless in excessive dosage-disorder the stomach. It does not coagulate albumin, and so, when swallowed, is readily absorbed. After absorption it speedily appears in the urine, as is demonstrable by chemical tests. Thera- peutically, the only reputation of gallic acid is for internal giving for the control of haemorrhages from inaccessible parts-for which purpose the efficacy of the medicine is very differently esteemed by different practitioners. Since, in the application in question, the acid must act by local contact as presented to the bleeding vessel in solu- Fig. 1378.-The Gamboge Plant. G. Hanbnrii. A. Branch with flowers and fruit; B, Stamens. (Baillou.) 1378 B) are short, broad, and top-shaped, opening by a transverse circular fissure. Pistil in this species, four- celled, front globular, fleshy, four- (or fewer) seeded. The above species is distinguished from the typical G. morella, by having shortly pedicellate, instead of ses- sile, male flowers. The Gamboge tree is a native of Cambogia, Siam, and Cochin China, whence the supply of the gum-resin for European and American consump- tion is obtained ; but there are besides several other spe- cies of Gardnia in India, China, and the Asiatic islands, which supply similar products, if not exactly the same. It is collected by cutting or wounding the twigs or trunks, when the bright yellow latex flows slowly out, and is collected in vessels, usually bamboo-joints, fastened at the lowest part of the incisions. Here it slowdy hardens, or is perhaps dried over a fire, until a solid cake results, of the shape, usually cylindrical, of the containing vessel. The bamboo is then split off, and the Gamboge, in cylindrical pieces, is packed in large boxes for trans- portation. 296 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gall-Bladder. Gangrene. Gamboge has been used in China and India as a pig- ment for many centuries, and appeared as a purgative in Europe early in the seventeenth century. Its use in medicine, however, has always been insignificant in com- narison with its consumption as a yellow paint, for which use it is hardly excelled by any pigment. The best of that which reaches us is almost always in the form of bamboo casts from three to five centimetres (1 to 2 inches) in diameter and from one to two or three decimetres long ; the surface is longitudinally striated, the color deep-orange, the fracture conchoidal. Fresh speci- mens are often pliable and may be variously curved; old and dry ones very brittle. The odor, when moist, is peculiar, the taste sharp and acrid. It does not dissolve in water, but forms a very tine, smooth, yellow emulsion with it. Soluble in part (the resinous) in alcohol, wholly in solutions of potash. It should be free from starch and much coarse impurity. Gamboge contains about seventy-two (Christison) per cent, of yellow resin called Gambogic acid, an orange- yellow, tasteless and odorless mass, soluble in alcohol and ether, but not in water, having the purgative proper- ties of Gamboge, but less intensely than the crude gum- resin itself. It also contains fifteen or more per cent, of gum. a little water, and some impurities. Action and Use.-This is one of the most violent of hydragogue cathartics, producing abundant watery stools and considerable griping, on which latter account it is not often now given alone, or for its full effect. It is, how- ever, frequently added in small doses to the other cathartic combinations, and experience has proved its usefulness. Administration.-The full dose of Gamboge is about 0.3 Gm. (= gr. v.), but less is advisable in compositions ; the maximum daily quantity is stated by the German Pharmacopoeia to be a gram. It is an ingredient in the compound cathartic pills {Pilules Cathartic® Composita, U. S. Ph.), each of which contains a quarter of a grain. Allied Plants.-Besides the several gamboge-yield- ing trees the genus contains also the Mangosteen {G. in- dica Choisy), from the seeds of which the fat called Kokum Butter is expressed. The order contains little else of commercial importance. Allied Drugs.-Euphorbium, Podophyllum, Scam- mony, Croton Oil, and a number of other irritant purges. For other vegetable coloring matters, etc., see Saffron. W. P. Bolles. outer one is a mere fibrous expansion. Since the latter does not, in all places, form a complete covering for the former, it is clear that hernial protrusions are invited. It is for this reason also that ganglia are so frequently seen on the back of the hand, and more particul«riy so at the wrist, where the great number of tendons, taken in con- junction with the frequent strain of manual exertion, favors a protrusion of the synovial portion of the tendon- sheaths. Ganglia are usually of slow growth, and rarely attain a size larger than that of a walnut. Their presence oc- casions but little discomfort to the patient. Some weak- ness of the muscle involved, a feeling of local tension, and occasionally painful sensations, are the chief com- plaints. Patients generally seek medical advice more on account of the visible deformity than for any other rea- son. Of course, a ganglion may become inflamed, and then violent symptoms will be observed. The contents of the swellings consist of a colorless or yellowish gelatinous substance. The so-called melon-seed bodies, or rice-water granules, are scarcely ever found in connection with them, a point which marks a frequent distinction between ganglion and ordinary hygroma. There is no difficulty about the diagnosis of ganglia. Their location, their contents, the history of their devel- opment, their round or ovoid shape, their painlessness, their tense elasticity, at once indicate the nature of the swelling. But as regards the particular variety of gan- glion we are dealing with, matters are often far from easy. In a general way, the seat of the protrusion will aid our judgment. It may also be said that, if continued gentle pressure causes the swelling to diminish in size or to dis- appear entirely, then it is most likely to be an articular ganglion. But this phenomenon is not an infallible sign of the nature of the swelling. The treatment of ganglion will vary with the circum- stances of the individual case. The old method of pro- ducing rupture by pressure is still much in vogue, and may safely be tried. If the cyst be thin-walled it gener- ally succeeds, although recurrence of the swelling is not at all unlikely. All force and violence are to be depre- cated, however, on account of the danger of subsequent spreading inflammation. Subcutaneous incision, or dis- cission (i.e., section w^h laceration of the sac), are appli- cable to those cases that do not yield to pressure. The most radical way to deal with these swellings consists in open incision or excision. With the observance of mod- ern antiseptic precautions, the old dangers of synovitis, suppuration, and the like, need not be dreaded any longer. The cure following these operations is a permanent one. Edmund C. Wendt. GANGLION. The term ganglion is used to designate, on the one hand, the well-known enlargements of the sympathetic nervous system, and on the other, certain swellings most frequently observed in connection with joints and tendons. In this article the word is employed in the latter sense. A number of somewhat different af- fections are commonly included under the head of gan- glion. We may distinguish between three varieties of these formations : 1. Simple Cystic Ganglia.-French writers speak of this variety as follicular ganglia, on the supposition that they take their origin from the alleged follicles of the synovial membranes of the tendons (follicules sy novipares). They really represent cystic formations with colloidal contents, which occur in connection with the sheaths, chiefly of the flexor tendons of the fingers. These ganglia rarely attain a size larger than that of a pea. They are some- times found in connection with the capsules of the smaller joints. 2. Articular Ganglia.-Abnormal protrusions of articu- lar synovial membrane, containing a serous fluid, gener- ally constitute this variety of the swellings in question. Sometimes, however, articular ganglia are formed by a serous distention of preformed, or so-called secondary or accidental, bursae mucosae. 3. Tendo-vaginal Ganglia.-This is the most frequent variety, and may be regarded as a hernia of the sheaths of a tendon. The origin and pathology of these swell- ings is readily understood when we remember the anatomy of the tendo-vaginal structures. They are composed of a double membranous layer, of which the one nearest the tendon constitutes a synovial membrane, whereas the GANGRENE. Definition. - The word gangrene is now held to mean death of a soft part. When a bone dies, or any part of it is deprived of life, the term necro- sis is used. There is some confusion in the literature of the subject as to the nomenclature of this condition. The terms mortification and sphacelus are now used as syn- onyms, but formerly, in the usage of many writers, the word mortification was held to include, as subdivisions, gangrene and sphacelus-gangrene, according to Mr. Liston, being " that state in which the larger arterial and nervous trunks still continue to perform their functions," and the part is " supposed still capable of recovery," and sphacelus the condition of "complete death, when putre- faction being no longer resisted, the part becomes black, cold, insensible, and fetid." This was the view held by Heister (1740), and by John Pearson (1788), who inciden- tally mention the term mortification, but speak of gan- grene and sphacelus as synonyms, to which the ancients gave the term cancrum (Celsus). It is doubtful if this use of the term sphacelus is sanctioned by the best classi- cal authority, for it is certain that, in describing sphacelus of the brain, Hippocrates described ramollissement and not gangrene ; however, tlie moderns have now adopted the term in its generic sense, and the confusing synonyms are rapidly becoming obsolete. Varieties.-The varieties of gangrene are : moist gan- grene ; dry gangrene ; senile gangrene ; ' ' white " gan- 297 Gangrene. Gangrene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. grene ; " symmetrical" gangrene ; " diabetic " gangrene ; "diphtheritic" gangrene; noma; and "hospital" gan- grene. Etiology and Pathology.-A general division of the causes of gangrene into traumatic and idiopathic may be made, but it is evident that, whether the local death of a part is produced by mechanical violence or by disease, the cause must be the same ; namely, an interference or ar- rest of the nutrition of the part. These causes are re- ferred to obstruction of the circulation, with the excep- tion of those cases of epidemic gangrene described by the ancients, and the modern cases of hospital gangrene. Nutrition is interfered with, or arrested, by obstruction in the arteries, such as occurs in cases of gunshot wounds ; ruptures by mechanical violence; compression or liga- ture ; by disease of the arterial coats ; by pressure of a tumor in the adjacent tissues, or by a thrombus ; by ob- struction in the capillaries, which may produce complete anaemia of the part, from pressure upon the capillary walls by tumors, extravasated blood or fibrin, or through fatty metamorphosis of connective-tissue corpuscles (Wag- ner), or by superficial pressure from bandaging. The ob- servation that tight bandaging would occasionally pro- duce gangrene is as old as Hippocrates, who distinctly refers to it. Anything, therefore, which will produce stasis in the capillary, of long continuance, whether by mechanical violence, inflammatory change, the internal administration of certain drugs, or the action of chemicals, must necessarily result in gangrene ; or by obstruction in the veins sufficient to entirely prevent the return circula- tion. Let us now examine these causative states somewhat in detail. Obstruction to the arterial circulation occurs in consequence of gunshot, lacerated, and incised w'ounds, whenever the artery is torn or cut, and this obstruction results in gangrene whenever the collateral circulation fails to become established. The plates accompanying this article, from the " Medical and Surgical History of the War of the Rebellion," show cases of this kiqd with great distinctness. Pressure upon arteries during the treatment for aneurism has also produced gangrene. Sur- geon Fessenden, of the Marine Hospital Service, has re- ported a case1 where compression was applied to the popli- teal artery, just above an aneurism of that vessel, for one hour, when pulsation ceased in the tumor; three days later, it was noticed that sensibility was lost in the foot and leg, which became very much discolored, and there occurred blebs on the foot ; a day later the entire foot and leg were gangrenous, and amputation was performed. Coagula (thrombi) may form in the arteries as a result of chronic endocarditis, or endarteritis, or even fatty degeneration or calcification of the arterial coats (Wagner). The embo- lus may lie near the gangrenous spot, but frequently far away from it. Acute inflammation of the arteries occa- sionally produces fatty degeneration, and it in turn, by reason of the loss of contractility of the vessel, allows a thrombus to form through sluggishness of the arterial circulation ; finally, stenosis of the vessel may occur (as in the pulmonary artery), and gangrene of the dependent tissues result. Obstruction to the capillaries is a prolific source of gangrene, and if those cases are included where stasis is produced at the veniole, it may be said to include nearly all the cases not directly dependent on arterial obstruction for their causation, exclusive of the phagadenic varieties under the head of hospital and epidemic gangrene. It is in the capillaries that the effect of diminished cardiac power is most manifest, especially in the parts remote from the heart. Chronic exhaustive diseases, senile and general debility, therefore, are important factors in the production of gangrene. Gangrene from the administra- tion of ergot is produced by the effect of the drug on the arterioles through the vaso-motor nerves, whereby these vessels are permanently diminished in calibre. The ex- periments of Holmes (1870) showed the effect of ergot upon animals to be manifested in the capillaries, as wit- nessed in frogs, and Peton (1878) observed the contrac- tion of the retinal vessels in man. Peton believes that this effect is produced, independently of any influence upon the vaso-motor system, by the direct action of the drug upon the muscular fibres. Nikitin (1878), however, denied this, and his investigations have led him to confirm the usually accepted theory. Ergotism, as a cause of certain epidemics of gangrene in man, was first described by Dodard in 1676, then by Saviard in 1694, and by Noel in 1710. The disease ap- peared in Switzerland in 1676, according to Langius and Quassond. It also appeared in Dauphine in 1709. Du- hamel, in the " Memoires de 1'Academie Royale de Paris " for 1748, states that the disease was accompanied with very great mortality, " not more than four or five Out of one hundred and twenty who had been attacked escaped with life." Pereira (1840) thinks this affection was known from a still earlier period, and quotes a pas- sage from Sigebert to support his views (South); " 1089, a pestilential year, especially in the western parts of Lor- raine, where many persons became putrid in consequence of their inward parts being consumed by St. Anthony's fire. Their limbs were rotten and became coal-black, they either perished miserably, or, deprived of their hands and feet, were reserved for a more miserable life." It is stated that "the bread which was eaten at this period was remarkable for its deep violet color." Notwithstanding the general concurrence of opinion as to the effects of ergotism on man, it has often been denied that it produced any such effect upon animals. Block, in 1811, fed nine pounds of ergot daily to twenty sheep, for four weeks, without any visible effect, and twenty sheep of another lot ate thirteen and a half pounds daily, for two months, without injury. Thirty cows took twenty-seven pounds daily for three months, and the only apparent effect was to injure the quality of the cream (Pereira). Tessier, however, in 1776, visited those countries in which the epidemic had prevailed, or was then present, and found that, although the quantity necessary varied, yet it finally produced the gangrenous affection (" Memoires de la Societe Royale de M6decine," 1776 and 1777-78). Instances are not wanting of the prevalence of gangrene as an epidemic among animals in the United States. Dr. Salmon, Chief of the Bureau of Animal Industry of the Agricultural Department, in a recent report on this subject (1885), has shown conclu- sively that many so-called epidemics of the "foot and mouth disease " of cattle are really epidemics of ergotism. He found much ergot in the heads of "red-top" grass, timothy, and in the chess or " cheat," as well as in rye ; and in the particular epidemic in Kansas which called out the inquiry, the ergot was found in the hay fed to the diseased animals in the proportion of about one to every seventy-five pounds. In these cases there were sloughing ulcers of the mouth, ulcers in the rectum, with diarrhoea, a temperature of 101° to 104° F., and a line of demarcation above the hoof-in some cases as high as the middle of the leg, and not infrequently the ends of the tails became gangrenous and dropped off. In an ex- haustive review of the history of epidemics of gangrene from ergotism, Dr. Salmon cites many instances to show that nearly all the domesticated animals have suffered from the effects of this poison. As bearing upon the question of treatment, it is interesting to note that Dr. Salmon considers that ergot in hay may be prevented by cutting the grass before the seeds have formed. The first effect of extreme cold upon the tissues is the contraction of the capillaries to the smallest practicable de- gree. A certain amount of blood serum is actually frozen and the capillary is ruptured, the circulation is not re- sumed when the parts are thawed, and gangrene results. Gangrene thus produced is usually of the dry variety, although, when the venioles or the larger venous trunks are frozen, by reason of the failure of the return circula- tion, moist gangrene is produced. Direct destruction of cells by caustic chemicals may produce gangrene of distal parts, through failure of both supply and return of blood. Gangrene of the perineum may occur from extravasated urine (Green, 1884), as even normal urine is highly irritating ; but in such cases there must have been antecedent local inflammation, and the death of the exu- date precedes the death of the adjacent cells. Urine 298 'EFEHENCE HANDBOOK OF THE Medical Sciences. PLATE XIV. FIGS. I AND 3. SHOWING EFFECTS OF HOSPITAL GANGRENE. FIG. 2. GANGRENE OF FOOT AFTER SHOTWOUND OF LEG. (from the medical and surgical history of the war of the rebellion.) H. BENCKE, LITH N Y REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gangrene. Gangrene. which has undergone putrefaction, being loaded with the putrefactive bacteria, is much more speedy in its action, especially as the tissues themselves are weak in their power of resistance ; while not absolutely devitalized, they are yet in a state of extreme inertia. It is well known that the power of resistance to the entrance and subse- quent development of the pathogenic bacteria is variable, and that, for instance, in cases of convalescence from such exhaustive diseases as typhoid, typhus, and the severer exanthemata, fatal forms of so-called blood-poi- soning are apt to make their appearance ; this condition, while perhaps immediately dependent upon diminished cardiac power, is one of deficient innervation ; for insuf- ficient nutrition of the nerve-centres is necessarily mani- fested in weakness of muscular tissues throughout the body. Obstruction of the veins, it will be seen, is very rarely a direct cause of gangrene; pressure or occlusion of the su- perficial veins alone will scarcely produce it, unless there is constitutional predisposition, as above set forth, for the deep veins will still carry away a large share of the re- turn blood-current. When gangrene does result from compression or ligature of superficial veins, it is by the production of stasis in the capillary ; to this cause we must refer the cases produced by tight bandaging, and, indeed, all of similar character, except those of venous thrombi. It thus appears that the starting-point of all our studies of the pathology of gangrene must be at the border line between the arteriole and the veniole, that hy- pothetical point termed the capillary. Those cases of gangrene following punctures in the skin to relieve the tension in cases of dropsy have their origin in the arteri ole and veniole. " Here the blood-vessels of the skin are already very much stretched by the fluid collected in the superficial fascia, and the nutrition of the integument is impaired in a corresponding degree. There is an imme- diate effort to repair the wound, but the afflux of blood to its margin lacking sufficient cardiac impulse, stagnates at once, and the enfeebled tissue, unable to react under the stimulus of the effort, dies forthwith in the stage of stasis, from entire stoppage of its nutrition " (Van Buren : Lectures, edited by Stimson, 1884). Finally, we may have gangrene from total disorganization of tissue elements ; the gangrene foudroy ante, such as occurs in severe crush- ing injuries, as well as in internal parts deeply bruised, such as the cervix uteri, vagina, and vulva after severe la- bors (Wagner). Moist Gangkene.-This form of gangrene, also called acute gangrene, hot gangrene, inflammatory gangrene, is always preceded by inflammation. The part is at first swollen and painful, there is almost always inflammation of the veins (phlebitis), and the moist condition depends upon the obstruction to the return circulation, by which the water is left in the tissues. Symptoms.-The history of an injury, and of antecedent inflammation, absence of pain in the part, although in the parts adjacent, where the inflammatory blush is pres- ent, the pain will be acute. Characteristic changes in color, at first livid, then bluish, and finally completely black ; swelling which is boggy to the touch (cedema- tous), sometimes accompanied with emphysematous creaking. This emphysema is due to the development of gases, loss of temperature, and complete destruction of function. It is sometimes said that sensation is not de- stroyed, but this, when present in appearance, is only the well-known phenomenon of the sensation in a wounded or severed nerve being felt as of its peripheral extremity. In the beginning the odor is imperceptible, but as the pu- trefactive change progresses, the odor is " sweetish," and finally stinking in the highest degree. Constitutional symptoms are usually present, such as suppurative or hectic fever (septicaemia), and in advanced stages of this fever it may be characterized by great prostration, even collapse ; diarrhoea may be present, and in exact propor- tion to the degree of fever, there are the profound rigors and profuse sweatings of pyaemia ; but if the gangrene is not extensive, and is well localized, there may be little general disturbance. In cases where the disease is pro- tracted, the septic fever pursues its usual course, and the well-known typhoid condition of the system is present, the various symptoms of which need not be here described. There is little difficulty in the diagnosis of this affec- tion, but in the lax condition of the skin of the aged, with its enfeebled circulation and diminished vitality, there is sometimes doubt whether the blackness of the surface is due simply to ecchymosis or to gangrene. I recently met with the case of an aged lady, who had sustained a frac- ture of the elbow-joint, in which it was scarcely possible to determine, for a period of nearly two days, whether the blackness was a sign of gangrene or not. On careful in- spection, however, the blackness seemed to entirely un- derlie the skin, and in a day or two the successive changes of the blood spectrum became apparent, the blue-black- ness giving way to violet and lemon yellow, and then nor- mal. When the extension of the gangrene becomes ar- rested there is seen, encircling the part, a series of vesicles, or sometimes a mere line of redness. This redness becomes deeper, the epidermis over it falls off, the dead part be- gins to shrink away, and nature commences, by the rapid consolidation of the inflammatory exudate, to prevent fur- ther absorption by the lymphatics of any septic material. This line of redness, termed the "line of demarcation," is a narrow band of granulation tissue, which conforms to all other granulation tissues in being devoid of lym- phatics, hence there is no absorption from them. The line of demarcation gradually extends entirely to the bone, in case an extremity is involved, and the dead soft part finally drops off. So long a time is required for the bones to undergo this process that they are usually seen protruding, and the case is seldom left to nature be- yond this point. Treatment.-When gangrene is threatened, the treat- ment should be directed toward its prevention, therefore the inflammation should be combated, the return circu- lation favored by massage and external heat. There is no single remedy so generally applicable, and so prompt in its effects, as external heat; the part, after gentle fric- tion, may be enveloped in hot flannel, frequently changed, bottles of hot water applied, or, if circumstances indicate a preference for irrigation with hot water, that plan may be adopted, but it must be as hot as can be borne, to be of service. Thus the feeblest circulation may often be en- couraged so that it once more becomes strong, and its ef- fect in keeping alive the collateral circulation in cases where the main artery is occluded from injury, operation, or disease is beneficial in the highest degree. The old axiom that "heat is life, and cold is death," is nowhere more applicable than in these cases. Where stasis is manifest by the oedema, and boggy feel of the tissues, broad punctures, deeply through the tissues, are of great service. The patient should be supported with tonic and stimulant remedies according to individual judg- ment. When the gangrene has become complete, local remedies are of no avail except to favor the production of sloughs, hasten the separation, and, by the use of an- tiseptics, to render the odor less offensive. Among these may be mentioned dilute pyroligneous acid, solutions of bromine, Labarraque's solution of chlorinated soda, and the solution of the bichloride of mercury. Carbolic acid, so frequently recommended, as well as iodoform, is quite as offensive in odor to some as the putrefying mass itself. The mass can be rendered quite innocuous by deep injections of the bromine solution. When the line of demarcation is fully established, operative interference is then demanded. The rule is, with two exceptions to be hereafter noted, to await the line of demarcation be- fore performing an amputation. The gases formed by the putrefactive decomposition of the dead tissue are not poisonous, they are nauseous and offensive, but not rap- idly disease-producing ; therefore, while the tissues above the obstruction point are gaining strength and recupera- tive power, the surgeon may well stay his hand. The exceptions are in those crushing injuries where the bones and soft tissues are bruised, lacerated, and torn, and the arterial supply is cut off. Amputation is then immedi- ately necessary. Again, in those cases of gangrene fol- lowing an injury, where the gangrene seems to be self- propagated and extends beyond the point of injury, and 299 Gangrene. Gangrene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the patient is rapidly failing under the septic fever ; in such cases, happily very rare, amputation is demanded. Dry Gangrene.-In this form of gangrene there is neither venous obstruction, nor failure of the lymphatics, and the fluids of the part are carried back into the system as fast as formed. As the arterial supply is gradually cut off, a drying or mummification of the tissue results. This condition frequently occurs in those suffering from starvation ; in those subject to gout (Chelius); or those who have exhausted themselves by excessive debauchery. There is frequently an absence of inflammatory symp- toms, and it may come on suddenly without premonition. There is usually organic disease of the heart and arteries. This is the chronic gangrene of Travers (South). Symptoms. - Corrugation and shrinking of the soft parts, and gradually deepening color, until the whole mass is of a coal-black ; pains of varying severity usually precede the discoloration, sometimes lasting for several weeks. Occasionally pain is absent, and the patient sim- ply experiences a sensation of numbness and coldness in the part. As the gangrene progresses, constitutional symp- toms are manifested, there is great mental depression, un- quiet sleep, palpitation of the heart, epigastric pain, and occa- sionally an intense internal cold (Chelius). Some times the distinc- tive characteris- tics between dry and moist gan- grene are so ob- scure that it is difficult to place the case in one class or the other server a palpable object lesson in senile calcification. The statement has been made that certain seasons spe- cially predispose to senile gangrene, and the winter is al- leged to be that season most favorable to its production, owing to the astringent effect of the cold; but there are no statistics to bear out this assertion, and the writer con- siders the case by no means made out. Symptoms.-After some months or weeks of pain, or otherwise unpleasant sensation in the part, a small bluish spot appears on one of the toes, frequently at the root of the nail, and the spot becomes black ; from this point the discoloration slowly spreads to the adjoining toes, and finally, if the patient survive 'ong enough, the whole foot and leg becomes involved. Sometimes the line of demar- cation is formed near the centre of the foot, but more of- ten the patient succumbs under the combined influence of the nervous exhaustion produced by the pain and the failure of the digestion. The pain accompanying the dis- ease is a prominent symptom, and gives the patient more immediate concern than the fear of losing the limb, or even life itself. The figure opposite, from a photograph of a patient under my care at the Providence Hospital, shows the stage of the disease at the time of her death. The notes are as follows : Elizabeth B , aged eighty- five, admitted to hospital April 13th, for a contusion of the knee, which, however, had left no trace ; the pain in the toes and foot was constant and harassing. Three weeks later a blue spot was noticed on the dorsum of second toe. The spot gradually spread to include the great toe, as shown in the photograph, and the patient died July 20, 1885. Treatment.-This has been well formulated by Van Buren (loo. cit.): "The treatment of senile gangrene is limited to a judicious husbanding of the patient's vital re- sources, looking to a possible self-limitation of the dis- ease, after which a cure may be completed by amputa- tion." To husband the patient's resources it is necessary, along with stimulating and supporting measures, to con- trol the pain ; here there is nothing more philosophical in its action than the hydrochlorate of cocaine injected into the painful tissue. Percival Pott claimed curative power for opium, but not only has this treatment failed in the majority of cases, but it actually hastens the fatal result by impairing the digestion. The cocaine, on the contrary, frequently subdues the pain at its seat, and does not de- range the stomach. Even its external application has been found beneficial, but it is manifestly less powerful than when used hypodermatically. In these cases, as in the foregoing varieties of gangrene, external heat will be found advantageous. "White" Gangrene seems to be simply a moist gangrene of chronic form, in which there is a serous ex- udate, with lymphatic obstruction, followed by complete anaemia ; the exudate dying, the parts are filled with pus. The condition scarcely deserved to be called a separate va- riety of gangrene, but as it is unaccompanied with the characteristic color-change of other varieties of gangrene, the distinction is made. Rokitansky applies the term to the sloughs themselves. The treatment consists in free incisions, anodynes, and external heat. As this disease occurs in the younger ages, the prognosis is more favor- able. Symmetrical Gangrene (Relapsing Gangrene).- This affection, probably first accurately described by Raynaud (" De 1'Asphyxie locale et de la Gangrene syme- trique des Extremites," 1862), is exceedingly rare, Bill- roth, up to 1872, having met with a single case, and other observers with extensive experience having seen no ex- ample. According to Raynaud, the disease occurs chiefly in chlorotic and nervous individuals of early adult life, pa- tients in convalescence from typhoid fever, and similar exhausting disease. Moore (" International Encylopaedia of Surgery") has seen a case presumably from this cause, and the appearance of the case is shown in the illustra- tion accompanying this, from Dr. Moore's article. " The disease most frequently attacks the fingers- rarely the toes, tip of the nose, and external ear ; often, for months beforehand, the affected parts suddenly be- come white, bloodless, without feeling, dead ; the skin is (Moore: "Int. Encyclo. Surgery," 1882). The remarks in the preceding page, relative to the treatment of moist gangrene, are equally applicable here, except that the powers of the system require a more supporting plan of treatment. As to operative interference, it is proper in all these cases to await the line of demarcation. The prognosis is unfavorable. Senile Gangrene.-This gangrene, which is usually of the dry variety, is almost wholly due to arterial obstruc- tion, the pathology of which has already been discussed ; but the obstruction is long in forming, and the progress of the disease is slow. The description by Percival Pott of the affection, as it occurs in the foot, was so striking that for a long time it was known as Pott's disease of the toe ; but, as the disease occasionally attacks the hands, the name was manifestly inappropriate. The condition of the arteries in these cases is one of ' ' ossification " or calci- fication, which results in a complete loss of elasticity, and consequent diminution of the blood-supply. The bead- like feel of the radial pulse, in the aged, gives the ob- Fig. 1379. 300 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gangrene. Gangrene. strongly wrinkled and shrunken, the ends of the fingers appear thin and conical. The temperature of the parts is sunken, and the muscular movement is as though par- alyzed. If this state extend over a whole extremity, the pulse becomes imperceptible. After a variable time there follows a painful reaction ; itching arises, and the feeling of overfilling of blood ; the skin becomes bluish- red. Severe pains precede the proper outbreak of gangrene. The extremities become bluish-white, violet, dark, livid, marbled ; they are insensible, but very painful, and icy cold ; then small vesicles appear which fill with sero- purulent liquid, and are usually destroyed, so that the cutis becomes laid bare. Even now, the part may be re- stored ; but for the most part, after a time the at- tack returns, and then the fingers show numerous small, white, depressed, and hard cicatrices on their extremities, which are found specially in front of and beneath the nails, and form conical callosities. If the ischaemia is of longer duration, there follows from the consecutive hyperaemia a true mummification, which terminates with the falling off of the last phalanx " (Wagner). This form of gangrene is, as will be seen, entirely dis- tinct from that form of double gangrene of both lower extremities resulting from embolism of the abdominal aorta at its bifurcation. Diabetic Gangrene.-The impoverished condition of the blood in cases of diabetes mellitus favors the produc- tion of gangrene, and it has been specifically named as a variety, although without any very good reason. As well might gangrene occurring in the progress of any chronic disease be separately named, and in most articles on the subject of diabetes the occurrence of gangrene is men- tioned as among the complications of that disease. " Spon- taneous gangrene of the lower extremities, with obstruc- tion of one or more arteries of the limb, is not infrequent in diabetes " (Marchal de Calvi). ' ' Ulcerated surfaces are slow to heal, and gangrene supervenes sometimes spon- taneously, but more often as the result of some trifling injury " (Tyson : Pepper's "System of Medicine," vol. ii.). The treatment of gangrene, when it occurs as a compli- cation of diabetes, does not present any striking variations from the general treatment of the disease elsewhere, or any cause to vary from the treatment necessary from that proper for the diabetes. Diphtheritic Gangrene. - This form is usually named as one of the varieties, but, like the last-mentioned, has no valid claim to be considered as a distinct affection. By some, indeed, it is considered as gangrenous diph- theria, by others as a variety of hospital gangrene. Diph- theritic patches resulting in gangrene are sometimes seen in the edges of the sore resulting from the incision in tracheotomy ; and when hospital gangrene is present in a hospital ward, wounds are frequently seen with the tough, fibrinous diphtheritic patch springing therefrom. In these cases the constitutional poisoning seems more se- vere, but whether on account of the increased number of micrococci present in the blood or not is not known. The question of the influence of bacteria in the production of gangrene in any of its forms is yet unsettled, and in re- gard to diphtheria, although examined with the greatest skill and enthusiasm, the question is no nearer solution (Jacobi). Jacobi (Pepper's " System of Medicine ") quotes approvingly the words of the late Professor Pauum: " We have but a feeble insight into the relations between these organisms and diseases, and in order to effect that much desired advance in scientific knowledge-a matter of con- siderable importance in the practice of medicine-it is necessary not only to grasp at isolated data, but carefully to observe and study all the facts before us, and even to devote some attention to those, which would tend to prove that there are bacteria and fungi which, under certain circumstances, are perfectly harmless, and that even some of the malignant ones among them do not commit all those outrages with which they are charged, directly and personally." The treatment of diphtheritic gangrene is the same as that of hospital gangrene, which will be mentioned in de- tail. Noma.-This is a gangrene affecting the pudenda and cheeks of young children from the age of weaning to that of puberty. Nurslings seem to have an immunity from it. When confined to the cheeks and mouth, it is vari- ously termed gangrenous stomatitis, gangrama oris, can- crum oris, gangrenopsis-stomato-necrosis, necrosis infan- tilis, buccal anthrax, water canker, sloughing phagedena of the mouth, and by the Germans Noma and Wasser- krebs ; by the French gangrene de la bouche. The disease has been known for a long period, and was first described by Carolus Battus, of Amsterdam. Van Sweiten (1699) recognized the disease as gangrene. Wiseman (1676) mentions the disease as Noma, which he describes as " a deep Ulcer that eats and spreads without Tumor, but hath a Rottenness and Putrefaction joined with it." The disease is attended by great mortality, but as it usually comes on while the patient is suffering from some other affection, it is difficult to determine its relative fa- tality with precision. The affection, whether it appear on the mucous surface of the qheek or on the vulva, is al- most invariably unilateral. It begins as an inflammation attended by great exudation, ulceration is set up, the ex- udate dies, and the general appearances of circumscribed gangrene, due to obstruction of the arterioles, are pres- ent. In the mouth the disease usually begins at the fre- num of the lip, but rarely on the outside of the cheek (Chelius), and as the cedematous inflammation extends the ulcerative process is carried down to the bone, and along- side of the nose, and frequently involves the whole Schneiderian membrane. Occasionally the disease begins on the gums at the alveolar border (Cohen). At the pu- denda the disease usually commences at the labial margin, and extends to the clitoris, nymphae and hymen, and some- times to the urethra, when the pain in micturition is acute ; the inflammation is rapid, and the tissues speedily fall out by sloughing, the disease spreads to the perineum, to the anus, the thigh, and to the mons veneris, and, as is the case when in the mouth, the sloughing is deep and frequently extends quite to the bone. Sometimes the affection begin- ning at the mouth is later on developed at the vulva, and frequently the noma is ushered in with general constitu- tional symptoms, such as rigors with fever; but, more commonly, its onset is masked by the particular affection from which the child has been suffering ; but always, in the later stage of the affection, there is great prostration, with feeble pulse, and chlorotic countenance. When the affection is on the pudenda, there is great pain in all movements of the lower extremities, and the child usu- ally assumes of its own accord the dorsal decubitus, and the legs are widely separated. There is retention of urine, owing to the severity of the urethritis, and consti- pation. There is rapid emaciation, and the patient sinks under the "typhoid condition" so constantly present in the later stages of the other forms of gangrene. Cohen remarks that pulmonary gangrene is often observed in the noma of the mouth as a complication, and frequently entero-colitis. When noma affects the mouth alone, there is great variability in the degree of constitutional sym- pathy, some patients being able to sit up and play, while others are hopelessly comatose from the outset. The contagion of the affection was claimed by the old Dutch writers who witnessed epidemics of gangrenous stomati- tis, but modern observation does not approve the theory of its contagion or inoculability. Haemorrhage from the facial, or from the pudendal branches of the pudic, may occur, but in this variety, as in other forms of gangrene, the arteries are plugged by thrombi long in advance of the loss of tissue. The treatment of noma is both local and constitutional; both are important, and neither can be safely neglected. The local treatment is the same as that recommended for hospital gangrene, and will be again adverted to. Quiniae sulphate in full doses, with the tincture of iron, should be kept up until the appetite is good and the tongue becomes normal in appearance. In case the stomach will not bear the continued administra- tion of the tincture of iron, or it produces much head- ache, owing to increased cerebral tension, the potassium chlorate should be substituted. Milk-punch and liquid food are always indicated, and it may be necessary to use nutritive enemata. The patient should be placed in a 301 Gangrene. Garlic. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. well-heated, well-ventilated apartment, with plenty of sunshine. Hospital Gangrene.-It only remains, in concluding the subject of gangrene, to discuss that form of the affec- tion known as hospital gangrene, hospital phagedena, gan- grana nosocomialis, and pourriture des hopitaux. Although the modern teaching is that hospital gangrene is a pre- ventable affection, and will not occur in any hospital where proper attention is paid to cleanliness and disinfec- tion, yet it is well to remember that the disease sometimes appears, in all its essential characteristics, in cases quite remote from hospitals, who had apparently not been ex- posed to contamination from any other patient (Billroth). The disease is now rarely seen in hospitals, but as the neg- lect of careful attention to the avoidance of the causes of the spread of the disease might once more render it preva- lent, it is well to remember that it was once one of the most common complications of wounds, and its history was marked by a fearful mortality ; and so inseparable was the disease once assumed to be from hospitals, that Poteau (1783), the first historian of the disease, himself a sufferer from it, in his earliest description says of the hospital air, " au mauvais air qu'on respire dans les grands hopitaux," and he proposed the inquiry whether, in view of the facts, " hospitals were not more pernicious than useful to hu- manity ? " But it is now known that wherever hygienic laws are violated, wherever wounded men are crowded together in ill-ventilated hospitals, with insufficient food, insufficient warmth, and lack of cleanliness, hospital gangrene is apt to show itself; and that a single case in such circumstances affords the nucleus for the spread of the disease, and the development of an epidemic. Mr. Blackadder (1818), indeed, claims that under such condi- tions the disease has been known from the earliest times, and cites passages from Celsus, Aetius, Paulus jEgineta, Rolandus, Guido, and others, to support the statement. In modern wars the relation between the hygienic cause and effect has been carefully studied by Ballingall, McLeod, Guthrie, Joseph Jones, and others. McLeod, who observed the disease at Scutari, in the Crimean war, observed that there was a great increase in the affection when the sirocco blew, that the atmosphere was surcharged with electricity, and that wounds generally assumed an unhealthy aspect for days when this pestilential wind prevailed. Chisholm (" Manual of Military Surgery for the use of Confederate Surgeons") states that he witnessed an epidemic of hospital gangrene in Milan in the summer of 1859. "A large number of Austrian wounded had been put in a barrack ; they had undergone many hard- ships, retreating daily before a victorious enemy, and had, prior to the battle of Solferino, tasted no food for forty- eight hours. They had been deceived by their leaders, who had taught them that certain death awaited them should they fall into the hands of the Italians. With these impressions, the wounded hid themselves in the ditches and underbrush of the battle-field, where many perished. Some were not discovered for two or three days, when they were sent to the hospital. The previous hardships they had undergone, their lymphatic tendencies, their irregular living, with the moral depression of re- peated defeat, exposed them to the ravages of the lowest forms of the disease. Many of their wounds were fright- ful from the extensive sloughing, and their worn frames and gaunt visages indicated a fearful combat with the disease. I was particularly struck with the mental depres- sion under which many of them were suffering-amount- ing to despondency." Dr. Joseph Jones had an oppor- tunity of studying the disease on a larger scale than any of his predecessors. He not only made special investiga- tions on the "dejected, debilitated, diseased, and filthy prisoners crowded into the foul prison and hospital at Andersonville, Ga.," but also investigations into all cases that occurred throughout the Confederate service ; and made numerous experiments on animals. His observa- tions (" Memoirs U. S. Sanitary Commission, Surgical Volume II." N. Y., 1871) confirm the previous theories of the predisposing causes of the disease, and put at rest the doctrine of the inoculability of the virus. Although it had long been known that certain old lint, sold from the Paris hospitals in 1797, had been washed and carried to Holland, where every ulcer to which it was applied subsequently became affected with hospital gangrene, and the experiment of M. Ollier, in 1810, by self-inocula- tion of the virus, had proved its inoculability, yet there have not been wanting those who denied every principle of contagion to hospital gangrene. Even so late as 1863, the editor of the American edition of Wagner's " Pathol- ogy " expressed doubts on the subject, and twice inocu- lated himself with the products of hospital gangrene without effect. The remarkable immunity in this case, however, must not be taken as conclusive evidence of the harmlessness of the poison, any more than the eating of trichinous pork by Drs. Belfield and Atwood proved that infected pork was a wholesome article of diet. The ex- periments of Joseph Jones, in the successful inoculation of animals, and the instances of the carrying of the con- tagion in sponges, have set the matter at rest, and its con- tagious quality is now admitted. Symptoms.-These are variable. Mr. Guthrie graphi- cally describes them: " A wound attacked by hospital gan- grene in its most concentrated and active form presents a horrible aspect after the first forty-eight hours. The whole surface has become of a dark-red color, of a ragged appearance, with blood partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle separating from half to three-fourths of an inch around, with a concentric circle of inflamma- tion extending an inch or two beyond it ; the limb is usu- ally swollen for some distance, of a white, shining color, not peculiarly sensible except in spots, the whole of it being cedematous or pasty. The pain is burning and un- bearable in the part itself, while the extension of the dis- ease, generally in a circular direction, may be marked from hour to hour ; so that, in from another twenty-four to forty-eight hours, nearly the whole of the calf of a leg, or the muscles of a buttock, or even the wall of the ab- domen, may disappear, leaving a deep great hollow or hiatus of the most destructive character, exhaling a pecul- iar stench which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield ; the largest nerves are destroyed, and the arteries give way, frequently closing the scene, after repeated haemorrhages, by one which proves the last solace of the unfortunate sufferer. . . . The joints offer little resistance ; the capsular and synovial membranes are soon invaded, and the ends of the bones laid bare. The extension of this disease is, in the first instance, through the cellular struct- ures. The skin is undermined and falls in, or a painful red, and soon black, patch is perceived at some distance from the original mischief, preparatory to the whole be- coming one mass of putridity, while the sufferings of the patient are extreme." The surface of the wound soon becomes a sticky, pulpy mass of a grayish color. This substance cannot be wiped off, and it resists the usual washings. If, at this stage, the further progress of the disease be not arrested, the patient succumbs, as from a fatal form of septicaemia. Treatment.-The local treatment of hospital gangrene has now become sufficiently simple owing to the introduc- tion of the use of bromine by Dr. M. Goldsmith, a med- ical director of volunteers in the United States Army dur- ing our last war. Dr. Goldsmith found that when the wounds affected with hospital gangrene were thoroughly cauterized with bromine, not only was the disease arrested, but the dis- semination of the vapors of the drug through the air of the ward materially aided in preventing the spread of the disease to other patients. The sloughs must be carefully trimmed away with the scissors or scalpel, and the bro- mine applied directly to the surface. Many cases of fail- ure were at first found to be due to the fact that the application was made on the outside of impenetrable sloughs, and failed to reach the real seat of the disease. The bromine may be applied by a stiff brush or a mop made of cotton or charpie. If there are pockets, the drug must be injected into them with a syringe. After this 302 Reference Handbook of the Medical Sciences. PLATE XV. GANGRENE FOLLOWING A SHOT LACERATION OF THE FEMORAL ARTERY (from the medical and surgical history of the war of the rebellion.) H BENCKt, LITH. N.Y. Gangrene. Garlic. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. injection all odor ceases, the part shrinks, and healing goes on, if at the same time the general health be at- tended to. The cauterization need not be repeated except at points where the disease seems not to have been reached, but a dilute solution of bromine may be used for several days. The solution recommended by Dr. Gold- smith is as follows : B. Bromini 32 grammes. Potass, brom 10 " Aquae dest q.s. ad. 128 " M. This solution can be used in any required dilution according to the necessities of the case, and for suppurat- ing wounds in general a solution of about one-eighth the strength given here will be found of the highest utility. It is not poisonous like the bichloride of mercury or car- bolic acid, and is in practice equally effective as a germi- cide. The solution of bromine diluted for individual cases should always be preferred for deep injections, where there is danger of absorption of a poisonous quan- tity of the mercury solution. In addition to the local and constitutional remedies, fresh air should be freely admitted, and all other patients promptly removed from the source of contagion. The prompt isolation of the first case of hospital gangrene oc- curring in a ward, is essentially necessary, not only to prevent the infection of the other wounded patients, but as an important element in the treatment. Nourishing food, and an antiscorbutic diet are properly regarded as necessary adjuncts to any course of local treatment that may be adopted. John B. Hamilton. 1 U. S, Marine Hospital Reports, 1882, pp. 160-162. servation. will continue to employ them, and, I think, too, with satisfaction to themselves and benefit to their pa- tients. In a considerable proportion of cases gargles are, of course, inadmissible, either on account of the tender age of the patient, or because of their use occasioning nausea and perhaps vomiting. Gargles may be classified in a general way as stim- ulant, astringent, sedative, and antiseptic, though, nat- urally, such a classification is quite arbitrary, since an individual one may be at the same time both sedative and antiseptic, or astringent and antiseptic, as the case may be. This classification is, however, convenient in prac- tice, and most practitioners recognize it whether formu- lated or not. Gargles are unofficinal preparations-that is, not recog- nized by the various national pharmacopoeias, though many hospitals and public institutions have adopted formulae for their own convenience. Below are given some of the formulae in use in the London Throat Hos- pital : B. Acetic acid 15 minims. Glycerin 18 minims. Water to 1 ounce. Mix. Stimulant and antiseptic. Very useful in the subacute inflammatory affections occurring during the course of the exanthemata. (Acetic acid, Br. Ph., is about one-fourth weaker than that of the U. S. Ph.) B. Carbolic acid 2 grains. Glycerin 24 minims. Water to 1 ounce. Mix. Stimulant and antiseptic. B- Dilute hydrochloric acid 12 minims. Glycerin 24 minims. Water to 1 ounce. Mix. Stimulant. B. Tannic acid 360 grains. Gallic acid 120 grains. Water 1 ounce. Rub the acids to a fine powder and mix with the water. This preparation is most useful for arresting haemorrhage from the uvula or tonsils after excision ; the patient should be directed to sip the mixture slowly, or hold it passively in the mouth till the haemorrhage is stopped. It should be made fresh, in quantities as re- quired. B- Borax 24 grains. Glycerin 24 minims. Tincture of myrrh 24 minims. Water to 1 ounce. Mix. Mild alkaline astringent. B- Solution of chlorinated soda... 24 minims. Water to 1 ounce. Mix. Disinfectant. Very useful in sloughing phag- edena and putrid conditions of the throat. The above will serve as illustrations of published formula of gargles; the list might be added to almost indefinitely. Hot and cold water, solutions of alum, chlorate of potash, sulphate of zinc, chloride of iron, and mixtures of water with compound tincture of benzoin, tincture of guaiac, tincture of opium, etc., are often used for purposes which will readily suggest themselves to the reader. Lime-water-on account of its solvent action on membranous exudation-sage-tea alone, or with alum for astringent effect, mucilaginous liquids, as infusions of flax-seed and slippery-elm, and many other prepara- tions of similar character, are in common use. Laurence Johnson. GARGLES (from yapyaplCw, to gargle, a word resem- bling in sound the act indicated) are liquid medicines used in washing the mouth and throat; in the latter case being held in the fauces and agitated by air expelled from the larynx. A gargle may consist of water alone, or of water or other liquid holding in solution mineral or vegetable sub- stances, and may be employed for simply cleansing the parts, or for therapeutic purposes. The term is, more- ever, commonly restricted to liquids applied to the throat by the act of gargling, while those used in the mouth alone are usually designated as mouth-washes. In former times gargles were used without much dis- crimination in all affections of the throat, varied, of course, in their composition according to the indications of the case in hand ; and, indeed, they are so used to a considerable extent at the present day. But since the in- vention of the laryngoscope and rhinoscope this practice has measurably declined. These instruments, and the more careful study which they have rendered possible, have led to more exact methods of treatment in throat affections, and consequently gargles, whose application must necessarily be made rather loosely, are falling into disfavor. Some of the most prominent laryngologists, among them Morrell Mackenzie, restrict their use entirely to affections of a chronic character, and situated not far- ther back than the anterior pillars of the fauces, holding that the pain induced by their employment in acute af- fections more than counterbalances any benefit derived. It seems to me, however, that this restriction is quite too stringent. We must take patients as we find them, and pre- scribe remedies, often because of their availability rather than that they are the best. Comparatively few patients are so situated as to admit of all the care required to pro- duce the best results of treatment. Of those suffering from the lighter forms of throat affections, whether acute or chronic, this remark is especially true; and in such cases gargles will continue to be prescribed and used, even though more exact and efficient methods might yield better results. And regarding their rejection in acute and painful affections of a graver character, such as tonsillitis, diphtheria, and the sore-throat of scarlet fever, notwithstanding the dictum of high authority I believe that a large body of the profession, confirmed in their opinion by the results of their experience and ob- GARLIC (Allium, U. S. Ph. ; Ail, Codex Med.). The bulb of Allium Sativum Linn. Order Liliacea, consist- ing of several bulblets, " cloves," enclosed in a common envelope, is still retained in the Pharmacopoeia with no very good reason, and prepared in the form of a syrup, (Syrupus Allii, U. S. Ph.), consisting of garlic 15, sugar 303 Garlic. Gawtrula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 60, diluted acetic acid 40. It is now and then given with some advantage, as an antispasmodic, and sometimes as an expectorant in chronic bronchitis and pharyngeal or laryn- geal catarrh. Internally taken, garlic, like the onion, etc., is an aromatic and carminative, and scents the breath with sulphur compounds during elimination. Garlic contains as its active principle-either already formed, or produced, as in mustard, etc., by the addition of water-a very irritating, pungent, and volatile oil, Sulphide of allyl, similar to that of the onion and others of the genus and belonging to the same group with the oils of mustard and other Cruciferce. Allied Plants.-Various species of Allium are used as seasoning vegetables, in most parts of the world ; for the order see Squill. Allied Drugs.-Mustard, asafoetida, tropoeolums (nas- turtium), etc., all contain similar sulphuretted oils. Musk and valerian have similar antispasmodic properties. IF. P. Bolles. The springs of Gastein are employed almost exclusively for bathing, for which purpose there are a dozen or more public and private establishments. The sensations produced by the bath are described as mildly stimulating, especially to the skin ; but the effect differs little, apparently, from that of an ordinary warm bath, except that it is free from depression. The baths, associated with a sojourn in the mountainous climate, are recommended particularly for nervous disorders, as neu- ralgias, hysteria, spinal irritation, hypochondriasis, and impotence ; for tabes dorsalis, and paralysis from apo- plexy ; for rheumatisms, exudations in the female pelvis, disorders of nutrition and of the blood-making functions, and for convalescence from wasting diseases. On ac- count of their remarkable effects on senile marasmus, the Gastein baths have been called the baths of the aged. They are recommended also for after-treatment to follow a course at Carlsbad, Marienbad, Franzenbad, Kissingen, etc. J. M. F. GASTEIN. One of the most remarkable natural baths of Germany. The village is situated in the Duchy of Salz- burg, Austria, on the northern slope of the Noric Alps, three hours by carriage from the station, Lend, seventy- four miles from Salzburg, on the railroad which connects that city with Tyrol. Its situation is one of the most romantic in the Alps, close to the glacier region, at an al- titude of more than three thousand feet above the level of the Mediterranean. The variations in temperature are moderate, since it is protected to a great extent by sur- rounding mountains from the force of the north and east winds. The following are given as the average tempera- tures and number of rainy days in the warm months. GASTRECTOMY, GASTROSTOMY, GASTROTOMY. By Gastrectomy (yaoT^p, stomach, Ik, from, out of, rop.^, sec- tion), is meant the resection of a portion of the stomach, as for instance a cancerous pylorus. By Gastrostomy (yaar-pp, stomach, <rr6pa, mouth), is meant the establishing of a permanent fistulous opening into the stomach for the purpose of habitually introducing food thereby. By Gastrotomy (yaffr^p, stomach, roph, section), is meant the making of a similar opening for a temporary purpose, usually the removal of a foreign body that has been swal- lowed, but occasionally to aid in making a diagnosis by direct examination of the interior of the viscus, or to di- late a contracted pylorus. Gastrotomy was first performed in 1602, to remove from a man thirty-six years of age a knife which he had swallowed seven weeks previously, and whose point was beginning to perforate the anterior abdominal wall. The operation has since been done about twenty times, and in only two cases has it caused death, both times by perito- nitis ; but the cases differ so widely from one another in their conditions and details, that this percentage of mor- tality cannot fairly be taken as an indication of the risks of the operation. In all but one or two of these cases the object of the operation has been the removal of a foreign body, and in some of them the stomach had become ad- herent to the anterior abdominal wall, and the foreign body had almost made its way out by ulceration ; in a re- cent case (1883) it was done to enable the operator to di- late the pylorus, which had become greatly narrowed by cicatricial contraction; the patient survived, and the symptoms dependent on the obstruction were relieved. Gastrostomy was first done in 1849 by Sedillot. In 1882 I collected 93 published cases, in all of which the operation was done to relieve the suffering occasioned by stricture of the oesophagus ; in 75 the stricture was due ro cancer-1 of the tonsil, the others of the oesophagus ; and in 18 it was due to cicatricial contraction caused by the swallowing of a caustic alkali or acid. The first 28 cases ended fatally within a few hours after the operation ; in the twenty-ninth case the patient survived forty days and died of bronchitis. Of the 18 cicatricial cases, 8 died in consequence of the operation, and 10 recovered from it. Of the 75 cancerous cases, 20 lived for periods varying from three weeks to eight months, two or three of them being still alive at the date of the last report; 54 died within three weeks after the operation, and the great ma- jority within the first week. The causes of death were peritonitis, exhaustion, the shock of the operation, and the progress of the disease, especially in the thoracic organs. In several of the successful cases, it is noted that the obstruction was not complete, and that the patient was nourished by the mouth up to the time of the operation. In cicatricial contraction the operation is called for only when the stricture is situated at so low a point that it can- not be exposed by an incision in the neck, and when it cannot be overcome by dilatation with bougies. April Temperature. 42.0° F. Rainy days. 7.3 May 50.4° F. 16.0 J une 54.5° F. 21.7 July 55.4° F. 22.0 August 60.8° F. 18.3 September 51.8° F. 15.7 October 45.0° F. 11.7 The average atmospheric pressure for a year is 29.50 inches, the barometric changes being but slight. The thermal springs are eighteen in number, many of which have received special names, as the Fiirstenquelle, the Doctor's-Quelle, the Spitalquelle, etc. Seven of these springs issue directly from the solid granite rock, rich in quartz, or from artificial clefts that have been made ; the remaining eleven issue from stratified beds of feldspar, gneiss, and mica. Reference need hardly be made to the speculations, here as elsewhere, with regard to the origin of the springs. The deep origin of all the waters appears to be in the heart of the great Graukogel; all discharge their waters into the dashing little river Ache. The temperature of the springs varies between 87° F. and 160° F. ; the temperature of the individual springs is about the same at all seasons, regardless of atmospheric changes. The flow is abundant, that of the Hauptquelle, which is the largest as well as the warmest, being 9.5 cubic feet in a minute. The specific gravity of the water is 1.003. Its conductibility of electricity stands to that of distilled water in the ratio of 6.1 to 1, being more than six times as great. According to the analysis of the water by Wolf, each pint contains : Grains. Sodium carbonate 0.04 Magnesium carbonate 0.02 Ferrous carbonate 0 05 Manganese carbonate 0.02 Calcium carbonate 0.36 Sodium chloride 0.36 Potassium sulphate 0.01 Sodium sulphate 1.51 Aluminium phosphate 0.04 Calcium fluoride traces. Strontia traces. Silica 0.24 Organic matter traces. Total 2.65 Gases. In 100 parts. Oxygen 30.89 Nitrogen 69.11 304 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Garlic. Gastrula. In cancerous obstruction the operation offers only palli- ation of the distressing symptoms during the period in- tervening between the operation and the death of the patient by the progress of the disease. An alternative that may occasionally offer is excision of the cancer when it is situated at the upper end of the oesophagus, and has not involved the adjoining parts. In the successful cases the patients have been fed through a tube introduced into the fistula. In some cases the food, chopped fine and mixed with water or milk, was poured into a funnel at the outer end of the tube ; in others it was taken into the mouth and chewed, and forced directly from the mouth through the tube into the stomach. The operative methods which seem to be in most favor at present, and most worthy of adoption, are as follows : 1. Make the incision parallel and close to the free bor- der of the costal cartilages on the left side, beginning about two inches below the xiphoid cartilage and extend- ing downward and outward for about the same distance. If, as is usual, the abdomen is greatly retracted, each layer of the abdominal wall will rise from the underlying ones when it is divided, and when the peritoneum is opened the air will rush in and lift the wall of the abdomen away from the stomach. I consider this entry of the air a formidable factor in the production of shock and peri- tonitis. It cannot be prevented by pressure upon the ab- domen, and it may be found worth while to try to inflate the stomach by passing a trocar into it after the perito- neum has been reached, and before it has been divided. The stomach, even when entirely empty, can be seen through the peritoneum and in contact with it, moving slightly up and down as the patient breathes. Failing this, or as a substitute, the surgeon should introduce purified and warmed air into the cavity of the abdomen by puncturing the peritoneum with a trocar connected with a reservoir of prepared air. In one or two cases the stomach has been distended by separately introducing into it through the mouth the two parts of a seidlitz powder ; but the object in these cases was to make the stomach more accessible through the wound, an unnecessary manoeuvre. 2. The peritoneum when reached should be divided to the extent of half an inch, a pair of dressing-forceps should then be introduced and carried along the anterior wall of the stomach for an inch or two toward the left, and the stomach caught and drawn out through the wound. The forceps should be passed to the left before grasping the stomach, because the part which lies im- mediately under the incision when the stomach is empty adjoins the pylorus, and it is desirable that the opening should be nearer the centre of the organ. If doubt is felt .as • to the identity of the presenting viscus, the greater or lesser curvature of the stomach should be sought for, either by drawing it out through the wound or by introducing the finger. 3. The divided edge of the parietal peritoneum should then be drawn out and stitched all around to the skin, after a small drainage-tube or a bundle of horse-hair has been placed on each side between its outer surface and the divided muscular planes. This stitching of the parie- tal peritoneum insures a broad surface of peritoneal contact with the stomach, and consequently a more rapid and firm sealing of the opening ; the drainage is needed because suppuration has taken place in a few cases be- tween the peritoneum and the divided muscular planes. 4. The stomach is secured in the opening by from four to eight silk sutures, passed for half an inch or more between its muscular and mucous coats, and including an equal breadth of the parietal peritoneum. Two long pins or two stout silk ligatures should be passed through the portion of the stomach that projects through the wound, for the purpose (in the case of the ligatures) of facilitating the making of the subsequent incision into the stomach, and also (in the case of the pins) as a precaution against the tearing out of the stitches if the patient vomits ; and finally for the purpose of facilitat- ing the return of the stomach into the abdominal cavity. This tearing out of the stitches happened in one of Se- dillot's cases, and one stitch tore out in one of Bryant's cases. In most of the later operations, the final step of open- ing the stomach has not been taken until after the lapse of several days-from three to eight; and it is perhaps worthy of mention that in one case in which it was opened on the eighth day, peritonitis developed shortly afterward and proved fatal. It is in these more recent cases in which the opening of the stomach by incision has been made a second operation, done several days after the first, that the number of successes has been largest. If the delay is impracticable, because of the necessity of feed- ing the patient by the stomach, the incision may be made at once, and kept closed in the intervals of feeding by a figure-of-eight ligature thrown around the transfixing pins, which, it is understood, simply rest upon the skin, and do not perforate it. Finally, the influence of the enfeebled condition pro- duced by starvation and cachexia upon the result is so marked that, if the operation is to be done at all, it should be done as early as is practicable. Lewis A. Stimson. GASTRULA. Gastrula is, properly speaking, a new name for the larval form called planula by older writers, but is generally employed to designate the ideal embry- onic stage, supposed by many writers to be common to all multicellular animals. In this latter sense a gastrula is an animal either adult or larval or embryonic, consisting of two epithelial layers or their homologues, with a closed space, the so-called segmentation cavity, between them, in which may or may not be cells representing a third layer. The two epithelia represent the ectoderm and entoderm, and differ in their character, the ectoderm cells being always the smaller. Typical gastrulae, supposed to conform more or less to the original pattern from which all have been evolved, are the larvae of various invertebrates. We may take Fig. 1380.-Section of a Gastrula of Toxopneustes lividus. (After Sel- enka.) ec, Ectoderm ; en, entoderm; mes, mesoderm ; 3Z, mouth. that of a sea-urchin as an example (Fig. 1380) ; the larva is round ; at one pole it has an opening, M, the gastrula mouth, leading into an internal cavity ; as this is a free swimming larva, it is provided with long cilia for organs of locomotion ; in many gastrulae the cilia are distributed over limited areas or may be wanting altogether. The larva consists of a double sac, a larger outer one of small epithelial cells, ec, the ectoderm, and a much smaller inner one composed of larger epithelial cells, en; at the mouth, M, of the inner sac, the two layers are continu- ous with one another; in the space between them are a few scattered cells, the first members of the mesoderm, mes. Now in many, especially of the higher, orders the de- velopment proceeds to a variable but considerably ad- vanced stage in the ovum, which is accordingly stocked by the parent with nutritive material (yolk) to sustain the intraovic growth of the embryo. This yolk is associated 305 Gastrula. <«enital Organa. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. always * with the entoderm, and modifies its early devel- opment extremely, and to an extent which varies with the amount of yolk, as is illustrated by the diagrams of Fig. 1381. In general it may be stated that the larger the yolk the more the division of the entoderm is retarded, and the larger are the entoderm cells. In Fig. 1381 the mesoderm is left out; A, corresponds to such a larva as Fig. 1380 ; the difference in size between the two sets of cells is slight but evident. In B, the difference is more marked, and fairly represents a gastrula of amphioxus. In C, the difference is very great and corresponds to that observed in certain gasteropod larvae. In D, the inner set is no longer separated into distinct cells, although there are a number of nuclei, each of which marks the centre of a future cell; in such instances we must regard the whole inner portion as not yet transformed into a definite entodermic cell-layer. This figure is particularly instruc- tive, because it shows that what wre call the yolk is not something distinct from the germ, but really belongs to the inner layer of the embryo. E shows a similar egg, in which the outer set of cells has not yet grown around the yolk. F shows the same egg not in section, but seen from lished, for there are many facts not brought into accord with the theory in its present form. Charles Sedgwick Minot. GAZOST. A cold sulphur-spring in the vicinity of Lourdes, in the department Hautes-Pyrenees, or Upper Pyrenees, about four thousand feet above the level of the sea. The water is used at the springs almost exclusively by the natives of the village, but it is also exported in large quantities to Bagneres-de-Bigorre, the most popular resort of the Pyrenees. The water of Gazost contains, in addition to sodium sulphate and calcium sulphate, a small amount of iodide and bromide, and the largest amount of the sodium chloride of the Pyrenees springs, 3.072 grains in a pint. J. M. F. GEILNAU. The seat of pure alkaline springs on the northern slope of the Taunus Province of Nassau, Ger- many, on the right bank of the Lahn, almost within sight of Fachingen. The waters resemble very closely those of Seltzer, but are of a lower temperature, contain a little less sodium chloride, and more free carbonic acid. They are, therefore, more pleasant to the taste. They have not, however, attained the repute of the latter resort, nor is the water exported to nearly so great an ex- tent. As a resort Geilnau has many advantages, on ac- count of its beauties of environment, and its short dis- tance from the metropolis, Nassau ; but it is very little frequented, the water being altogether exported. An analysis of the water by Fresenius gives the follow- ing contents of a pint : Grains. Sodium bicarbonate 8.142 Calcium bicarbonate 8.767 Magnesium bicarbonate 2.788 Barium bicarbonate 0.001 Ferrous bicarbonate 0.294 Manganese bicarbonate 0.0d5 Potassium sulphate 0.135 Sodium sulphate O.i'66 Sodium phosphate 0.003 Sodium chloride 0.278 Fig. 1381.-Diagrams of the Principal Modifications of the Gastrula (see text). A-E represent sections. the outer surface in order to exhibit the cap of small cells (blastoderm) resting upon the yolk. To convert a gastrula into a bilateral animal, we have only to flatten it and elongate the mouth. If the mouth were pulled out so as to make a long narrow slit, the new longitudinal axis would be well marked. If, further in the progress of evolution, the lips of the slit-like mouth should come together and unite in their middle part, the animal would still have the two ends of the original mouth left open, and would so acquire an alimentary canal with two apertures ; from this beginning we may deduce all bilateral animals. (It may be noted that in Peripatus, according to Sedgwick, the history of development is ex- actly as here described.) There are numerous reasons which lead me to the belief that this was the actual method by which the gastrula was evolved into higher forms, and I see in the concrescence of the vertebrate em- bryo only a modification of the union of the gastrula lips, cf. Fcetus. The term gastrula was introduced by Haeckel, and is now universally used by embryologists. The discovery of the importance of the gastrula is due to the brilliant re- searches of Kowalewski on various invertebrates, includ- ing Amphioxus, then supposed to be a vertebrate. Haeckel then seized upon the idea of the gastrula and wrote an essay upon it, which from its brilliant style attracted much notice, and did much to direct attention to the im- portant discovery of Kowalewski. Although Haeckel indulged his fantasy unduly and was misled into specula- tions which are now unheeded and almost forgotten, he did great good by starting the interest of zoologists in the right direction. By a remarkable coincidence, Lankester published an essay, of very similar purport to Haeckel's, at about the same time. A great deal remains to be done before the gastrula theory of evolution can be fully estab- Total 16.699 Grains. Ammonium bicarbonate 0.010 Free carbonic acid 21.400 Nitrogen 0.119 Total 21.529 Also traces of lithium carbonate, sodium borate, alumina, sodium nitrate, calcium fluoride, strontium carbonate, organic matter, and hydrogen sulphide gas. Indications.-Geilnau water is recommended in all the affections for which the simple alkaline waters are indi- cated, in chronic catarrhs of the respiratory, digestive, or urinary organs, gout, etc. J. M. F. GENITAL ORGANS, MALE, MALFORMATIONS, IN- JURIES, AND NEW GROWTHS OF* Injuries and Wounds of the Scrotum.-From its pendent location the scrotum is markedly subject to injuries, such as con- tusions, wounds, burns, urinary infiltrations, etc. Contusions.-These are very common, and result from such accidents as kicks, blows, and the falling of the pa- tient astride of hard objects. Owing to the absence of subcutaneous fat, contusions of the scrotum, like those of the eyelids, show the dark color of ecchymosis more clearly than most other parts. As the testes generally participate in any severe contusion, there is often pain referred to the loins, nausea, faintness, etc. ; but these are not properly scrotal symptoms, and will be fully consid- ered in the section on testes. The extravasated blood is sometimes large in quantity, distending the pouch and constituting a considerable tumor of a blackish color, commonly called haematocele. These tumors preserve the same name, according to most authors, regardless of the exact location of the blood ; hence, precision requires them to be divided into three classes, viz. : 1. Hsematocele of the Dartoid Tissue. * It is possible that certain sponges form an exception to this law, the yolk occurring in the ectoderm. I deem it, however, more probable that there is some error of observation or interpretation than that there is really such an exception. * The malformations, injuries, and new growths of the penis will be considered under the heading Penis, in a later volume. 306 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gastrula. Genital Organs. 2. Hematocele of the Tunica Vaginalis. 3. Hematocele of the Spermatic Cord. These may exist singly or together. In the further progress of the case, the blood is usually absorbed with- out suppuration, but when the tunica vaginalis is filled with clot, and septic germs are introduced into it through a co-existing wound, a dangerous and putrid suppuration ensues which greatly endangers the patient by septicae- mia. Contusions of this part are rarely so severe as to cause mortification, but they are prone to kindle consid- erable inflammation, which in turn may result in abscess. The treatment of scrotal contusions is very simple. Mild cases recover without any care. Severer ones re- quire the patient to be placed in bed. A cushion should be placed between the thighs on which the scrotum can rest in an easy position and not hang its weight painfully by the inflamed cords. For local applications I prefer cold lead-water containing one part to forty of carbolic acid. The energy of the cold should be graded by the severity of the inflammation, and it is exceedingly efficient if applied early. However, some surgeons prefer a series of hot applications, but they have always seemed to me less decisive than a resolute application of cold. A sort of dropsy of the dartoid coat in children, and of the tunica vaginalis at all ages, may follow contusions, but it is of short duration. If desired, the fluid can be withdrawn by punctures from the dartoid tissue, or by tapping from the tunica vaginalis. Incised Wounds.-So far as these affect the scrotum only, and not the testes and tunica vaginalis, they are like incised wounds elsewhere. In transverse incisions there are commonly one or two small arteries found bleeding near the raphe, and sometimes branches at other points, which should all be well ligated to prevent haemorrhage into the loose dartoid spaces after the wound is dressed. The contractile power of the dartoid tunic is such that it often holds wounds in good apposition without sutures or ad- hesive plasters ; but if this spontaneous closure does not occur, the ordinary retentive appliances must be em- ployed. In either case the wound should be dressed an- tiseptically. In all varieties of scrotal wounds, one should remem- ber that there may be a scrotal hernia present, and that consequently the included intestine may be wounded. Careful examination is required on this point, and if such a wounded viscus is found, it should be treated on the principles detailed below under the head of gunshot wounds of the scrotum. Lacerated Wounds.-These are caused by machinery, by splinters, hooks, horns of vicious cattle, etc. A singular accident sometimes happens to laborers about threshing machines which use a " tumbling-rod " placed near the ground. In these cases the bottom of the cloth- ing is caught on the tumbling-rod and wound upon it with instantaneous rapidity. As the pants and drawers leave the waist and are stripped suddenly down over the hips, they entangle the scrotum and penis, and strip the skin completely off from both, leaving the penis and testes completely naked, and the latter hanging very low on their stretched and elongated spermatic cords. It is not generally necessary to sever the stretched cords and re- move the testicles, but it is often advisable to make a plastic operation, and to cover the stripped organs with flaps of skin from the adjacent parts. It would, how- ever, be best in the first place to immediately reapply the original skin, so as to save every chance, however small, that it may contract a living adhesion. Recent experi- ments show that severed skin may preserve its vitality at least one hundred and eighteen hours. I removed a piece of skin from a scrotum in Chicago, on Saturday afternoon, at my regular clinic. In the evening it was shipped in ice by express to the iron mining region of Lake Supe- rior. The following Monday it was used for skin-graft- ing by Dr. Hirschman, surgeon of an iron mine in the town of Norway, in Upper Michigan. Over a hundred grafts were placed, most of which lived. Among those living was one piece half an inch wide and an inch and a half long. In view of such experiments, both by Dr. Hirschman and others, there is good reason to hope that more or less of the stripped integument may regain its hold upon life if promptly, or even very tardily, replaced in position. Lacerated wounds with no great loss of sub- stance should first be cleansed and rendered aseptic. If no special circumstances prohibit, it is best to pare the edges, unite them with sutures, and treat the case as an in- cised wound. But if this is prevented, the wound must heal by granulation. The contractile power of ulcers re- sulting from loss of substance in the scrotum is surpris- ing, and the wound, even after great loss of substance, often leaves only a linear cicatrix. Even when almost the entire scrotal integument seems to be torn away, there is no occasion for discouragement. Owing to the great wrinkling and contraction of the skin of the part, that which at first appears as a miserably small and in- sufficient remnant can be unfolded and stretched out to a surprising extent, and often, by paring the edges, made to unite by first intention and cover the testes completely. If this cannot be done, the pouch of granulations cover- ing the testes soon contracts, lifts them up, draws down the remnant of skin, and soon effects a cure with a de- formity surprisingly slight. If, however, the whole scro- tum is absolutely gone, it may be necessary to bring in for covering some flaps from adjacent parts. Gunshot Wounds.-These vary from small perfora- tions to a complete tearing away of the whole organ. Spent bullets sometimes lodge in the pouch, and are apt to be masked by the swelling and clots, so as to escape the search of careless examiners. Gunshot wmunds of the scrotum should be treated by cold and by antiseptics, like other lacerated injuries. The contractility of the integu- ment is so great that the orifice must often be enlarged to make room for cleansing the wound, or for the introduc- tion of tubes for drainage. In some cases it is best to re- move the shattered relics of the testis. In all cases the horizontal position, and the support of a cushion for the scrotum, are to be desired. In examining gunshot wounds of the scrotum, one should always bear in mind the possi- ble presence of a scrotal hernia, and consequently of the presence of a perforated intestine. In such case the return of the wounded gut, without first most carefully closing the perforations in it, would necessarily be fatal in all ordi- nary cases. The intestine in such cases must be promptly secured before it has any opportunity to slip back, and very carefully examined. If badly disorganized, the link may have to be excised, and the ends secured to the edges of an opening near the external ring, as in operations for strangulated hernia with mortification ; but if the intes- tine is simply perforated in one or two places, the wounds can be closed by the form of suture usually recommended for wounded hollow viscera. An effort is to be made to fold the edges of the mucous coat inward, and to close the opening in it with fine sutures cut off short. The peritoneal edge is then to be folded in, also, and carefully closed with sutures, in such a manner as to place the peritoneal surfaces completely in contact with each other. The peritoneal sutures are not in any case to penetrate the cavity of the bowel, but are to take up a liberal breadth of peritoneal and muscular coat. The perfora- tions being thus secured, the gut may be returned, pro- vided the neck of the hernial sac is large enough to allow it to pass without the employment of such force as might derange the perfection of the sutures. If the latter dis- aster is to be feared, the neck of the sac may be enlarged, or else the gut may be retained in the scrotum. The lat- ter course is generally undesirable, because the intestine will contract adhesions and become irreducible. If, by any accident, a gut known to be perforated slips back into the abdomen before the wound is sutured, it is safest to take the bold course, and seek to recover it by laparot- omy. The war record of gunshot wounds of the scro- tum is very scanty, and there are not on record cases enough to enable us to give any valuable statistics. The location of the organ is such that a bullet in traversing the scrotum generally pierces the hips, thighs, penis, or testes, so that gunshot wounds of the scrotum alone are rare. When they do occur, they seem not to be danger- ous, but to heal with safety and rapidity. Punctured Wounds.-These are seldom of much conse- 307 Genital Organs, Genital Organs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tient does not die of the blood-poisoning, the testes and the tunicse vaginales are found uninjured. They hang down two or three inches below the edges of the living skin, and are soon covered with a thick growth of new granulations, constituting a sort of suspensory bag. There is generally a rim of wrinkled scrotal integument left above, which unfolds and expands wonderfully, as it feels the tension of the granulating and contracting pouch below. In the end this pouch, partly by lifting the testes, and partly by drawing down the remnant of the integument, contrives to enclose the exposed organs in a very creditable sort of scrotum, if we consider the amount of tissue lost. Burns and Potential Cauteries.-These accidents are somewhat rare on account of the location of the parts. When they affect the scrotum only in the first or second degree, they are trifling, and may be treated as similar injuries elsewhere. When they cause sloughing of the scrotum, they are subject to the rules just laid down for a scrotum mortified from infiltration. If too much tis- sue is lost, and yet the testes are saved, they may be cov- ered by flaps from adjacent parts. Malformations of the Scrotum.-Malformations of the scrotum include certain cases of congenital deficiency of the normal parts constituting the so-called hermaphro- dism, which may become important from a medico-legal standpoint. These are instances of cleft or fissured scro- tum with absence or malformation of the penis. The testes may lie concealed in a cleft scrotum with a pair of tegumentary folds closely imitating the external appearance of the labia majora in the female. In epispadias or extroversion of the bladder, the scro- tum may be wanting. Such cases are sexually incapaci- tated. Adhesion to Penis.-Adhesion of the scrotum to the penis by a fold of integument is sometimes seen. This is always a congenital malformation. Operative measures are often called for in such cases to release the member from its unnatural adhesion. In mild cases simple divi- sion of the fold will be found sufficient. The lateral edges of the wound thus formed through the skin should then be brought into coaptation by sutures, so as to form a longitudinal line on the under surface of the penis (Bouis- son, Ashhurst). Holmes suggests the introduction of a tegumentary flap from the thigh or inguinal region, in cases which do not allow the skin easily to be drawn together after dissect- ing the penis from its faulty attachment. Diseases and New Growths of the Scrotum.- Elephantiasis.-Hypertrophy of the scrotum from the dis- ease known as Elephantiasis Arabum, is common in tropi- cal countries, but rare in Europe and North America. When attacked by this disease, the scrotum sometimes be- comes enormously large so as to reach to the knees, or even hang to the ground when the patient stands upright. Cases are on record in which the tumor attained a weight as great as all the rest of the body. The causes of this en- largement are not known. It is in the nature of a benign growth and proves harmless except by its size and weight. The only treatment known to afford any relief is the cutting away of the diseased mass. This operation is a simple one, and only proves dangerous when the tumor is of large size. Haemorrhage is the chief danger. For the purpose of preventing loss of blood a tourniquet may be placed around the neck of the tumor. Where the growth is of great size the penis and testes are concealed in its mass, and it is advised by Erichsen that no effort be made to save them lest the delay cause fatal haemor- rhage. Where the growth is moderate these important organs can always be preserved by dissecting them out from the diseased mass. The redundant scrotum is then simply cut off with a few rapid strokes of the scalpel or catlin, and the haemorrhage controlled as quickly as possible. A large number of vessels require ligatures. It is immate- rial whether the wound be closed by flaps or allowed to granulate. This will depend upon the ability of the upper parts of the scrotum to furnish healthy skin for a cover- ing. When the wound remains open the testes hang down quence, except when they penetrate the tunica vaginalis, in which case they may cause important evils, which are discussed in the section relating to the testes. The causes are the catching of the organ upon pitchforks, meat-hooks, nails, splinters, etc. If the wounding implement is con- taminated with septic material, as in butchers' hooks, etc., very great mischief may ensue from erysipelas or septic gangrene; but in general the punctured wounds of this part heal very readily under simple cleanliness and pro- tection. either with or without antiseptics. If, however, septic disease should manifest itself, free incisions should be made early and thorough antiseptic measures inaugu- rated. Internal medication should also be carried out with tincture of iron, quinine, etc., as in other cases where sep- ticaemia is feared. If a punctured wound occurs in a scrotum occupied by a hernia, the question immediately arises whether the gut is perforated. A free incision must be made, and the viscus be secured and examined. If a wound be discovered in the intestine, it must be treated on the same principles as have already been de- tailed under the head of gunshot wounds of the hernial scrotum. Hematocele of the Dartoid Tissue.-As the consequence of the rupture of vessels with or without external vio- lence, the dartoid tissue may become distended with blood, constituting the accident termed Hsematocele of the Dartos. The skin becomes very purple or black with the effused blood, and a good deal distended, but the pain is slight unless other mischief besides mere disten- tion is produced at the same time with the extravasation. The thickness of the swollen mass conceals the testes from the touch. Generally the blood is slowly absorbed, leaving no organic injury, but in severer cases, especially if there has been external violence, or a penetrating wound, severe inflammation may ensue. In such cases, the pa- tient should be placed in the horizontal position with a cushion under the organ, and cold antiseptic dressings should be applied with whatever energy may be required to effectually subdue the inflammation. If an abscess en- sues it must be treated by incision, and such other treat- ment should be employed as abscesses of other soft parts require. Infiltration with Urine.-From any rupture or perfora- tion of the urethra without a perfectly free outlet into the external air, the urine is liable to be injected into the loose connective tissue of the perineum and of the adja- cent parts, and especially into the scrotum. This acci- dent is caused by contusions, punctures, bullet-wounds, lacerations made by improper use of sounds and catheters, ulcerations of the urethra, ruptures of its distended coats caused by long pressure of urine behind a stricture, and may also result from the ulceration caused by small cal- culi and foreign bodies lodged in the urethral canal. I once opened an infiltrated scrotum in a child aged eighteen months, and found in it a small calculus which had ulcerated through from the urethra, thus making a track which the urine followed. Whatever the cause, the organ becomes distended with urine, forming a translucent watery spelling which has a doughy feeling and pits deeply upon pressure. A low form of inflammation ensues, followed at the very best by an abscess, and even more frequently by actual gan- grene. Mortification and sloughing abscesses are also likely to occur in the adjacent parts, wherever the urine gets opportunity to exercise its destructive chemical effect upon the connective tissue. The patient's blood is poi- soned, and in a considerable portion of cases death en- sues. The treatment should be energetic. First of all, free incisions must be made deep into the infiltrated tissue, so as to drain away the urine already effused. The scrotum, especially, must be deeply slashed on both sides of the raphe. At the same time a free and straight opening must be made from the external air to the exact spot where the urethra is perforated, so as to lead the escaping fluid directly outward, and to leave it no opportunity to be injected into the connective tissue. Antiseptics are re- quired locally, and quinine and tincture of iron inter- nally. If the infiltrated scrotum sloughs off, and the pa- 308 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Genital Organs, Genital Organs. alarmingly at first, but soon become covered by granula- tions and draw upward into place. This is true whether the tunica vaginalis has been removed or is left undis- turbed. In all cases where it is included in the hyper- trophied tissue the tunica vaginalis should be excised with the rest of the growth. Cancer of Scrotum.-Epithelioma of the scrotum is a disease comparatively unknown in America, but was once quite prevalent in English cities. It is a very singular fact that it occurred almost exclusively among persons of one occupation, viz., chimney-sweeps, and the deduction is plain that the occupation in some way caused the dis- ease. This affection was known as chimney-sweeps' can- cer. The number of cases in London has of late years diminished, coincidently with the introduction of sweep- ing-machines to take the place of manual labor, and the general substitution of coal for wood as fuel. The soot from chimneys was formerly collected and sold in England. Many persons were engaged in sifting and preparing it, as well as in removing it from the flues. Such persons were often found affected with cancerous disease in the scrotum. The rugae of the skin, retaining soot for long periods, became persistently irritated, and ultimately infiltrated, and thickened into cancerous nod- ules. Sir James Earle saw a cancer under the arm of a gardener who had persistently carried a soot-bag there. Volkmann asserts that "chimney-sweeps' cancer" is still prevalent at those places on the continent of Europe where coal-tar products are manufactured. It has been observed among smelters. The analogy of this form of epithelioma to that which appears upon the lower lip of an inveterate smoker is in- teresting, though quite possibly accidental. In both cases we have to do with the local effects of the products of combustion applied to an abraded surface. "Chimney-sweeps' cancer" first shows itself in the form of a small indurated nodule upon the scrotal skin, spreading from this point, and involving the adjacent parts. It is slow of development, but sooner or later in- volves the surrounding tissues, and always ends fatally, unless extirpated when small, or before the adjacent lymphatics take on secondary cancerous growth. En- cephaloid carcinoma of the scrotum is occasionally met with. This is sometimes pigmented, forming melanotic cancer. Scirrhus may also affect the organ. Treatment.-In all forms of carcinoma of the scrotum early excision is the treatment to be adopted. No other remedy is worth mentioning as of any real value. In the "epithelial variety," i.e., the "chimney-sweeps' cancer," there are good prospects of a cure when the removal is made early, because in this variety the general dissemina- tion of the disease is slow. The presence of enlarged inguinal glands diminishes, but does not extinguish the hope of success. They should be excised with the original tumor. Mr. Humphrey, of England, advises that if the glands are only slightly enlarged they be left alone until they be- come larger. This advice is absurd. If they are even sus- pected they should be removed, for delay means the throwing away of the patient's chances of life. Sarcoma.-Sarcoma of the scrotum is rare. Its diag- nosis from other growths might depend upon microscop- ical examination. The treatment would be prompt ex- cision. Fibroid Tumors.-Sir William Ferguson met one case of fibroid tumor of the scrotum. Enchondroma.-Enchondromata are very rare, but are described. They may be excised when large and trouble- some. Lupus.-Lupus of the scrotum is essentially like the same disease elsewhere. It should be treated by thor- oughly scraping away the diseased tissue with the finger- nail or blunt steel instrument, and especial care should be taken to remove the elevated circumference. The whole may then be cauterized with chromic acid, or with any of the more energetic caustics. Malformations of the Testes.-Kolliker has shown that in foetal life the testes and epididymis are developed from different structures. The latter only is formed from the Wolffian body itself, the gland proper being formed out of tissues lying in front of this body. This fact may have some bearing on the etiology of congenital malformations of the testes. Absence.-Absence of one or both testicles is not infre- quent. Cases of partially formed testes also are met with. In such cases the epididymis may be fully de- veloped, or the cord only may be present. Entire ab- sence of the testes does not necessarily indicate the ab- sence of sexual desire, provided the epididymis and cord are present. Persons so affected are virile, but sterile. M. Gosselin declares that they have the stature and phys- ical and moral powers of other men. No spermatozoa are found in their semen. Retained Testis.-Sometimes one of the testes is re- tained in the abdomen at birth, and later descends into the scrotum. This descent takes place, if at all, in in- fancy, and is liable to be complicated by congenital hernia, or hernia in the tunica vaginalis-a form in which the intestine and the testicle occupy the same sac. In other cases the testis never descends through the abdominal ring. One or both organs may be retained in the abdomen. The causes are not well known. Defec- tive action of the gubernaculum has been invoked as a reason for the failure to descend. In most cases cited the testes were found undeveloped, or atrophied. It is entirely conjectural whether the imperfect development is a cause of the retention, or vice versa. Testis in the Groin.-It is not rare to find a partially de- scended testicle lodged in the inguinal canal and forming a small tumor in the groin. Instances are credibly re- ported in which this condition has been diagnosed as ob- lique inguinal hernia and treated by trusses. Except as to matters of diagnosis this malposition is unimportant. In case the testis becomes diseased the pain will be re- ferred to the abdomen, as is usual in troubles of the testi- cle, and this sign, together with the absence of the gland from the scrotum, will enable the physician to make a correct diagnosis. Orchitis in Retained Testis.-A retained testicle which has become inflamed by gonorrhoeal infection might be mistaken for a bubo ami incised, and, in fact, this blunder is well known to have occurred. Ricord, Sir Astley Cooper, and Humphrey consider that care is necessary to guard against a repetition of this blunder. Hydrocele of Retained Testis.-In its retained position the testis may become affected by hydrocele. At least three such cases are well authenticated. It is admissible to as- pirate such a hydrocele, but not to lay open its sac or in- ject iodine to produce a radical cure. This is because there may be a communication with the general peritoneal cavity leading from the interior of the hydrocele. Dr. Gherni has reported a case of fatal peritonitis following the opening of a hydrocele in the groin. Hernia complicated by Retained Testis.-The existence of a retained testis complicating inguinal hernia is so com- mon as to make watchfulness necessary in the examina- tion of all children when trusses are applied. I saw one patient in whom this state of affairs existed, but was not suspected until the operation of herniotomy had become necessary when the surgeon recognized the gland after laying open the sac. Advantage was taken of this opportunity to remove the misplaced organ. Simi- lar cases are reported in which the testis was drawn down and placed in the scrotum, but it returns usually to its false position from the tension of the cord. Inguinal Castration.-The presence of a retained testicle in the inguinal canal may prevent the application of a spring truss, in which case it should be excised. This operation has been minutely described by two French writers, Monod and Terrilon, under the name "inguinal castration." The operation is equally applicable to the cases of dis- ease above mentioned, and also to tumors of retained testes. The steps of the operation are similar to those of herniotomy. The cord should be treated as in the ordi- nary castration. 309 Genital Organs. Genital Organs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Many surgeons condemn this operation as hazardous. Monod and Terrilon have shown it to be nearly as safe as simple castration when done with proper precautions, and doubtless in the future it will be more thoroughly tested. 1'estis in the Perineum.-Many surgeons have met with cases of testis in the perineum. Erichsen reports a testi- cle lodged near the anus, and another case in which it was found within the pelvic cavity. There are well-authenticated instances in which the gland has been found assuming the location and aspect of a femoral hernia, having passed through the crural ring and out of the saphenous opening upon the groin. The chief importance of most of these misplacements lies in the necessity of recognizing their existence and so avoiding the blunder of puncturing or incising the gland. Inversion of the Testis.-Among the malformations of the testis is to be noticed the occasional complete inver- sion of the gland, the epididymis being thereby brought in front. This malposition is interesting to the surgeon, because in hydrocele it brings the testis to the anterior side of the tumor, a fact to be remembered in using the trocar. Injuries of the Testes.-From their exposed loca- tion the testicles are subject to frequent injuries, both from mechanical violence and from burns and potential cauteries. Contusions of the Testes.-Bruises of these organs are caused by kicks, blows, and projectiles. The first symp- toms are a peculiar sickening pain characteristic of . the testis, and largely referred by the patient to that part of the abdominal region below the kidney, from which the testicle came in the foetal state. If the contusion is severe, there is often faintness and vomiting, and occasionally much more shock than is usual from injuries to organs of such small size. From their peculiar behavior in these respects (the production of faintness and shock,) when they are injured, as well as the reference of the resulting pain to the foetal location, it appears that the testes throughout the whole period of life preserve the charac- ter and nervous sympathies of true abdominal viscera, such as they originally were. Slight contusions recover rapidly without any special treatment, but severer ones give rise to various organic changes, such as haematocele of the tunica vaginalis or of the cord, temporary hydrocele, swelling, inflammatory fever, and abscess. As inflammation will follow all the severer contusions, the treatment should be planned from the outset in view of that result. The patient should be placed in the hori- zontal position, with the scrotum supported upon a cushion placed between the thighs. As soon as reaction super- venes, cold applications should be made with an energy sufficient to quench the inflammation from the very out- set. This is always possible, because the organs are so located that any amount of cold can be brought to bear upon them. If this treatment be resolutely kept up night and day for a few days, the tendency to inflammation will cease, and the parts will recover with the minimum of organic injury, and without abscess. This irresistible power of cold causes it to be a favorite with surgeons who love positive measures, but there are many who prefer hot applications. Though less energetic and less positive in their effect, they are often very grateful to the patient, and by a gentle soothing power they will guide the less severe cases to a prosperous termination. The efficiency of both the hot and cold applications is believed to be increased by the presence, in the fluid used, of carbolic acid in the proportion of one part to forty, and by the addition of some unirritating astringent. If inflammatory fever ensue, it is amenable to internal medication, precisely as though the testes were still regu- lar abdominal viscera. Hence aconite, veratrum, opium, and refrigerant doses of quinine are powerful for good in such cases. The old surgeons fifty years ago used with effect vigorous doses of tartar emetic, but the same end is now better gained by aconite or veratrum. In one re- spect, however, we would do well to return to the prac- tice of our predecessors, and treat plethoric cases with a good copious venesection in the early inflammatory stage. Incised Wounds of the Testes.-In this injury the knife wounds not only the testicle but lays open the tunica va- ginalis to the external air. If the knife be foul, or the ex- posure to the air be long, and antiseptic rinsing be not well attended to, there will be a suppurative inflammation of the sac, followed by adhesion to the testis and conse- quent obliteration of the cavity. Incisions into the body of the testis itself are followed by some gaping of the wound in the tunica albuginea, and by a slight tendency of the mass of seminiferous tubules to protrude into the cavity of the tunica vaginalis, but generally this causes no injurious results. The wound heals, without perceptible impairment of function, with such readiness that many surgeons have practised slashing the testicle to relieve the pain in orchitis, with the full belief it was a harmless antiphlogistic measure. If an incised wound of t he testi- cle be narrow, the haemorrhage may fill the tunica vagi- nalis with a firm clot, which, if it has received any septic germs from the external air, either at the time of injury or afterward, may undergo putrefaction and cause dan- gerous mischief, by inducing an unhealthy inflammation with septicaemia. This accident is the more dangerous, because the putrid clot is concealed from the surgeon's view, and gives no positive proof of its existence until it has brought the patient near to death with septicaemia. So slight a wound as that made by putting a seton into the sac of a hydrocele has produced this disaster in some cases. The treatment therefore requires that, at the first cleans- ing of the wound, all clots be removed from the tunica vaginalis, and the cavity be washed with antiseptics. If necessary, the external incision may be widened for the purpose. If the testis be laid broadly open, two or three fine antiseptic catgut sutures should be taken in the tu- nica albuginea. The tunica vaginalis requires no stitches, but a few are advisable in the external integument, un- less it close spontaneously, which it often does. A small drainage-tube is desirable for twenty-four hours, and the parts require antiseptic dressings. If secondary haemorrhage occur in the tunica vaginalis, it should be resolutely opened and the clot turned out to avoid septic dangers. Punctured Wounds of the Testicle.-These may occur from various causes, of which the most common is the ac- cidental puncture of the testicle by the trocar in tapping a hydrocele. I have never known any mischief to en- sue ; but, of course, orchitis might occur, and require all the treatment mentioned under that heading. If the ac- cident is produced by an instrument foul with putrid materials, septic abscesses may occur requiring free open- ing and antiseptic injections. Lacerated and GunshotWounds of the Testes.-These are immediately followed by great pain, referred to the loins, and accompanied in many cases by vomiting, faintness, and shock, followed by reaction, and afterward by in- flammation, swelling, and inflammatory fever. The wounded organ may subsequently become atrophied. Generally there is suppuration, and sometimes gangrene of the mangled testicle. Owing to their position gunshot wounds of these parts are apt to be accompanied with in- juries of the thighs and the hips, which, of course, de- mand appropriate treatment. The records of the War of the Rebellion, published by the Surgeon-General of the United States army, report 586 cases of gunshot wounds of the testicles. In a very large number the cicatrix, after healing, is alleged by the patients to be tender and neural- gic ; but as the statements come mostly from pension claimants, who have a motive for exaggerating their pain and disability, the assertions are to be received with cau- tion. Gunshot and lacerated wounds of the testes should first be cleansed of clots and foreign bodies, not forgetting the bullet, which is apt to be hidden in the dartos. If one tes- ticle be torn to pieces, while the other remains sound, it will be well to remove the remnants of the injured one ; but if both are wounded, or if the unwounded one be useless from atrophy, then conservative treatment is demanded. 310 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Genital Organs* Genital Organs. The patient should be dressed antiseptically, placed in the bed, the scrotum supported on a cushion, and both local and general antiphlogistic treatment be inaugurated with energy and persistence. The patient will thus re- cover with the least amount of distress and of permanent injury possible to the case. Burns and Potential Cautery of the Testes.-These in- juries are rare, owing to the organs being covered with the skin and dartos. If they occur, they are to be treated on the general principles already given. Organic Diseases of the Testes.-Inflammation of the Serous Coat of the Testis.-As the testicle is covered with a serous membrane, it is liable sometimes, though rarely, to inflammation of that investment, without the body of the organ being much affected. There is no technical term in general use to designate this disease, which in a pure form, separate from inflammation of the body of the glands, so seldom exists that it is important only as a complication. All the discussion needful on this topic will be found below, under the heading Hydrocele. Epididymitis.-The general mass of the testicle is com- posed of the epididymis and of the gland proper, the lat- ter containing the secretory apparatus. These twro parts of the organ may be inflamed separately : hence the term epididymitis and orchitis. Professor Sigmund, in col- lating 1,342 cases of epididymitis, found about two-thirds of them on the left side ; while orchitis, according to Curl- ing and Bryant, occurs oftenest on the right side. The question whether the case will be epididymitis or orchitis, depends largely on the cause. When the inflammation approaches the organ along the track of the vas deferens, as in gonorrhoea or in prostatitis, the epididymis is first, and often solely, affected ; but when the onset is deter- mined by mechanical violence, or by constitutional causes, as mumps, syphilis, etc., the testicle is the part chiefly involved. When inflammation attacks the epi- didymis first, it may confine itself to that part alone, or it may extend to the body of the organ, and vice versa, the body of the gland may be first inflamed and then extend to the epididymis, thus causing the presence of epididy- mitis and orchitis simultaneously. This extension exists to some degree in most cases, so that the words as used in practice are only approximately accurate, and imply rather a dominance of one inflammation over the other than an absolute absence of either. The most frequent causes of epididymitis are gonor- rhoea and inflammations of the prostatic region, in conse- quence of the ready spread of inflammatory action along the vas deferens ; however, the attack sometimes comes from the opposite direction, being an extension of the at- tack from an orchitis proper into the epididymis. Doubt- less also the inflammatory action may also develop primar- ily in the epididymis itself. The invasion is generally rapid, though as a complication in gonorrhoea it begins late in the disease. Sometimes the action extends not only to the body of the testis, but even to its serous covering, in which case it produces a temporary hydrocele which soon disappears. When the serous coat is involved the whole scrotum, even to the skin, is apt to participate sufficiently to become red, swollen, and tender. Epididymitis pro- duces pain, referred to the groin and to the loins, and causes some inflammatory fever. The swollen organ can be felt as an elongated mass along the border of the testis, and is very tender to pressure. If the inflammation reaches the part by way of the vas deferens, prostatitis and cystitis are occasionally present also. Suppuration is rather uncommon, nearly all cases recovering by resolu- tion in twenty or thirty days. Some cases of gonorrhoeal origin seem to be followed by a stricture of the seminal ducts, analogous to the strict- ures of the urethra. I am not aware, however, that this supposed stricture has been demonstrated by dissection, but the clinical fact observed is that, after a severe attack of double gonorrhoeal epididymitis, many patients are found permanently sterile. In these cases the patient is not impotent, and his testes are not atrophied. He passes a natural-looking semen, but it is found by the micro- scope to be devoid of spermatozoids. The treatment in the acute stage of epididymitis should be active. The horizontal position, with the scrotum sup- ported on a cushion, is very important. Cold, astringent, carbolized solutions are the best local applications, but, to be efficient, the cold should be applied with more energy than is usually employed. A neat and thorough plan is to apply the solutions once an hour with a brush, and to use for producing cold a long, soft rubber tube, coiled and fastened into a concave cap to partly envelop the scrotum. Through this a constant current of very cold water can be passed without wetting the bed, thus obtaining any de- sired amount of refrigeration. Leiter's tubes are admir- able for this purpose. Many surgeons are fond of hot applications, and often obtain excellent results with them, so that the practitioner may properly take his choice ; yet a vigorous use of cold is more positive and irresistible in its effect. Leeches are useful, but the absence of fat in the scrotum permits the development of an extensive and very black ecchymosis around the bites, which sometimes terrifies the patient with the idea that mortification has attacked the scrotum. Internal remedies are valuable adjuvants. Aconite and veratrum viride reduce both pulse and temperature, and are powerful general antiphlogistics. Opium in full doses does the same to some extent, and also relieves the pain. The bromides are also useful. If, in consequence of the case being mild, the patient insist on walking about, the treatment will be much less efficient, but should be the same in its general principles. In such a case the scrotum should be suspended in a net or handkerchief. Orchitis.-When the secretory part of the testicle is attacked, the disease is termed orchitis. The most com- mon causes are external violence, the extension of inflam- mation from the epididymis, and various internal dis- eases, such as mumps, syphilis, tuberculosis, etc. Simple idiopathic orchitis is unknown, except, perhaps, in young infants in whom the testis sometimes becomes enlarged and tender without obvious cause. It is a common opin- ion that lifting, straining, exposure to cold, excessive venery, horseback riding, and alcoholic intoxication are frequent causes. When the inflammation is acute, the swelling takes place with rapidity, forming a round tumor of consider- able size. As in epididymitis, it is prone to affect the tu- nica vaginalis, causing temporary hydrocele, as well as thickening of the dartos, and redness of the scrotum. The temporary hydroceles are very common after contu- sions of the part. The pain is dull and sickening, and referred largely to the part of the abdomen where the testis originated in the foetal state. Like a true abdominal viscus, the inflamed testis readily arouses an inflamma- tory fever, and in the same manner is more amenable than most external organs to the sedative power of antipyretics and opium. Suppuration may ensue, but the great majority of cases escape it, and recover in the course of a month by resolution. Some, however, last longer, and a few be- come decidedly chronic from special causes, such as the presence of undrained abscess, tubercle, and certain viti- ated constitutional conditions. After violent inflamma- tions atrophy may follow. Acute orchitis may be treated, in the main, exactly like acute epididymitis, but it is still more amenable to con- stitutional antiphlogistics. Hence, in addition to the re- cumbent position, and the local measures above directed, it is well not only to use the quinia, aconite, veratrum, and opium freely, but, in plethoric cases, to use early an old-fashioned venesection. The old surgeons resorted to tartar-emetic vomitings with prompt and decisive effect, but the harshness of the remedy has justly caused it to give way to arterial sedatives, which are at once more efficient and less unpleasant. In the later stages of acute inflammation, and in chronic inflammatory enlargements, the reduction of the swelling can be greatly hastened by compression. The old plan of compression by adhesive straps, not- withstanding its imperfections, is still extensively in vogue. The scrotum being shaved, and diachylon plaster having been cut in strips, the operator first separates the swollen testis from its fellowq and constricting the integu- 311 Genital Organs. Genital Organs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ment above it, winds a strap, with moderate tension, a few times around the constriction. Next he applies other straps, one by one, beginning at the circular plaster and passing the strips obliquely under and up to the circular band again. The oblique plas- ters cross each other in a spica (see Fig. 1382), are pretty firmly drawn, and are made to cover the entire surface. Some, instead of the spica, prefer to pass the straps straight under the testis and up the other side, making them all cross under the centre of the organ. Either plan is vexatious and troublesome. Diachylon plaster slides a little on the skin, and re- laxes the pressure. It must, therefore, be reapplied daily. Rubber plaster does not slide, but the compres- sion of the swelling relaxes the tension, and the plaster adheres so firmly that it is torture to the patient to have it pulled off. Still, it can be removed with less pain if the surgeon drips a little ether under the surface as he raises it from the skin. For some years I have advised the following plan : Take a piece of moderately thin, pure gum, sheet-rub- ber large enough to fold com- pletely over the swollen part, and also a long, narrow strip of rubber plaster, or a roll of tape or narrow bandage. Fold the rubber sheet up over the swollen testis, separated from its fellow, of course, and, stretching it tightly, tie or strap it into the constriction above the organ ; then, folding the edge of the rubber down over the band, apply another strap or tape just below the first, to prevent the rubber from pulling out beneath the band. (See Fig. 1383.) This holds securely, and has the advantage that it will not slide upon the skin, and, moreover, that as the swelling diminishes the elastic rubber follows it up and continues the compression, so that it does not often need readjustment. Still another' plan is to take a thin rubber air-bag, large enough to cover perhaps half the swollen testis. Applying this in a collapsed state against one side of the testis, the surgeon wraps a piece of soft but strong linen or cotton around the whole, and ties or straps it into the constriction above the swelling, using two bands as be- fore. The tube of the air-sac is allowed to protrude through a hole in the linen. (See Fig. 1384.) Now, if a syringe be applied to the end of the rubber tube it will inflate it, and thus gently com- press the testicle. The air can be kept in by a small faucet, or even by a string applied to the tube. This method with the rubber air-sac was devised by myself, without any idea that others had employed the same principle ; but Dr. Hawes, of California, has since published in the New York Medical liecord an ac- count of a double-walled rubber envelope for the testicle, by which he makes-compression with condensed air on a somewhat similar plan. Both his apparatus and mine enable one easily to regulate the energy of the pressure by the amount of air injected. Simple Abscess of the Testis.-This occurs as a natural termination of severe inflammation, or even of a slighter grade, if the patient happens at the time to be in a state of pyaemia or of septicaemia. It is a plain corollary, therefore, that the best preventive of simple abscess is to combat the inflammation, and to prevent septic contami- nation of the system. After a collection of pus is once formed it burrows toward the surface, unless opened by art, and discharges itself. Owing to the contractility of the dartoid coat the fistula is liable to become constricted and to prevent free discharge, thus keeping the cavity distended with pus. This is all the worse, because the whole cavity of the tunica vaginalis may become a part of the abscess. This peculiar contraction of the orifice tends to prolong the case for months, unless it is com- bated by surgical means. The pus should be promptly evacuated through a free incision ; a drainage-tube should then be inserted, and the case treated on antiseptic princi- ples. By these means simple abscesses will heal without serious difficulty. Mumps.-In adult males the disease called mumps often takes effect upon the testes. There is considerable swell- ing, tenderness, and inflammatory fever, but seldom or never any suppuration. The disease subsides in due time, and generally leaves the testicles sound and perfect ; but in a few cases, one or both of them may be somewhat atrophied. The usual treatment is to place the patient in the hori- zontal position, support the scrotum, and abate the fever gently by aconite, etc., while waiting the natural subsi- dence of the inflammation. I am not aware of any experi- ence to show what the result would be of a vigorous use of cold applications, and certainly the majority of the pro- fession would fear to resort to it in mumps. Syphilitic and tubercular abscesses will be considered further on. Fungus of the Testicle, or Hernia Testis.-When an ab- scess by its ulcerative action destroys a portion of the tunica albuginea, the contraction of that tunic, or of the coating of granulations covering it, compresses the tes- ticle and causes a slow bulging of a considerable mass of tubuli seminiferi through the opening of the abscess, so that it overhangs the adjacent skin, and being covered with granulationsit appears like a simple, fungous growth. The same thing may follow an incised wound of the tes- ticle. It is said that, on pinching the mass, the peculiar pain of a testicle is produced, which will help to distin- guish it from a fungus haematodes. The fact that it is the sequel of either a recent abscess or a wound, will pre- vent it from being confounded with a malignant growth. It has been stated that a similarly looking fungus may grow from the external surface of the tunica vaginalis, or of the tunica albuginea, without any protrusion from within. If this is true, it must be rare. As the fungus overhangs the surrounding skin, it me- chanically prevents the progress of cicatrization. A large portion of the cases can be cured by touching the granulations with nitrate of silver or dusting them with tannin, and strapping the surface firmly with adhesive plaster. If this fails, the projecting mass can be shaved off and the adjacent scrotal integument raised and stitched over the wound, and there supported by sutures and col- lodion until union takes place. Atrophy of the Testis.-A testicle which does not ac- complish its descent to the scrotum is usually in a state of atrophy, but whether the failure of development is caused by the abnormal retention is doubtful. Testes which have attained a full development may become atrophied from the effects of severe inflammation, whether from mumps or from mechanical causes. It is also said that the injury to the nerves and vessels incident to operations on the veins for varicocele, in some cases brings about a similar result. Indeed, it is alleged that varicocele itself, without any operation, may cause atrophy. The instances, however, must be rare, for a Fig. 1382. Fig. 1383. Fig. 1384. 312 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Genital Organs. Genital Organs. very extended observation has never brought to my notice a case of pronounced atrophy caused either by the vari- cose veins or by the operation for the cure of this disease. A prolonged condition of total or partial impotency from almost any cause, such, for instance, as cerebral, neph- ritic, or prostatic disease, is often accompanied by a moderate diminution of the bulk of the organs, leading the patient to think they are going to " wither away " and disappear entirely; but this slight diminution from in- activity is of no local importance. The glands will re- sume their size and efficiency if the depressing cause is removed. True atrophy does not appear to be curable, and the treatment is, therefore, practically nothing. Hypertrophy of the Testicle.-This is much more rare than atrophy. In a very few cases in which there is found only a single testis in the scrotum, the other being con- genitally absent, the one present is abnormally large, as if it combined the functions of both ; but the loss of one organ in adult life does not seem to result in any materi- ally increased bulk of the other. The few rare cases of hypertrophy that occur have not led to the development of any treatment. Tuberculosis of the Testes.-This disease is not limited to any age, and is occasionally bilateral. The causes, be- yond doubt, must be the same as in tuberculosis else- where. There is generally at the outset very little if any pain ; indeed there is sometimes a diminished sensibility, so that pressure fails to elicit the kind of uneasiness peculiar to the organ. The gland enlarges, becomes indurated, and often knobby, and the disease may spread to the epi- didymis, to the vas deferens, and to the prostatic region. The interior of the enlarged gland seems studded with ir- regular cheesy masses of tubercle, which in time soften and become, one after another, the foci of abscesses. These, breaking, keep up for months or years a series of discharging sores of the most annoying character. If the tubercles of the testis proper are the only ones ex- isting, they may, after a time, all heal up, leaving the patient in vigorous general health, but with the testis more or less injured by the ulceration. Notwithstand- ing the doleful prognosis of many of the standard au- thors, whose experience was gained in climates very productive of tubercles, I have repeatedly ventured, in Illinois, where tuberculosis is far less prevalent than on the sea-coast, to take the patients through the whole affec- tion without other operation than the lancing, drainage, and cleansing of the abscesses ; and the patients have ulti- mately done excellently well, and no infection of the lungs or the prostate followed. Still, it is occasionally true, even here, that abscesses of the prostate and of ad- jacent glands follow, or pulmonary tuberculosis sets in. I believe that on the North Atlantic seaboard, where tuber- culosis is about three or four times more abundant than in our central States, these dangerous sequelae may be much more common than with us. The diagnosis of tubercle from carcinoma and sarcoma of the testis is often impossible at the early stage when the surgeon ought to decide the question of operation. At this period only vague probabilities can be obtained. For instance, tenderness and lancinating pains point- though dubiously-to carcinoma. A known tuberculous diathesis points to tubercle. The fact of both testes being involved does the same, but the later developments render the distinction clearer. A series of abscesses dis- charging pus would not come from a cancer, but they may spring from tubercles or from syphilitic gummata. Treatment of Sarcocele.-The treatment of all enlarged testicles, in general, is to be decided by several considera- tions. In tumors of the testicle early and energetic action is important. If the growth cannot be accounted for as an inflammatory swelling, and is not a hydrocele nor a varicocele, it is in all probability either a syphilitic de- posit, a tuberculous mass, or a malignant tumor. If there is any syphilitic history, either confessed or reasonably suspected, a few weeks may be spent in testing the question by administering full doses of antisyphilitic medicines. But if syphilis is originally out of the question, or removed from reasonable belief by the medicinal test, then we are, in all human probability, in the presence of either a tuber- culous or a malignant growth. Eminent authors differ as to the prognosis in case the disease is tuberculous. Some authors go so far as to say that there is very great danger that the tubercles will secondarily infect the lungs and the prostate, and cause the death of the patient. This doleful prognosis is not borne out by experience in our interior American States, where tubercles are only about one- fourth as frequent in the community as along the Atlantic seaboard. Here the patients generally get through their troubles after a longer or shorter series of months, and become healthy. It may be that the tuberculous sea-coast climate makes a great difference in results, and thus causes surgeons in the two regions to have conflicting experiences and opinions ; yet Mr. Poland, of England, where tuber- cles are rife, and Professor Agnew, of Philadelphia, both favor the conservative course, and advise against a gen- eral edict of castration for this disease. However, the practical surgeon will have to confess that in the earliest stages he, in most instances, cannot with certainty distin- guish tubercle, sarcoma, and carcinoma from each other. He must act on rational probabilities. If there happen to be present pretty decisive indications that the case is tu- berculous, he may, in our central American States, safely adopt the conservative course ; but if in more unfavorable climates or circumstances, he must incline more to opera- tive measures. If, on the contrary, there is strong reason to fear malignancy, the surgeon may properly consider that if the testicle is tuberculous, it is likely to be ruined or seriously damaged in function, and may be sacrificed with less reluctance on that account; while if it be a ma- lignant tumor, the only hope of life lies in an early re- moval. In case the patient is already far advanced toward re- covery from a series of tuberculous abscesses, and espe- cially if both testes are affected, so that castration would render the patient a complete eunuch, there will be no harm if the surgeon elects the conservative plan and treats the abscesses by incisions, drainage-tubes, and antiseptics, as well as by constitutional management. In this late stage the lungs and the prostate are already infected, if they are going to be, and the risk will not be increased ma- terially by healing the sores without castration. Still the recovery will be slow, and where only one testis is af- fected, there can be no serious objection to its ablation. Castration.-If the testicle is to be removed, the fol- lowing is the method of procedure : Shave the pubes and scrotum, and anaesthetize the patient. Take the posterior half of the tumor in the left hand, and with the scalpel divide the integuments from near the external ring well down to the bottom of the scrotum. Divide the cover- ings and expose the spermatic cord as high up as the dis- eased condition renders advisable. Pass a strong ligature through it near the ring, and tie the ends together, so that if haemorrhage occurs after its retraction into the inguinal canal the surgeon can draw down the bleeding part. Now divide the cord, tie the spermatic artery and the artery of the vas deferens, and any other twigs requiring it. Next dissect out the testis and tunica vaginalis, close the wound with sutures, place a drainage-tube in its lower end, and dress antiseptically. The double ligature introduced to secure the cord may be left a few days, till there is no longer risk of secondary haemorrhage, when it may be cut on one side of the knot and drawn out. Adhesive plasters will not be required. Syphilitic Disease of the Testis.-Both the secondary and the tertiary stages of syphilis may manifest them- selves in the testis. Secondary syphilis may produce a chronic inflammation either of the epididymis or of the body of the gland. The parts are large, knobby, and in- durated, as much as in tuberculous sarcocele, but often more tender ; but as long as the secondary stage contin- ues the inflamed mass will not suppurate, that termina- tion being the special trait of tertiary deposits, but not of secondary syphilis nor of cancer. Tertiary syphilis of the testis consists in the growth within it of gummata, which after a time suppurate, and thus establish slow and indolent, or else phagedenic, ab- scesses. The pus discharged is sometimes of a semi 313 Genital Organs. Genital Organs, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. transparent appearance, like turbid stationer's gum, and at other times it is a well-formed pus. The diagnosis cannot be established by clinical inspection of the tumor alone, on account of the resemblance to tuberculosis, but a full investigation of the history and present condition of the patient usually clears up the obscurity. The treatment consists in mercurials for the secondary stage, and iodides or iodine for the tertiary. The local management consists in lancing the abscesses early and treating them antiseptically. Varicocele.-Varicocele has been termed varix of the spermatic veins. The immediate causes of the varicose condition are not all known. It is likely that there may be, in some cases, a deficiency in the strength of the ve- nous coating, and in others a paralysis of the vaso-motor nerves which govern the contractile coat of the veins; but when we consider that the trouble is almost always on the left side, and that the spermatic vein of that side runs a very long subperitoneal course up to the renal vein, so that it can easily be obstructed by the presence of any inflammatory deposits in its vicinity, or even by impaction of the descending colon, we are inclined to at- tribute the venous dilatation to the simple mechanical tension induced by pressure on the vein above. In some cases I have found the disease actually coming on as the sequel of inflammations in the vicinity of the upper course of the left vein. Some argue that the reason of the immunity of the right spermatic vein from varicosities is the presence of a valvular arrangement where it enters the side of the vena cava, it being claimed that the valve sustains the column of blood, and thus prevents distention. The remarks of some authors on this point are based on a mechanical er- ror. A valve does not sustain anything when it is open, and has no tendency to prevent tension if there were any obstruction to the vein, so that in all ordinary circum- stances the valve does not relieve the pressure ; it is true, however, that in jumps and falls where the individual lands on the feet, the sudden down-thrust of the column of blood is divided by the valve, so that only that part be- low it acts on the scrotal veins, and hence the valve, though not availing against steady obstruction, is a true protection from sudden distention. Even the left vein is not wholly destitute of valves, so that these appendages cannot account for the difference in the frequency of varices on the two sides. Whatever the cause may be, the statistics of the case are remark- able. In the war offices of Europe and America there are records of 35,639 recruits rejected for varicocele, and of these only 344 had the disease on the right side. With the patient in the upright position, a varicocele presents a moderate enlargement of the scrotum, which is soft to the touch, and feels, to use the ancient simile, as though a bunch of angle-worms were underneath the skin. In the horizontal position the veins empty themselves, and the peculiar sensation disappears. Sometimes the varices are mainly in the upper part of the sac, and in others they extend downward and envelop the epididymis and whole lower half of the testis, and even affect the cu- taneous veins of the part. In cold weather the muscular coats of the veins contract and give considerable relief to the patient, while in summer they relax and cause him increased discomfort. There is no tendency to ulcera- tion, and rarely any rupture of the veins, or any other important complication, but the patient feels an annoying sense of weight and a dull pain extending upward into the loin. Atrophy of the testicle is said to ensue occa- sionally. The statement is sometimes made that all cases of varicocele are the result of masturbation. A recent work has made this assertion. I believe it to be false and misleading. Some of the patients assert that the disease causes in them a chronic tendency to unreasonably low spirits, while others are exempt from any such reflex impressions and only complain of the actual physical pain. The diagnosis is not difficult, but careless practitioners have been known to take a varicocele for a hernia and apply a truss. The patients themselves often commit this error, and present themselves in trusses of their own se- lection. The only confusing symptom is that a pretty large varicocele will give a distensive succussion upon coughing, something like a scrotal hernia ; but if the surgeon grasp the upper part of the scrotum gently, and keep his hold while the patient lies down, he will find that the enlargement oozes imperceptibly away without any intestine or omentum slipping past his fingers. Con- versely, if after the disappearance he firmly close the in- guinal ring, and then cause the patient to rise, the en- largement will reappear without any omentum or bowel slipping down. If there is, in rare cases, any question about hydrocele, the light test and the exploring-needle will clear up the diagnosis. The treatment is either palliative or curative. The usual palliative appliance is a suspensory net attached to a belt around the waist. This supports the weight of the part, gently compresses the scrotum, and greatly im- proves the comfort of the patient. Many persons have used a small steel ring as a support, the article being se- lected by trial, so as to be of just the right diameter, so that when it is slipped upward over the lower half of the scrotum it will retain its position by its tightness, and hold the testes well up to the top of the sac. The un- pleasant constriction of the skin by the ring has driven it mostly out of use. Morgan, of Dublin, has employed the following ingenious contrivance : He has a small net or sac, of any kind, which envelops the testis and is gathered above it by a thick lead wire, in such a way that the sac cannot slip off. To the bottom of the bag is sewed a double tape. He then draws the tapes upward and ties them to a belt about the waist with such a tension as will lift the testicle well upward and cause it to hang inverted from the belt, thus relieving the weight more effectually than the ordinary suspensory net. The surgical operations practised for the relief of vari- cocele are commonly called " radical cures," though it is well known that they rarely or never effect a complete removal of the varicose condition. They are numerous in their variations, but may be summed up in three groups: 1. The ablation of the enlarged veins. The patient be- ing anaesthetized the front of the scrotum is freely in- cised and the enlarged veins laid bare and examined. If greater distention is desired for the examination, a tem- porary clamp can be applied to them below the inguinal ring. After their extent has been traced they are separated from the two arteries and vas deferens, and then snipped out. Professor Frank Hamilton says that ligatures are not necessary, yet I have generally applied them. If, as often happens, the clustering varices envelop the epidid- ymis and lower end of the testis, the venous masses there are to be gathered up and treated in the same way. The wound is closed, drained, and treated antiseptically. This operation is radical, and considered to involve all the dangers belonging to operations on veins in general. Some deaths are recorded, but there are no late statistics adequate to measure the risk. Under modern antiseptic usages, and with well-ventilated apartments or wards, the danger must be much less than formerly, and though real, it is not great. 2. The obliteration of the veins in situ. This group of operations has always been the favorite, and is still the choice of most authors. The obliteration may be effected by the ligature, the ecraseur, the electro-cautery, or by caustics. The hypodermic injection of coagulants into the veins is generally repudiated, because of the difficulty of inserting the point of the injecting instrument actually into the veins, and because of the danger of embolism. The methods of ligation are numerous. The following method is much used : The scrotum having been washed with antiseptics, the elements of the cord are made to slip outward between the thumb and finger until the veins are passed outward and the vas deferens remains on the inner side. A needle is now passed through the scrotum, from front to back, between the vas deferens and the veins, drawing a ligature after it. The veins are now pressed inward past the punctures, and the needle is passed back through the same opening. The ligature now surrounds the veins and both ends 314 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Genital Organs. Genital Organs. emerge in front, w'hile the loop behind has sunk into the opening out of sight. Two or three such ligatures are passed one above another. They are then variously treated, according to the choice of the operators. The old plan was to use silk ligatures, tie them in front over a piece of bougie, and remove them again after forty-eight hours. A favorite plan now is to use fine silver or gold wires, twist them tightly, cut them off pretty closely, and allow them to sink through the orifice in the skin and remain permanently, the puncture being closed antiseptically. The use of catgut ligatures, cut short in the same way, has not been satisfactory on account of their seeming to loosen and to fail of obliterating the veins, but better tying might obviate that defect. Antiseptic silk could probably be allowed to remain permanently imbedded with as much impunity as silver or gold wire. Some have endeavored to coagulate the blood in the veins by inserting needles, and passing a coagulating galvanic current. Others pre- fer to pass a platinum wire around the vessels, and apply- ing a heating battery, cut them off by the cautery. Others have used steel wire, and crushed the varices at several points by an ecraseur. Finally, the veins may be hooked up through small incisions and clumsily obliterated by the application of caustics. These are all operations upon the veins themselves, and involve a slight but real danger. It is not so great, in the opinion of most surgeons, as to render it necessary to re- fuse the operation where a patient suffers material loss of happiness and usefulness. Professor Frank Hamilton, however, says that he has often ligated the veins for vari- cocele, and though he has yet met no fatal case, his experience and observation have been of a nature to con- vince him fully that the risk is greater " than ought to be incurred for a disease which itself never causes death." He has therefore abandoned the plan. In this connection it is important to add that none of these efforts completely obliterate the plexus of veins, and they fail completely when a large part of the varices hug the lower half of the testis. In ligating, also, trunks of nerves are unavoid- ably included in the loops, giving rise to occasional neu- ralgic cicatrices, and it is charged that atrophy of the testis sometimes follows. From these varied causes a good many mortifying failures ensue, which are most un- candidly concealed by the advocates of several plans. 3. I prefer, to all other operative measures, Sir Astley Cooper's original method, viz., the amputation of the lower half of the scrotum, and have adopted it exclu- sively in my recent clinical and private practice. It is certain that Cooper was impressed with the danger fol- lowing operations upon the spermatic veins, and devised the plan of shortening the scrotum so as to make its own integuments support the testis and compress the varices. Professor Hamilton strongly advocates, by example and precept, a general return to this method, claiming after long experience that it obtains " eventually a more com- plete subsidence of the varicosity " and a more perfect res- toration of comfort than the other plans, and that it com- pletely avoids all the dangers of operating on the spermatic veins, as well as all risk of atrophy and of neuralgic cica- trices. My personal experience corroborates that of Pro- fessor Hamilton, and leads me to the same conclusion. The majority of surgical authors have apparently con- fined themselves to the obliteration plan, and scarcely mention Sir Astley Cooper's operation. Examination of surgical literature show's that this opinion preponderates in the systematic treatises. For shortening of the scrotum: Sir Astley Cooper; Frank Hamilton ; Hutchinson, of Brooklyn; Henry, of New York ; Andrews, of Chicago ; and others. For ligatures or pins : Agnew, Curling, Wood, Erich- sen, Gross, Lee, Ricord, Bryant, Humphrey, Sir B. Bro- die, Holmes, and others. Nevertheless, clinical teachers in America, who are a few years in advance of the standard authorities, are cer- tainly looking more favorably now than formerly upon Cooper's plan. The same tendency is seen in American periodical literature of the last few years. The operation of shortening the scrotum is performed as follows: The pubis, scrotum, and perineum having been previously shaved and cleansed with care, the pa- tient is anaesthetized and the parts washed with sublimate or carbolized solution. Pressing the testes well upward toward the inguinal rings, the surgeon grasps the pendu- lous scrotal skin and endeavors to decide how high up it should be cut off. The scrotum can be drawn down- ward with the left hand, while two fingers of the right hand slightly separated are used to push up the testes. In this way the skin is smoothly drawn out and the best location for the line of incision can be chosen. Two errors are to be guarded against in this step of the operation. One consists in only shortening the skin on the affected side. The w'hole lower half of the scro- tum should be removed, otherwise the tumor settles down into the opposite side, and the case is only slightly benefited. The other mistake is the insufficient shortening of the scrotum. The skin here is quite distensible. A recur- rence may therefore be expected, unless all redundant portions are removed. Instead of using the fingers for the purpose of holding back the testes, it is much better for the surgeon to sub- stitute a clamp of some form when he is ready to make the incision. This should be pressed upward until the integument is seen to be moderately tense, and then it should be fastened. The upper half of a long-handled bullet-forceps or needle-holder may be employed, in de- fault of a regular instrument, to clamp the skin while the cutting is done. A single transverse incision is now made a short dis- tance below the clamp, so as to allow room for the sut- ures. Either the scissors or scalpel may be used for this, purpose. A few loops of thread are next passed through the lips of the wound to prevent a wide gaping, and the clamp loosened in order that bleeding vessels may be detected. Unless the edges of the wound be prevented from separating too widely, the testes will hang out be- yond the retracted skin, exposing the dartoid tissue un- duly to the irritating effects of the atmosphere. This is not a serious mishap, but probably it tends to inter- fere with subsequent plastic healing by first intention. The real cause of most of the failures to obtain primary union after this operation is the presence of blood-clots in the cellular network of the scrotum. These often be- come so large that it becomes necessary to evacuate them by removing part or all of the stitches, in which case a part of the wound will heal by granulations. It is extremely important, therefore, to secure every bleed- ing point, even the most minute, before closing the wound with sutures. The vessels here seem to have less power of self-closing than in most other tissues. I have repeatedly observed the scrotum to become filled with a large thrombus a few hours after this operation, sometimes necessitating a second employment of the anaesthesia to secure the bleeding point which had es- caped observation. I have known a sudden and dan- gerous haemorrhage to occur from one of these little scrotal arteries, which at the time of the operation gave no sign of its presence. Every bleeding point, including the veins, should be separately ligated or t wisted before the sutures are taken. An artery is usually found upon each side of the raphe. Even the slight general oozing which takes place from the tissues may be sufficient to distend the scrotum, and interfere with union. A drainage-tube would, therefore, seem desirable, but this, too, is prone to interfere with union, unless it be a slender one. A large number of fine sutures should be used to join the lips of the wound. Great care is necessary to make smooth and clean work in joining the two edges. The scrotal skin is delicate, and liable to overlap if the stitches are carelessly inserted. When the wound has been closed and the skin thor- oughly dried with napkins, four or six long strips of rubber adhesive plaster are attached to the perineum and carried, slightly diverging, across the wound, forward on each side of the penis, and upward upon the abdomen, two-thirds as high as the umbilicus. This care in strap- ping is very important. A dry dressing of sublimate, iodoform, or carbolized 315 tteuJ-trni^Neuroses. REFERENCE^HANDBOOK OF THE MEDICAL SCIENCES. gauze, or of antiseptic cotton, is next applied and con- fined firmly with a T-bandage. The usual suspensory net, such as varicocele patients commonly keep, may be used as the only bandage after the first few days, and es- pecially when the patient is allowed to leave the bed. On account of the reduced size of the scrotum the net may now be made to fit on over the dressings, and by a little care it need not become stained with the discharges from the wound. Patients accustomed to the suspensory bandage find it the most eligible means of retaining the dressings. They should wear it tightly drawn up, and packed snugly with absorbent cotton, lint, or gauze. With men who have never learned the use of the suspen- sory it is as well to employ a T-bandage throughout the treatment. What is known as rubber adhesive plaster is so much superior to the old diachylon plaster that it may truly be said to have put this operation upon a new footing, since the supporting straps are so essential to success. The rub- ber plaster will not slip from the skin if applied as directed above, but will hold firmly for a week if necessary, so as to take all tension from the sutures, and will hold the parts in good apposition even after the latter have all been loosened and removed. Some pains should be taken that the perineum be kept reasonably dry and protected from discharges. Should the straps become finally loosened at this point, they still remain firmly adherent to the posterior half of the scrotum and to each other, constituting a firm suspen- sory support. The value of this is especially noticed when union fails in the whole or part of the incision, for gaping ,of the wound is prevented, and it is very quickly closed by granulations. Without the straps the granulating sur- face is two or three inches wide and six in length, re- quiring about three weeks to close, and leaving a larger cicatrix. If all the steps of the operation have been carefully taken, and especially if the haemorrhage has been entirely controlled, union per primam may confidently be looked for. Several forms of clamps have been used to hold the scrotum and facilitate the insertion of sutures. All these have the evil of compressing the arteries and ren- dering it difficult to find and ligature them, so that, when the surgeon has closed the wound, haemorrhage is liable to take place inside the scrotum. To avoid this In cases of general anasarca the tunica vaginalis is often distended. It is well to look for general or local causes in all cases of this affection, as these may have an impor- tant bearing on the question of treatment. After tapping a hydrocele it is not uncommon to find an evident cause for its existence in the presence of a malignant enlargement of the testes. In such a case cas- tration takes the place of any operation for a radical cure. Obstructions of the spermatic vein by inflammatory exuda- tions in its course behind the peritoneum doubtless cause the effusion in certain cases. The distended sac forms a globular translucent tumor, not extending upward into the abdominal ring, but abruptly terminating above. By this fact alone, hydro- cele of the testis may be distinguished from inguinal her- nia, which always has a perceptible connection with the abdomen along the inguinal canal. The fluctuation will serve to distinguish it from solid tumors of the testis, and the translucency to a strong beam of light is sufficient to distinguish it from every other form of swelling. This is seen best when direct sunlight is allowed to fall upon the scrotum. When sunlight is not available a roll or cylinder may be placed against the tumor and a light held near the opposite side. If the observer's eye be now placed at the open end of the tube, it will be plainly seen that the tumor transmits light. Treatment.-The treatment of hydrocele is palliative, as by tapping, or radical. The withdrawal of the serum by the trocar or aspirator is to be recommended as affording temporary relief, and in a few cases a final cure. The tumor usually returns in a few months, and the tapping has to be repeated. Many patients go on for years with occasional withdrawals of the fluid, and thus obtain com- parative comfort. The lower and anterior side of the sac should be selected for the insertion of the trocar in tap- ping a hydrocele. For the radical cure of hydrocele several methods are practised, all seeking either the obliteration of the cavity or an alteration in the secreting and absorbing functions of the serous membrane. The means employed are irri- tating injections, or free incisions, drainage, and the in- troduction of tents to cause sharp inflammation of the linings of the cavity. The injection method commonly employed consists in first evacuating the contents of the sac, and, while the cannula is still in place, washing the interior with tincture of iodine. Half an ounce should be thrown in and al- lowed to run out again through the tube. It is expected that a portion of the injection will be retained, but none of it should be allowed to make its way into the dartos, as it is prone to excite sloughing. It is worth remember- ing that silver cannulas are destroyed by tincture of iodine. The immediate effect of the injection is severe pain in many cases. Some patients, however, endure the opera- tion without an anaesthetic. Considerable inflammation follows, and a temporary increase of the effusion. When this has subsided the hydrocele is found to be cured in many cases. Unfortunately this method is far from certain in its re- sults. In a certain proportion of cases it is a failure and has to be repeated, or some other plan resorted to. Carbolic acid has been used instead of iodine by some American surgeons, during the last few years. One or two drachms of the melted crystals, or the ninety-five-per- cent. solution, are thrown into the interior and allowed to remain. This treatment is less painfid than the iodine injection, on account of the benumbing power of the acid. It is equally uncertain, but, like it, often makes a perfect cure. A previous injection of a solution of co- caine hydrochlorate would probably render the procedure nearly painless. The use of the seton is all but obsolete in the treatment of hydrocele. I believe it ought to be condemned. The open method is the most certain one we have at com- mand. It is especially valuable in cases which the injec- tions have failed to benefit. Volkmann has practised a so-called antiseptic method which consists in laying the sac freely open, and dressing it antiseptically. This is essentially the same as that Fig. 1385. difficulty I have devised and used with satisfaction a sort of bow in place of the clamp. This instrument consists of two curved steel bars rigidly joined at the extremities and separated three-eighths of an inch. Through these bars there are drilled twelve small holes intended for the insertion of a number of common pins. In using this instrument the lower half of the scro- tum is drawn through the slot until the skin is somewhat tense over the testes. A single pin may be thrust through at first and the skin adjusted on each side until the tension is equal, when a number more may be inserted. If the skin be now cut off half an inch from the instrument, the tissues will not retract, and the bleeding points may be quickly detected and secured. This part of the opera- tion should be done in a leisurely, and not in a hurried, manner. When all haemorrhage is suppressed the sut- ures are inserted and then the pins removed. Hydrocele.-Hydrocele, or dropsical effusion in the tuni- ca vaginalis of the testis or cord, is the result of acute or chronic inflammation of this membrane, induced by vari- ous causes. Injuries and inflammations of the testes often produce temporary hydroceles. Tumors and organic diseases of these organs also induce collections of serum. 316 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Genital Organs. Gen.-Urin. Neuroses. commonly practised, except that it is usual to provide a tent in the opening to prevent too early closure and to ex- cite irritation in the interior. When suppuration has been established within the serous envelope, the tent may be removed, and the wound allowed to heal under anti- septic dressings, with the certainty of a radical cure by obliteration of the sac. Hydrocele of the Cord.-Hydrocele of the cord consists of an effusion in the serous covering of this part. In ap- pearance it resembles a hernia and may be mistaken for one, since it can be pushed upward into the inguinal canal or beyond it. However, it yields no impulse on cough- ing, and has not the doughy feeling of a rupture. The aspirator may be employed with perfect safety to com- plete the diagnosis. The treatment is the injection method, as in ordinary hydrocele. Congenital Ilydrocele.-A form of enlargement some- times met with, called congenital hydrocele, is unsuited for any of the methods of radical cure. In this variety there exists an open communication between the cavity of the hydrocele and the peritoneum above, through the funicular process surrounding the cord. The serum of the peritoneal cavity gravitates into this sac and keeps it distended. The coverings are the same as those of a con- genital hernia. Haematocele.-Haematocele is a collection of blood in the tunica vaginalis or tissues higher up. Thus we may have luematocele of the tunic or of the cord. The haemorrhage is commonly the result of injury to the parts, but may come on spontaneously from the bursting of some small vessel. In appearance the tumor resembles hydrocele, but is opaque and sometimes becomes solid from the co- agulation of the effused blood. Usually the contents re- main fluid and gradually undergo alteration to a dark brown liquid of the consistence of syrup. The tumor is frequently small, but occasionally it reaches the size of a child's head. The treatment will vary according to the size of the swelling. When small and recent the tumor will disap- pear by absorption. The trocar or large aspirator needle may be used to draw off the collection of blood in many cases, with beneficial results. After tapping, the scrotum should be firmly compressed to prevent further effusion of blood into the sac. Erichsen recommends, in all bad cases of haematocele, that the sac be laid freely open, cleansed, and allowed to granulate, so as to be obliterated. In case the testicle be found diseased or atrophied, it may be removed to facili- tate the cure. Where a haematocele has been produced by an external wound the danger lies in the septic results following the breaking down and discharge of the clots. Wide incisions and free evacuation of the decomposing material is the proper treatment in cases of this class. Occasional instances are reported of haematocele in the spermatic cord from rupture of some varicose vessel in its substance. This is a rare affection. Aspermatism or Sterility.-True impotence may result, among other causes, from the entire lack of functional power of the testes. This may be congenital, in which case the organs are sometimes partially developed. Un- descended or retained testes are without function in most cases. Individuals with undeveloped testes may be virile, though sterile. .Interesting medico-legal questions have arisen out of the question of sterility and impotence, and the subject is receiving much attention of late years. Microscopic examination for the presence of the spermatozoa in the semen forms the only positive test in the question of sterility. Inflammations of the testes or cord may result in sterility by closing the tubules with plastic adhesions, or blocking the ducts by a species of stricture. All organic diseases which affect the body of the gland, such as syphilis, tuberculosis, cancer, or cystic degenera- tion, result sooner or later in aspermatism or destruction of secreting power. These causes are apart from the vari- ous functional derangements of the testes, which are else- where considered. Edmund Andrews, GENITO-URINARY NEUROSES. The neurotic dis- orders of the genito-urinary tract are exceedingly com- mon and troublesome affections. They often render the patient's life so miserable that suicide is resorted to. Again, we have a distinct and numerous class of in- sanities directly caused by these disorders. We may have neurosis of the uro-genital tract arising idiopathically in a neurotic subject. It is, however, much more common to find the origin in some local inflammatory trouble. In the latter, the superadded neurotic disturbance soon, in the majority of cases, becomes the chief ailment, and persists after the cause which gave it origin has entirely disappeared. The neuroses due to local changes in the genital or urinary passages are reflex neuroses. The gonorrhoeal process is by far the most common antecedent of either a genital or a urinary neurosis. A gonorrhoea which extends until it has involved the pros- tatic part of the urethra is almost sure to originate the disturbances in question in a neurotic subject. Next to gonorrhoeal inflammation we have onanism as the most frequent cause. Sexual excesses, also, are not uncom- mon originators of the neuroses in question. The fre- quent sexual irritation originates a hyperaemia of the mu- cous membrane of the posterior portion of the urethra. Symptoms Common to the Genito-urinary Neu- roses.-It is a well-known fact that polyuria is a symp- tom observed in general as well as in special neurotic troubles. It is an almost constant symptom during the course of the genito-urinary neuroses. The urine is great in amount, pale, and of a low specific gravity. Its passage does not cause any pain. Temporary glycosuria and albuminuria are also not uncommon. It is difficult to explain how disturbed general innervation gives rise to a temporary albuminuria. It has been shown by Capitan that irritation of special nerve-centres sometimes causes albuminuria. The impression of a sudden and strong light on the retina, for instance, will, according to Capitan, cause a temporary albuminuria. The cause of the temporary appearance of sugar in the urine is equally obscure. The urine is commonly neu- tral or even alkaline in reaction, and contains usually earthy phosphates in abundance. Indican is present in greatly increased quantities, especially when the cause of the neurosis has been onanism. The pollutions of these patients have often a bluish color from the excess of in- dican. This frequently is the occasion of unnecessary alarm. Indican is generally found dissolved in the urine, but it may be present in minute microscopic scales. Its presence can be suspected when, on the addition of nitric acid to a sample of the urine, we find, in addition to the normal reddish zone, one of a blue color. To test the urine for indican, add an equal quantity of hydrochloric acid to the suspected liquid, and afterward two or three drops of a cold saturated solution of chloride of lime. If indican is present, the mixture acquires a deep violet tint. The addition of chloroform, which falls on account of its weight to the bottom of the test- tube, taking with it the indican, leaves two layers, an upper colorless one, and a lower violet one. Among the urinary sediments found in the neuroses of the genito-urinary organs, the most common, and the most characteristic, is oxalate of lime. The amorphous carbonate of lime and the amorphous and crystalline phosphate of lime are also frequently present. Spermatozoa are also frequently to be detected. The general nervous symptoms present in these cases do not differ from those seen in any of the general neuroses. When the neurotic disturbance is confined principally to the urinary tract, the patient complains of a severe burning sensation along the urethra. Frequently this sensation is compared to the feeling that would be pro- duced by drawing a hot iron along the course of the urethra. It is especially acute and distressing near the meatus, and is worse for some minutes after urination. In addition there is a hyperaesthetic state of the skin in the neighborhood of the genital organs. 317 lit 111 lit 11 • [_■ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, After a short time it is not to be wondered that there is superadded a general neurotic state which, if com- plained of by a female, would be commonly called hys- teria. The bladder frequently shares also in the dis- turbance, micturition being frequent and painful. The passage of an instrument into the bladder gives rise to the most exquisite pain. At times cases will be found when it is necessary to use a general anaesthetic to permit the introduction of an instrument. In the great majority of cases the production of a slight degree of local anaesthesia will, however, be sufficient. This can be best effected by smearing the catheter, or by previously in jecting a five-per-cent, solution of the oleate of cocaine. The use of the cocaine in this way has also a directly curative action, as it diminishes the sensibility, and thus lessens reflex influences. Its action in constricting the capillary vessels and arterioles leads to a direct action on the hyperaemia of the posterior part of the urethra. A gonorrhoea, especially one that has lasted some time, and has involved secondarily the epididymis and bladder, is by far the most common cause of urinary neurosis. The starting-point is from the posterior part of the urethra, and the only satisfactory treatment is the removal of the cause-the catarrh or hyperaemia of the prostatic urethra ; and, to effect this, local measures are necessary. The internal administration of drugs in these cases can do little or nothing. We may, by the exhibition of motor depressants, like potassium bromide, dull the general and local sensibility, and in this way in some measure relieve the patient's suffering, but at best such measures are only temporary ones, and very inefficient at that. Of all general measures, the use of daily warm hip-baths are the most efficient. The soothing effects of the baths are much ap- preciated by the patients. For the cure of the local affection-the catarrh of the posterior urethra-our agents, to be effective, must be ap- plied directly to the diseased parts. The irrigation of the posterior part of the urethra with weak solutions of zinc sulphate or carbolic acid is the most efficient means. In order to carry this out, it is necessary to use a catheter, which must be introduced, and passed beyond the com- pressor urethrae muscle. The injection of solutions from the meatus is useless, for they cannot reach the diseased part. Several catheters have been devised for the purpose of the local medication of the deep urethra. Ultzmann's an- swers every purpose. It is sixteen centimetres (6| in.) long, and corresponds to No. 18 of the French scale. The ves- ical end, which has the medium curve, has four narrow, longitudinal slits, while the external end has a round plate which prevents it from going too far into the urethra when introduced. The instrument is introduced into the urethra until its point has just passed the compressor muscles. A syringe filled with one hundred grammes of a one-half per cent, solution of carbolic acid is inserted into the catheter, and the fluid is slowly injected into the bladder. If the fluid returns, it proves that the instru- ment is not beyond the compressor muscles. The in- strument once beyond these, there will be no return of fluid ; it will find its way all into the bladder. It is im- portant that the patient should lie quiet for some min- utes afterward, and then he can empty his bladder. It is equally important that the bladder should be emptied be- fore irrigating, otherwise infectious material may be forced into it, where it will set up a putrefactive catarrh. The irrigations should be repeated daily, and it is advis- able to change the carbolic solution for one of a one- half per cent, solution of zinc sulphate, after a few days. The strength of the solutions can be gradually increased until those of three per cent., or even four per cent., may be used without causing any annoyance to the patient. After a very few irrigations the patients feel much im- proved, and in the course of a few weeks a complete cure is generally effected. Neuralgia of the Testicles.-This form of neu- rotic disorder of the genital apparatus is not common. When present, it is characterized by neuralgic-like pains in the testicles, which especially reach a severe grade dur- ing micturition or during tlie ejaculation of semen. The testicles are frequently very tender on pressure. Neuralgia of the testicles may be either reflex or idio- pathic. In the former case, the cause generally lies in an irritable state of the urethra or rectum; in the latter, general agencies can be usually discovered which have led to the trouble, such as we generally find in the idio- pathic neuralgias of other parts. The treatment of the reflex neuralgias must be conducted with the view of re- moving the cause. If it is due to a hyperaesthetic urethra, then the daily passage of a large sound smeared with the oleate of cocaine will generally be quickly effective in re- moving it; if to rectal or other causes, the removal of these, when possible, is the proper procedure to employ. For neuralgias of the testicles of idiopathic origin, the measures employed for neuralgia must be resorted to. Many of these are very intractable, resisting as a rule the influence of our most prized agents. Neurotic Impotence.-This is a well-known condi- tion. It may be due to central (functional) disturbances of the brain or cord, or it may be reflex. The influence of depressing or other emotions in caus- ing impotence is a fact with which every one is familiar. This form is generally very temporary. It, however, may be permanent. Cases are recorded where great grief or sudden fright has led to a permanent impotence. How such psychical influences can lead to a complete and per- manent inhibition of the erection centre is difficult to ex- plain. Neurotic impotence is, however, more frequently im- aginary than real. A patient who is troubled with a stricture of the urethra, or a varicocele, often imagines that he is unable to have full intercourse. Masturbators are particularly prone to think that they are impotent. The treatment of impotence due to the causes above mentioned does not essentially differ from that of a gen- eral neurosis. The most frequent cause of neurotic impotence is the hyperaesthetic state of the posterior part of the urethra, which is induced by unnatural sexual excesses. As a re- sult, there is diminished irritability of the erection centre. In these cases we have frequently, in addition, a neurotic hyperaesthetic condition of the whole urethra, such as was described under the head of neuroses of the urethra. We have, in fact, a combined genito-urinary neurosis. In treating these cases it is, in the first place, of great importance to insist on the stoppage of all unnatural prac- tices. Then the local treatment of the urethra should be attended to. If the desired result is not quickly obtained, the daily injection of three or four ounces of cold water into the rectum will be found to be useful. The use of galvanism is strongly recommended by some authors also : positive pole in the lumbar region, negative over the peri- neum ; stabile current with about five cells. Enuresis.-This form of urinary disturbance is in the majority of cases a pure neurosis. It is principally seen in children, and disappears usually at puberty By en- uresis is meant the involuntary discharge of normal urine in an otherwise healthy condition of the urinary organs. Enuresis appears generally only during the hours of sleep, when it is called nocturnal enuresis. If it appears only during waking hours, which is very rare, it is known as diurnal enuresis. It is still rarer to find an enuresis continuous, both during the day and during the night. A child who is troubled with enuresis may wet the bed every night, or only occasionally. Usually, when the trouble is firmly established,it takes place several times during each night. The state of the general health varies in children troubled with enuresis. It is as frequent in robust, healthy children, as it is in the scrofulous and rachitic. It is commonly asserted that it only occurs when sleep is very profound, but when we take into consideration that nearly all healthy children sleep deeply, the impor- tance of this as an etiological factor must be small indeed. Further, it is not uncommon to be told by the parents that the bed is often wetted shortly after the child goes to sleep, even if the bladder is emptied just before retiring. The true cause of enuresis lies in a disturbed innervation 318 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Aeolian™™ Yro8e"Z of the sphincter and detrusor of the bladder ; the proper relation existing normally between these two sets of muscles is disturbed. This disturbance is of a pure neu- rotic character. It consists in a deficient action of the sphincter, and an over-action of the detrusor. It is alleged that there are cases of enuresis due to a deficient development of the sphincter. That this is a very rare event is shown by the result of stimulating the sphincter with a faradic current. Frequently a single application is sufficient to cure the condition, which would not be possible if the cause were due to deficient development of the muscle. Presently it will be shown, from the action of belladonna, that enuresis is in the vast majority of cases a neurosis, and not due to any want of development. Enuresis is as common in girls as in boys. It appears, however, to be more intractable in the former. It is not uncommon to find it in girls up to the fifteenth or six- teenth year, while this is rare in the other sex. Enuresis may be excited and kept up by an abnormal condition of the urine ; hence it is necessary in all cases to make an ex- amination of this fluid, in order to determine its freedom from excess of oxalates, or urates especially. Polypoid growths in the meatus may also act as an exciting cause, as well as leucorrhoeal discharges in girls. A close ex- amination of these parts should always be made. The treatment should be directed to the cause. If an ab- normal condition of the urine exists, it should be cor- rected ; if there are any small growths in the urinary or genital passages, they should be removed. For a simple neurotic enuresis there is no medical agent to be compared with belladonna. In order, how- ever, to obtain full benefit from it, it is necessary to give it in full adult doses. It can be administered in the form of the tincture, or the alkaloid can be used. It should be continued for a period of at least three or four weeks. If there is not marked amelioration in the symptoms in this time, there is no use of continuing it.. An enuresis that is not cured in three weeks with full doses of belladonna will probably not be cured by it at all. Many of the failures are due to the insufficiency of dosage. As a rule, children bear belladonna as well as adults, and to produce the phy- siological effects of the drug in them (children) it is neces- sary to give it in adult doses. Belladonna acts in a two- fold manner in enuresis. It gives rise (1) to a semiparetic state of the detrusor, and (2) it diminishes the sensibility of the mucous lining, by the depressing effects which it exerts on the sensory nerve endings ; and for the produc- tion of these effects it is necessary to employ it in such quantities as will bring about the dryness of the mucous membrane of the throat. We would judge, then, that many cases of neurotic enuresis are due to (1) hyper-exci- tability of the vesical detrusor, and (2) to a hyper-excita- bility of the vesical mucous membrane. There is, however, another set of cases in which the pa- thological factor is a paresis (semi) of the sphincter, and here the faradic current is the means to employ. The negative electrode is to be placed in the rectum and the positive over the perineum. Daily sittings of ten minutes' duration are recommended. The cases of enuresis that resist both of these forms of treatment are extremely few. Reference is only made here to the neurotic variety of enuresis. James Steicart. metres in diameter), about ten in the axis of each floral bract, standing upon pedicles about as long as the corolla. The calyx is membranaceous, enclosing the bud and split- ting down the Side as the flower expands. Corolla six- parted, almost to the base; segments, strap-shaped, narrow spreading ; stamens live, pistil one, one-celled, with two placentae and numerous ovules. The floral envelopes are persistent, withering around the capsule as it grows and Fig. 1386.-Gentian, Plant, Pod, and Seed. (From Bailion.) GENTIAN, Gentiana. U. S. Ph.; Gentiana Radix, Br. Ph.; Gentiane, Codex Med.; Radix Gentiana, Ph. G. (the latter including the roots of G. Panonica, G. purpurea, and G. punctata, as well as that of G. lutea, which alone is recognized by the other authorities above named). The yellow or officinal gentian {Gentiana lutea Linn.) is one of the largest and showiest species of the genus. It is a tall, sturdy, mountain perennial, arising from a thick, fleshy, slightly branching or simple, and sometimes very long (from half a metre to one metre or more), yellowish- brown root, by one or two, rarely several tall and leafy stems ; these attain to a metre or so in height, are erect, smooth, partly hollow, and bear several pairs of opposite, light green, sessile, ovate, five- to seven-nerved leaves in the lower half, and a series of compact axillary cymes in the upper. The flowers are large (from two to fivecenti- ripens. The yellow gentian is a striking and showy, but not exactly handsome plant. It grows abundantly in the elevated and mountainous parts of Southern and Middle Europe, Asia Minor, etc. In Switzerland, Southern Fig. 1387.-Gentiana Acaulis Linn. (Baillon.) (Not official.) 319 Gentian. Germicides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. France, and the hilly parts of Germany, it is collected for use. Although sometimes cultivated for ornament, it does not thrive well, and rarely flowers except in its native past- ures. G. panonica Scop, has a bell-shaped, regularly lobed calyx, and a dark-purple, punctated, open-tubular corolla. It is a smaller plant than the above, and has a smaller, slenderer, but otherwise similar root. Grows in the Aus- trian Alps, Bohemia, etc. G. purpurea Linn, has a bell-shaped corolla , purple with- out and yellow within. It is fewer flowered and smaller than G. lutea, and its root is usually easily distinguished from that of the yellow Gentian by the numerous branches into which it divides at the top, each bearing an aerial stem. It inhabits the same regions as G. lutea, but extends farther north than that species. Besides these there are half a dozen more species and a good many hybrids in Europe, all of which have similar, if not the same, qualities, and may be collected sometimes for sale. History.-The name is said to be derived from Gen- tius, one of the kings of Illyria (a.d. 167-180), who no- ticed it (Fliickiger). The root has been used as a medi- cine for centuries. Description.-The root of G. lutea is in large, hygro- scopic, and slightly flexible, generally simple, or slightly uble in alcohol. It is not an active substance. The root also contains a good deal of pectic matters, sugar (Geutia- nose), etc., but no starch, and probably no tannic acid, unless the gentisic acid be considered a form of tannin. Action and Use.-Gentian is the most perfect type at our command of the class of medicine called " bitter ton- ics." In the purity of its bitter taste, the promptness of its action upon the assimilating organs, and the absence of other qualities even in considerably larger than me- dicinal doses, it has no equal. Concerning its physiolog- ical action in a definite way-that is, as shown by experi- ments in laboratories-we know but little, the more striking effects of active poisons having greater fascina- tion for physiologists. Gentisic acid, to the extent of several grams, has no special action. Gentiopicrin has not been tested, to the writer's knowledge, in a pure state; but the older gentianins, etc., consisting of mixtures of the above two substances, have never shown themselves poisonous. In excessive quantities Gentian and its prepa- rations disturb the stomach and bowels, and may occa- sion nausea and vomiting. Sometimes it appears to be slightly laxative. The employment of Gentian in medi- cine is almost exclusively to obtain its stimulating effect upon the assimilating functions. Under its influence the appetite improves, the feeling of weight or discomfort felt in the stomach or bowels after eating-if due to debility of those organs-disappears, more food is taken, and prob- ably more of what is taken is assimilated. The secondary effect to this, the improved nutrition of all the organs, and their consequently better performance of their various functions, is what is known as a tonic effect. Strength, weight, color, firmness of tissue, are all improved, and better health results. This drug is, then, indicated in debility, with poor appetite, of a more or less chronic character. Of course, acute and sudden depression, such as collapse or shock, or the weakness of fevers during the stage of high temperatures, are to be treated by stim- ulants, and are not suitable ones for tonics alone ; but, on the other hand, during the recovery from all severe illness- es it may be of great value. It is often of service in dys- pepsia, and, in combination with iron, in simple anaemia. As an antiperiodic it has been completely superseded by quinine; as a substitute for tobacco and opium in the treatment of those habits it has no special value. Administration.-Gentian, in the form of the whole root, is sometimes chewed, and the salivary extract swal- lowed ; the method, although troublesome, is not a bad one for those who are fond of the bitter taste. The dose is not particularly important, but two or three grams will probably do as much good as a larger quantity. There are several widely used preparations, all good. The extract (Extractum Gentiana, U. S. Ph.), an in- fusion evaporated to a pillular consistence, is a nearly black, pleasant-smelling, but very bitter, soft solid, scarcely firm enough to make permanent pills. Dose, a gram or less. The fluid extract (Extractum Gentian® Fluidum, U. S. Ph.), made with diluted alcohol, is less used than the other preparations, but represents the root well. The compound infusion (Infusum Gentian® Compos- itum, Br. Ph.), although not now officinal here, is consid- erably used ; its strength is fifty-five grains to ten ounces, with orange and lemon peel. Dose, a wineglassful or two. But the most commonly used of all, and probably the most perfect bitter tonic ever made, is the compound tinct- ure (Tinctura Gentian® Composita, U. S. Ph.), which has the following composition: Gentian, 8 parts; bitter or- ange peel, 4 parts; cardamom, 2 parts; percolated with diluted alcohol until 100 parts of tincture are obtained. The addition of aromatics in the two last preparations greatly enhances their value. Allied Plants. - Besides those mentioned in the botanical section of this article, one or two other Euro- pean species may occasionally be found in samples of com- mercial Gentian ; the substitution is not a serious one, as they all have about the same properties. The genus in- cludes about a hundred and eighty species, scattered all over the temperate parts of the earth, and having in general the medicinal qualities of those mentioned. Nearly a dozen are natives of the United States, all bitter. One Fig. 1388.-Gentian Root, transverse section, magnified. (Bailion.) branched yellow-brown pieces, from one to three centi- metres in diameter, and from ten to thirty in length ; it is considerably shrunken, and longitudinally wrinkled below, but at the apex it is firmer, less shrivelled, and encircled by numerous fine, transverse wrinkles ; crown usually single and scaly. The odor of Gentian is heavy and earthy, but rather characteristic ; the taste intensely and purely bitter. The internal color is pale ashy, or cream with a dark cambium ring. The roots of other species are distinguished by their smaller size and tendency to divide into numerous branches at the top. Composition.-The principal constituent of this and other Gentians is the peculiar, intensely bitter, crystalline glucoside, Gentiopicrin, first obtained in a state of purity in 1868, by Kromeyer, from fresh Gentian root. It can- not, so it is said, be made to crystallize from that which has been dried. It forms clear, radiate, or clus- tered needles; is soluble in water and diluted alcohol, but not in ether ; and by means of diluted acids it is separated into sugar and Gentiogenine, a yellow, bitter, neutral powder. The yield is about one and two-thirds per mille. Gentisic acid is more abundant, but of doubt- ful value. It is in large needle-shaped crystals, tasteless, and almost insoluble in water and ether, but slightly sol- 320 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gentian. Germicides. (G. Catesloei Walt.) was formerly officinal, and is still in use. It has a root consisting of a cluster of thick fibres, not at all resembling any of the European Gentian roots, but it is equally bitter and probably just as good. The other is, however, so cheap and abundant that ours is not likely at present to be much collected. Other genera of the order are noted as bitter tonics: Swertia (Chirata), Frasera (American Columbo), Sabbatia (American Cen- taury), Erythrcea (Centaury), etc., are examples. Meny- anthes (Buckbean), belonging to a distinct suborder of the family, is not so pure a tonic and often emetic. Allied Drugs.-The bitter tonics are a miscellaneous group of vegetable substances, having two properties in common, a bitter taste, and the power, in suitable doses, of improving the appetite and digestion. They may owe their value to neutral substances like gentian, quassia, dog- wood, etc.; to bitter acids(columbo), to alkaloids, colum- bo, barberry, box, and others, or to various as yet unde- termined extracts. Occasionally bitter substances of the greatest activity, like strychnine or quinine, in minute quantities, act as tonics. The dose of these bitters appears to be of little consequence, provided it is not too large ; above a certain point, increasing it does not increase its tonic effect or in any way hasten the cure, but, on the other hand, may retard it by disturbing the stomach, or by some other untoward effect. It is probably the local influence of the physical property that gives the sense of bitterness to the tongue, upon the stomach and intestines, that constitutes the usefulness of these drugs, stimulating those organs in a similar way to that in which the tongue and fauces are stimulated by sapid and agreeable articles of food. Besides the members of the Gentian order, the most important bitter tonics are ; Quassia, Simaruba, Columbo, Barberry and other berberine-containing sub- stances, Nectandra and other Zumw-containing drugs, the Dogw'oods, and numerous other bitter barks, herbs, etc. The Cinchonas and Nux Vomica are important drugs in other directions, which are incidentally tonics. The asso- ciation of bitterness with astringency or with spiciness, as in many mints and compositse, is very common, and some of these natural combinations are of considerable value. The mints themselves and aromatics are useful tonics, and excellent adjuvants to the simple bitters. With iron and the mineral tonics the bitters have little in common ; with the vegetable " alteratives " they are evidently con- nected, although obscurely. W. P. Bolles. element of an animal or vegetable organism. But med- ical authors, in advance of exact knowledge, have long been in the habit of speaking of the ' ' germs of disease; " and since it has been shown that in certain instances these disease-germs are minute vegetable organisms, belonging to the bacteria, a more definite idea is attached to the word germ, and the term germicide is understood as re- ferring to an agent which has the power to destroy or- ganisms of this class-micrococci, bacilli, and spirilla. It is evident that an exact knowledge of the germicidal power of various substances is desirable with a view to therapeutic possibilities, and especially with reference to the destruction of disease-germs external to the bodies of infected individuals-disinfection. As methods have been perfected by which organisms of this class-pathogenic or non-pathogenic-may be isolated and cultivated through successive generations in sterilized media-" pure cult- ures "-it has become possible to determine in an exact manner the germicidal power of a given agent as regards a particular germ ; and in a general way to classify chem- ical agents with reference to their power to destroy bac- terial organisms. Already much pioneer work has been done in this direction, and it is the object of the present article to place upon record the results of the determina- tions which have been made up to the present date. But before referring in detail to the experimental data, it will be desirable to give an account of the methods of research, and to call attention to the various circum- stances which influence the result, and which must be taken into consideration if we attempt to compare the data obtained by different experimenters. In the case of pathogenic organisms two methods of de- termination are available : (a) the inoculation of germs which have been exposed to the action of a supposed ger- micide into a susceptible animal ; (b) the attempt to cul- tivate germs exposed in the same way in suitable cult- ure-media. In the one case failure to multiply in the body of the test-animal, and in the other failure to multi- ply under favorable conditions, is taken as evidence of the germicidal power of the agent tested. Extended experiments by the method of inoculation have been made upon the anthrax bacillus (Davaine, Koch), upon the tubercle bacillus (Schill and Fischer), and upon the micrococcus of rabbit septicaemia (Davaine, Sternberg). Experiments have also been made upon the virus of glanders (Reynal, Peuch, Vallin), upon that of symptomatic anthrax (Arloing, Cornevin, and Thomas), and upon the micrococcus of fowl cholera (Salmon). This method is very definite and satisfactory so far as the negative results are concerned-that is to say, when the agent under trial fails to exercise any germicidal power. In this case the death of the test-animal, and the fact that the pathogenic organism to which this result is due is found in its blood or tissues, is sufficient evidence of the failure of the agent under trial to destroy the vital- ity of the germ. But the survival of the test-animal can- not be taken as positive proof that the agent to the action of which the test-organism was submitted has completely destroyed the vitality of this organism. This for two reasons : first, the inoculated animal may suffer from a modified and non-fatal attack of the infectious disease, the germ of which is used in the test; second, in the case of a chemical agent which has been mixed in a given amount with a pure culture of the test-organism, or with blood from an infected animal containing this organism, the agent is necessarily injected into the test-animal along with the germs which have been subjected to its action, and may exercise a restraining influence upon the develop- ment of these germs without destroying their vitality. This would give time for their destruction in the body of the animal by those means which have been provided by nature. The writer has elsewhere suggested that this is probably one of the functions of the white blood-corpus- cles, and that, when the developing power of pathogenic organisms is restrained in any way, before or after their introduction into the body of a susceptible animal, this provision of nature may suffice to prevent an attack of the disease, or at least to modify its severity. The second method permits of a more accurate deter- GERMANDER (Germandree Chamadrys, Codex Med.; the plant in flower), Teucrium Chamadris Linn.; order, Labiates, is one species of a large genus of variable-some- times pretty and fragrant, in other cases disagreeable- smelling-weed-like labiates, characterized by having the upper lip of the flower so deeply bifid, and its lobes so united with the under, as to appear to have only one five- lobed lip, with a deep cleft in the upper side of the corolla. They are largely European and Asiatic plants, but one species (T. cauadense Linn.) is found in our own meadows and woods. T. Ghamosdris has rather pretty rose-colored flowers, an agreeable odor, and a bitter taste. It has not been analyzed, but probably accords in general with the bitterer genera of the order (Horehound, Mother- wort, Dead Nettle, Bugle Weed, etc.), and like them has vbeen used as diaphoretic, anti-scorbutic, stomachic, etc. It has had some reputation (as what has not ?) in gouty diseases. Dose, two or three grams, in infusion or other- wise. Allied Plants and Drugs.-Several other species of Teucrium(T. Scorodonia Linn., Scordium ou Germandree d'eau, Codex Med.) have somewhat similar, not very valu- able, qualities. For the order, see Peppermint. W. P. Bolles. GERMICIDES. Modern science having established the fact that certain infectious diseases of man and of the lower animals are due to minute micro-organisms, popu- larly spoken of as " germs," the term germicides has been introduced to designate those agents which have the power of destroying the vital activity of such organisms. Strictly speaking, a germ is the primitive reproductive 321 Germicides. Germicides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mination when the experiments are conducted with a due regard to the possible restraining influence of the germi- cide agent, which by preventing growth might lead to the mistaken inference that the vitality of the test-organ- isms had been destroyed. This error is to be avoided by diluting the germicide agent so largely with the sterilized culture-fluid into which it is introduced, along with the test-organisms which have been exposed to its action, that its restraining influence is rendered nil. Suppose, for example, that we mix with a culture of the anthrax bacillus containing spores an equal quantity of a solution of mercuric chloride of the strength of 1 to 1,000, making the proportion of the salt in the mixture 1 to 2,000. Now, if we take one part of this mixture and add it to ten parts of sterilized bouillon, w'e shall have the mercuric chloride present in the proportion of 1 to 20,000. Experiments upon the restraining power of this salt show that anthrax spores will not grow in culture-solutions containing 1 to 300,000, and that their development is retarded by so- lutions of 1 to 600,000. Failure to develop in this case would therefore be no proof that the growing power of the anthrax spores had been destroyed. This proof is only to be attained by adding sufficient culture-fluid to dilute the mercuric chloride beyond its restraining power. The use of a comparatively large amount of the culture- fluid, and of an extremely small quantity of the material containing the test-organisms, permits us to exclude this source of error, for a few germs serve as well for the test as a large number. For the reason stated fluid-culture media are more suitable for experiments of this nature than solids. If we bring a little of our material containing mercuric chlo- ride in the proportion of 1 to 2,000 upon the surface of a cooked potato, or introduce it with a needle into a gela- tine-culture medium, the salt will not be diluted, and would exercise its restraining influence upon the germs if they had not already been destroyed by its action. On the other hand, if we add 1 part of the material to 100 parts of bouillon and mix thoroughly by shaking, the mer- curic chloride will be diluted to 1 to 200,000; this being still within the limits of its restraining action, we may take one part of the mixture and add it to ten parts of the sterile bouillon. The mercuric chloride will now be di- luted to 1 to 2,000,000, a proportion quite beyond the lim- its of restraining action. But there will be a sufficient number of anthrax spores in the culture-medium to test the question as to whether the growing power of these particular " germs " is destroyed by mercuric chloride in the proportion named. It is probable that this source of error has not been kept sufficiently in view in some of the experiments here- tofore made. Again, it often happens that no develop- ment occurs for a time, but that after several days the germs which have been exposed to the action of a chem- ical agent- commence to grow, and finally produce an abundant and vigorous progeny. In this case mistakes are likely to arise from terminating the experiment too soon. Anthrax spores, for example, develop, in a suit- able culture-medium, at a temperature of 80° to 100° F., within twenty-four hours, and give rise to numerous characteristic flocculi, made up of long filaments, which are readily distinguished by the naked eye. But after exposure to a germicide agent in less amount than is nec- essary to completely destroy their vitality, they may fail to develop under the same circumstances in forty-eight or seventy-two hours, and yet finally produce an abun- dant crop of filaments. Bearing in mind these sources of error, the germicidal value of a given agent may be determined approximately by a series of experiments, in which the quantity of the agent under trial is increased or diminished according as it fails or is successful in destroying the vitality of the test-organism. But the data obtained by experiments upon a single organism can only be applied in a general way to others of the same class, for experiments which have been made show that within certain limits there are manifest differences in resisting power, and especially that there is a wide difference in this regard between or- ganisms in active growth-micrococci, spirilla, or bacilli -and the reproductive bodies, called spores, which are developed in the interior of the bacilli at a certain period in their life-history. It will be seen from what has been said, that the ger- micidal power of a chemical agent can only be stated in a definite manner when reference is made to a particular germ. It is also necessary to take into account certain circumstances relating to the test-organism and the me- dium in which it is placed, and, especially, to consider the time during which this has been exposed to the action of the germicide. Thus we may, by our experiments, deter- mine how long a time will be required for the destruction of a given germ by means of a standard solution of a cer- tain chemical agent. Or, on the other hand, we may de- termine the proportion in which this agent must be used in order to be effective in a given time. In Dr. Koch's elaborate experiments, published in the first volume of the " Mittheilungen aus dem Kaiserlichen Gesundheits- amte," the time is made the variable quantity. In the writer's numerous experiments a standard time has been adopted-two hours in the more recent experiments-and the object in view has been to determine the minimum quantity of the agent under trial which is effective in this time. Evidently, a comparison of the results reported by dif- ferent experimenters requires a consideration of this es- sential condition. But in addition to this we must con- sider the following circumstances : (a) The presence or absence of spores. (b) The physical condition of the test-organism - whether it is dry or moist, whether suspended in fluid or imbedded in masses of albuminous material, etc. (c) The chemical properties and mode of action of the agent which is being tested. (a) As already remarked, spores are far more resistant than bacteria in active growth. Thus the spores of the anthrax bacillus require for their destruction a boiling temperature, while the bacillus itself is quickly destroyed by a temperature of 140° F. The same spores are not de- stroyed by being immersed for one month in- a five per cent, solution of chloride of zinc, or for three months in absolute alcohol, or one hundred and ten days in a five per cent, solution of carbolic acid in oil; the last-men- tioned solution, however, destroys the bacilli, in the ab- sence of spores, in six days (Koch). (5) The germicidal power of sulphur dioxide and of other gases is largely influenced by the physical condi- tion of the test-organisms-as to whether they are dry or moist, whether they are exposed in masses or in thin films, etc. And the same circumstances influence the result, to a less extent, in experiments with aqueous so- lutions of various agents. This is especially true as re- gards those agents which enter into combination with al- buminous material; thus Schill and Fischer found that the tubercle bacillus was not destroyed in tuberculous sputum exposed for twenty-four hours to the action of mercuric chloride in solution in the proportion of 1 to 2,000, while dried sputum exposed to a solution of 1 to 5,000 failed to produce tuberculosis when inocu- lated into guinea-pigs. The difference was no doubt due to the fact that in the moist sputum the bacilli in the interior of the mass were protected from the action of the germicide agent. The result is also largely influenced in certain cases by the amount of non-living organic material associated with the germs to be destroyed. This is espe- cially true as regards the oxidizing disinfectants. If, for example, we subject a given quantity of germs suspended in pure water to the action of potassium permanganate or of hypochlorite of lime, these agents will be effective in dilute solutions. But if the germs are suspended in a rich culture-medium, or imbedded in masses of organic material, this material will be quickly oxidized, and in the chemical reaction which occurs an amount of the reagent will be decomposed corresponding with the amount of or- ganic material present in the solution ; and only the excess of the oxidizing agent will be available for the destruction of such germs as may have escaped immediate destruction by reason of their resisting power, or because they were protected by being imbedded in masses of material. 322 Germicides. Germicides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It will be desirable to extend the experimental re- searches in this direction as new pathogenic organisms are discovered, and to determine in an exact manner the value of each agent which has been shown to possess ger- micidal power for each organism of this class. In many of the experiments which have been made test-organisms have been used which are known to be non-pathogenic, but which, belonging to the same class, give valuable data for the determination in a general way of the com- parative germicidal value of various chemical agents. Thus, in many of the writer's experiments the bacteria of putrefaction, as found in "broken-down" beef-tea freely exposed to the air, have served as the test. As a variety of bacterial organisms are present in such material, includ- ing one -or more species of spore-bearing bacilli, this serves as a general test, and there is reason to believe that all known pathogenic organisms would be destroyed by an agent capable of destroying all germs found in such material. These experiments, therefore, furnish reliable data upon which to base practical measures of disinfec- tion. In practice it will be best to select such agents as stand the most rigid tests, and to use them in amounts somewhat in excess of what is shown by such tests to be necessary. (See article on Disinfectants.) For convenience of reference we have arranged the fol- lowing summary of the experimental data in alphabetical order: Acetone.-Anthrax spores grow freely after two days' exposure to the action of this agent; after five days the development is feeble (Koch). Acetic Acid.-A five per cent, solution did not prevent the development of anthrax spores after five days' expos- ure (Koch). In recent experiments made by Abbott, glacial, acetic acid in the proportion of fifty per cent, failed to destroy anthrax spores in two hours, but twenty per cent, was effective with the spores of B. subtilis, and with the mixed organisms in broken-down beef-tea ; and micrococci were destroyed in the same time by a one per cent, solution. Alcohol.-In the writer's experiments it was found that ninety-five per cent, alcohol did not destroy the vitality of the organisms in broken-down beef-tea in forty-eight hours. The septic micrococcus (rabbit septicaemia) was destroyed by two hours' exposure to a twenty-four per cent, solution. A micrococcus obtained from gonor- rhoeal pus required a forty per cent, solution. Koch found that absolute alcohol had no effect upon the vital- ity of anthrax spores which were immersed in it for one hundred and ten days. When saturated with camphor, alcohol does not destroy the virus of symptomatic an- thrax (Arloing, Cornevin, and Thomas). In the propor- tion of 1 to 1.5 it destroys the bacteria which cause the acid fermentation of milk (Molke). Schill and Fischer found that when tuberculous sputum was mixed with an equal quantity of absolute alcohol, its infecting power was not destroyed (in twenty-four hours), but that, in the proportion of 5 parts to 1 of sputum, this agent was effec- tive in destroying the tubercle bacillus, as proved by in- oculation experiments. Ammonium Chloride.-A five per cent, solution failed in twenty-five days to destroy the vitality of anthrax spores (Koch). Ammonium Sulphate.-A five per cent, solution was effective in five days, but failed in two days to destroy anthrax spores (Koch). Ammonia does not destroy the virus of symptomatic anthrax (Arloing, Cornevin, and Thomas), or the spores of anthrax (Koch). Aromatic Products of Decomposition.-Klein has tested the germicidal power of phenyl-proprionic and of phenyl- acetic acid. He finds that anthrax spores resist both of these acids in the proportion of 1 to 400, after two days' exposure ; but anthrax bacilli, in the absence of spores, are quickly killed by a solution of this strength. Certain non-pathogenic micrococci were not killed by exposure for twenty-five minutes to a solution of 1 to 200. Expos- ure for ninety-six hours to these acids, in the proportion of 1 to 200, did not prevent the caseous matter of pulmon- ary tuberculosis from infecting guinea-pigs; 1 to 800 was effective in destroying the virulence of swine-plague virus. Arsenious Acid.-A one per cent, solution destroyed the vitality of anthrax spores in ten days, but failed to do so in six days (Koch). The infective power of tubercu- lous sputum, as shown by inoculation into guinea-pigs, is not destroyed by twenty hours' exposure to a one percent, solution. Benzol.-Exposure for twenty days failed to destroy the vitality of anthrax spores (Koch). Benzoic Acid.-This agent was found by De la Croix to destroy the bacteria of broken-down beef-tea in the pro- portion of 1 to 77, while 1 to 121 failed. A saturated aque- ous solution failed to destroy anthrax spores in seventy days (Koch). Boric Acid (boracic acid).-In the writer's experiments a saturated solution failed to destroy any of the test-or- ganisms-two species of micrococci and B. termo. A rive per- cent, solution failed in ten days to destroy anthrax spores (Koch). According to Arloing, Cornevin, and Thomas, the activity of the fresh virus of symptomatic anthrax is destroyed by 1 in 5 (twenty per cent.), the time of exposure being forty-eight hours. Bromine.-A two per cent, aqueous solution destroys the vitality of anthrax spores in twenty-four hours (Koch), f'ischer and Proskauer have studied the action of bromine vapor upon various micro-organisms. They find that exposure for three hours, in a dry atmosphere, to three per cent, does not destroy the tubercle bacillus in sputum, or the spores of anthrax. But when the atmos- phere is saturated with moisture 1 part in 500 is effec- tive, and when the time of exposure is extended to twenty- four hours, 1 part in 3,500. Bromine vapor is the most active agent for the destruction of the virus of symp- tomatic anthrax (Arloing, Cornevin, and Thomas). It destroys the ferment of sour milk (Bacterium lactis} in the proportion of 1 to 348 (Molke). The bacteria of broken-down beef-tea are destroyed by 1 to 336 (De la Croix). Butyric Acid.-Five days' immersion in this acid failed to destroy the vitality of anthrax spores (Koch). Calcium Chloride.-A saturated solution has no de- structive action on anthrax spores (Koch). Camphor.-Alcohol saturated with camphor has no ef- fect upon the fresh virus of symptomatic anthrax (Ar- loing, Cornevin, and Thomas). Carbolic Acid.-Tested upon anthrax spores, Koch found a one per cent, solution to be without effect after fifteen days' exposure ; a two per cent, solution retarded the development of spores, but did not completely destroy their vitality in seven days ; a three per cent, solution was effective in two days. In the absence of spores, Koch found that a one per cent, solution quickly destroys the vitality of anthrax bacilli. The same author recommends a five per cent, solution for the destruction of the "com- ma-bacillus " in the discharges of cholera patients, and a two per cent, solution for the disinfection of surfaces and articles soiled by such discharges. The writer has found that, in the proportion of 1 to 200, this agent destroys B. termo and a septic micrococcus (M. Pasteuri) in active growth, while 1 to 25 failed to destroy the bacteria in broken-down beef-tea. A micrococcus obtained from the pus of an acute abscess was destroyed by 0.8 percent., while 0.5 per cent, failed. In all of these experiments the time of exposure was two hours. According to Sal- mon, the micrococcus of swine-plague multiplies abun- dantly in urine containing one per cent, of carbolic acid, while the micrococcus of fowl-cholera is destroyed by six hours' exposure in a solution of this strength (one per cent). A two per cent, solution destroys the bacterium of symptomatic anthrax (dried virus) in forty-eight hours (Arloing, Cornevin, and Thomas). The bacteria in broken- down beef-tea are not destroyed by a ten per cent, solu- tion (De la Croix). Davaine showed, by inoculation experiments, that an- thrax bacilli in fresh blood are destroyed by being ex- posed to the action of a one per cent, solution for one hour. Solutions in oil and in alcohol have been shown by Koch to be less effective than aqueous solutions. 323 Germicides. Germicides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Thus a five per cent, solution in oil failed to destroy the vitality of anthrax spores in 110 days, and the same solu- tion did not destroy the bacilli in the absence of spores in less than six days. A control experiment showed that olive-oil alone was effective in the same time. A five per cent, solution in alcohol did not destroy anthrax spores in seventy days. Schill and Fischer found that the infect- ing power of tuberculous sputum, as shown by inocula- tion into guinea-pigs, is destroyed by twenty-four hours' exposure to a five per cent, solution. The same result was obtained with a three per cent, solution, while one and two per cent, solutions failed. Carbonic Oxide.-This gas has no effect upon bacteria, which freely develop in it (Hamlet). Chloral Hydrate.-In the writer's experiments this agent was found to destroy micrococci in the proportion of twenty per cent., and to fail in ten per cent, solution, the time of exposure being two hours. Chlorine.-Fischer and Proskauer have made an elab- orate research with reference to the germicidal power of this agent, as tested by a variety of micro-organisms. In the absence of moisture these experimenters found that desiccated anthrax spores were not destroyed by expos- ure for an hour in an atmosphere containing 44.7 per cent, of this gas. When, however, the spores were mois- tened, an exposure for one hour in a moist atmosphere containing four per cent, of chlorine was effective, and by extending the time to three hours one per cent, suf- ficed to destroy the vitality of the spores. The anthrax bacillus, in the absence of spores, was killed by exposure in a moist atmosphere containing 1 part in 2,500, the time of exposure being twenty-four hours, and the same amount was effective for Micrococcus tetragonus; while the micrococcus of erysipelas and the micrococcus of fowl- cholera were killed by 1 to 25,000 in twenty-four hours, and 1 to 2,500 in three hours. The bacillus of mouse sep- ticaemia was destroyed in one hour by 1 to 200, and the same proportion was effective for the tubercle bacillus in sputum. In the writer's experiments made in 1880, the bacteria present in urine which had been freely exposed to the air and had become putrid were destroyed by ex- posure for one hour in an atmosphere containing 1 to 400. Koch found that after immersion for twenty-four hours in chlorine water, anthrax spores do not develop in a suitable culture-medium. Chlorine destroys the fresh virus of symptomatic anthrax, but is powerless against that which has been dried (Arloing, Cornevin, and Thomas). The bacteria of broken-down beef-tea are de- stroyed by 1 to 1,061 (De la Croix). Chloride of Lime.-(See Hypochlorites.) Chloroform.-Immersion for one hundred days in chloroform does not destroy anthrax spores (Koch). This agent is without effect upon the virus of symptomatic anthrax (Arloing, Cornevin, and Thomas). One part to 1.22 failed to destroy the bacteria of broken-down beef- tea (De la Croix). Chromic Acid.-An aqueous solution of 1 to 100 does not destroy the spores of anthrax in two days (Koch). Citric Acid.-In the writer's experiments upon micro- cocci from the pus of an acute abscess, twelve per cent, was effective and ten per cent, failed. Abbott reports that twenty-five per cent, failed to destroy the organisms in broken-down beef-tea, and the spores of B. subtilis and B. anthracis, but that 1.25 percent, was active in the case of micrococci. Creosote.-This agent was found by the writer to be fatal to micrococci in the proportion of 1 to 200. In the proportion of one per cent, it failed, after twenty hours' exposure, to destroy the tubercle bacillus in sputum (Schill and Fischer). Cupric Sulphate.-This salt failed, in the writer's ex- periments, to destroy the spores of B. anthracis and of B. subtilis in two hours' time in a t wenty per cent, solution. Arloing, Cornevin, and Thomas report that the dried virus of symptomatic anthrax is destroyed in forty-eight hours by a twenty per cent, solution. In Koch's experiments a five per cent, solution failed to destroy anthrax spores in ten days. The writer has found, however, that this salt is effective in the proportion of 1 to 200 for the de- struction of micrococci, the time of exposure being two hours. Ether.-Anthrax spores may germinate after being im- mersed in ether for eight days, but thirty days' exposure is effective for the destruction of these spores^Koch). Eucalyptol.-The bacteria in broken-down beef-tea are not destroyed by 1 to 14 (De la Croix). Ferrous Sulphate.-In the writer's experiments, re- ported in the American Journal of the Medical Sciences (April, 1883), a solution of twenty per cent, of this salt failed to destroy micrococci and the bacteria in broken- down beef-tea. In more recent experiments a ten per cent, solution was found to be fatal to Micrococcus tetragonus, but failed in the case of another micrococcus obtained from the pus of an acute abscess. Koch found that a five per cent, solution did not destroy anthrax spores in six days. According to Arloing, Cornevin, and Thomas, exposure to a twenty per cent, solution for forty-eight hours does not destroy the virus of symptomatic an- thrax. Ferri Chloridi Tinct.-In the writer's experiments a four per cent, solution was fatal to micrococci, and a two per cent, solution failed. Ferric Chloride.-A five per cent, solution failed in two days to destroy anthrax spores, but was effective in six days (Koch). Formic Acid.-This acid, of the specific gravity of 1.120, failed in two days to destroy anthrax spores, but was effective in four days. Gallic Acid.-Abbott finds this acid to be effective for the destruction of the organisms in broken-down beef-tea in the proportion of 2.375 per cent.; tested upon the spores of the anthrax bacillus, and of B. subtilis, it failed in this proportion, the time of exposure being two hours. Mi- crococci were destroyed by 0.7 per cent., while 0.4 per cent. (1 to 250) failed. Glycerine has no action upon the fresh virus of symp- tomatic anthrax (Arloing, Cornevin, and Thomas); and is inert as regards the spores of bacilli (Koch). Heat.-(a) Dry heat. Werner, in 1879, found that pu- trefactive bacteria enveloped in dry cotton were destroyed by exposure for one hour to a temperature of 125° C. (257° F). Wernich also experimented upon the bacteria of putrefaction, and found that exposure for five minutes to a temperature of 125° to 150° C. secured their destruc- tion. The virulence of dried tuberculous sputum is not destroyed with certainty by exposure for one hour to 100° C. (Schill and Fischer). Koch and Wolffhiigle, as the result of an elaborate series of experiments, arrive at the following conclusions : 1. A temperature of 100° C. (212° F., dry heat), main- tained for an hour and an half, will destroy organisms which do not contain spores. 2. Spores of mould-fungi require for their destruction in hot air a temperature of from 110° to 115° C. (230° to 239° F.), maintained for an hour and a half. 3. Bacillus spores require for their destruction in hot air a temperature of 140° C. (284° F.), maintained for three hours. (b) Moist heat. Davaine, in 1873, showed that the vir- ulence of fresh anthrax blood which does not contain spores is destroyed by a temperature of 55° C. (131° F.), maintained for five minutes ; or by 50° C. (122° F.) for ten minutes; or by 48° C. (118° F.) for fifteen minutes. The writer has fixed the thermal death-point of several species of micrococcus at 60° C. (140° F.), the time of ex- posure being ten minutes. This temperature is also fatal to the micrococcus of swine-plague, while the micrococ- cus of fowl-cholera is destroyed by exposure for fifteen minutes to a temperature of 132° F. (Salmon). The de- struction of spores is a very different matter, and requires a boiling temperature, maintained, in the case of some of these reproductive bodies, for several hours. But a tem- perature of 5° C. above the boiling point quickly destroys the most refractory spores. Thus the writer has found, as the result of repeated experiments, that this tempera- ture-105° C. (221° F.)-maintained for ten minutes, is fatal to the spores of B. subtilis, and that the same tempera- ture in two minutes' time destroyed the vitality of anthrax 324 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Germicides. Germicides. spores. Koch, Gaffky, and Loeffler also report that a temperature of 105° and upward, maintained for ten min- utes, is fatal to all spores, as shown by their failure to de- velop in culture-solutions. Where a temperature of 110° C. was reached, the experiment could be stopped, as no spores were capable of germinating after exposure to this temperature. The tubercle bacillus in fresh sputum is destroyed by fifteen minutes' exposure in a jet of steam having a tem- perature of 100° C.; and dried sputum lost its virulence by similar exposure for thirty minutes-no shorter expos- ures made (Schill and Fischer). Hydrochloric Acid.-In experiments upon broken-down beef-tea, the writer found this acid to be effective in the proportion of fifteen per cent., and to fail at ten per cent, (two hours' exposure). One part in two hundred was found to destroy the virulence of septic blood (rabbit sep- ticaemia), as proved by inoculation experiments. Anthrax spores are destroyed in ten days by a tw'O per cent, solu- tion, but not in five days (Koch). Hydrogen.-Bacteria may develop in an atmosphere of hydrogen (Hamlet). Hydrogen Peroxide.-In the writer's experiments, a so- lution containing 3.98 per cent, of H2O2 was found to de- stroy the organisms in broken-down beef-tea in the pro- portion of thirty per cent, The same solution failed in twenty per cent. Tested upon a pure culture of B. an- thrncis containing spores, the same solution was effective at twenty per cent. (0.8 per cent. H2O2 = 1 to 125), and failed at ten per cent. Tested upon micrococci, ten per cent, was effective, and five per cent, failed. The solution used in these experiments contained five per cent, of sul- phuric acid, and the germicidal power of this agent must be considered in estimating their value as determining the effect of II2O2 upon the vitality of the test-organisms. Hypochlorites of Lime and of Soda. -Commercial chlo- ride of lime contains from twenty to thirty per cent, of available chlorine, and Labarraque's solution of good quality from two to three per cent. According to Dug- gan, a solution containing 0.25 of one per cent. (1 to 400) of chlorine as hypochlorite is an effective germicide, even when allowed to act only one or two minutes, while 0.06 of one per cent. (6 to 10,000) will kill spores of B. an- thracis and B. subtilis in two hours. These results are not in accord with those of Koch, who reports that a five per cent, solution of chloride of lime (value in available chlorine not given) failed in two days to destroy the vital- ity of anthrax spores, but was effective in five days. The development of the spores was, however, retarded by one day's exposure. De la Croix states that the development of bacteria in unboiled beef-infusion is prevented by the presence of 1 part of chlorine in 15,606 of the culture- medium. Indol.-When added to water in excess, failed in eighty days to destroy anthrax spores (Koch). Iodine.-In the writer's experiments, iodine in aqueous solution with potassium iodide was found to be fatal to the micrococcus of rabbit septicaemia in the proportion of 1 to 1,000, and to a micrococcus obtained from the pus of an acute abscess in 1 to 500. De la Croix reports that 1 to 410 destroys the bacteria of broken-down beef-tea. Salmon found 1 to 1,000 to be fatal to the micrococcus of fowl-cholera. " Iodine water " was found by Koch to destroy the vitality of anthrax spores in twenty-four hours. The same author reports that exposure for forty- eight hours to a two per cent, solution of iodine in alco- hol failed to destroy anthrax spores, but that exposure in such a solution for five days was effective. In the ex- periments of Schill and Fischer, twenty hours' contact with a solution of the strength of 1 to 500 failed to de- stroy the virulence of tuberculous sputum, as tested by inoculation experiments. Iodoform.-Dissolved in oil, in the proportion of five per cent., iodoform failed in an hour and a half to destroy tubercle bacilli in fresh sputum. A saturated solution in water also failed after twenty-four hours' con- tact ; as did also a five per cent, solution in oil of turpen- tine (an hour and a half's exposure). No better results were obtained in an experiment in which the material was exposed for twenty hours to dry iodoform vapor, but in the presence of moisture dried sputum was disin- fected in two hours. Mixing the sputum with moistened iodoform wTas also effective after twenty-four hours' con- tact (Schill and Fischer). Iodol.-The writer has recently made experiments which show that bacteria are not destroyed by adding iodol in excess to culture-solutions-probably because it is quite insoluble. Labarraque's Solution.-(See Hypochlorites.) Lactic Acid.-A five per cent, solution failed in five days to destroy anthrax spores (Koch). Abbott reports that a twenty per cent, solution of concentrated lactic acid (specific gravity 1.21) was effective for the destruction of the bacteria in broken-down beef-tea and the spores of B. subtilis, while fifteen per cent, failed. Upon an- thrax spores lactic acid of the same strength failed in the proportion of fifty per cent. Micrococci were destroyed by a one per cent, solution, while 0.5 per cent, failed; time of exposure in these experiments two hours. Lime-water.-Immersion for twenty days in lime-water does not destroy the vitality of anthrax spores (Koch). Mercuric Chloride.-According to Koch, mercuric chlo- ride in the proportion of 1 to 1,000 destroys all spores in a few minutes, and he has shown, by culture and inocula- tion experiments, that the vitality of anthrax spores is destroyed by much weaker solutions (1 to 10,000) when the time of exposure is prolonged. The writer's experiments have given results in accord with those of Koch. Expos- ure for one hour to solutions of the strength of 1 to 10,000 was found to destroy the vitality of anthrax spores and of the spores of B. subtilis. The organisms iu broken-down beef-tea (old stock containing spores of various bacilli) were destroyed by two hours' exposure in a solution of the same strength, and micrococci failed to develop after exposure for the same time in solutions containing 1 to 20,000. The activity of the virus of symptomatic an- thrax (dried) is destroyed by 1 to 5,000 (Arloing, Corne- vin, and Thomas). The bacteria in broken-down beef- tea are destroyed by 1 to 6,500 (De la Croix). Extended experiments upon the disinfection of tubercu- lous sputum with this agent have been made by Schill and Fischer. In a first series of experiments with dried sputum, which had been kept for several months, a nega- tive result was obtained in every case from the fol- lowing inoculations : Two guinea-pigs, inoculated with material exposed for twenty-four hours to 1 to 1,000 ; three with material exposed for twenty hours to 1 to 2,500 ; and three with material exposed for twenty hours to 1 to 5,000. In another series of experiments with fresh sputum, in which the sublimate solution and the material to be disinfected were used in equal amounts, tuberculosis resulted in all the test-animals. Three of these were inoculated with material exposed for twenty- four hours to 1 to 2,000 (i.e., equal parts of the sputum and a 1 to 1,000 solution), and three to material exposed for twenty-four hours to 1 to 1,000. Nitric Acid.-This acid, in the proportion of 1 to 400, was found by the writer to neutralize the virulence of septic blood (rabbit septicsemia). In the proportion of eight per cent, it destroys the organisms in broken-down beef-tea, but failed at five per cent. Nitrous Acid.-Exact experiments to determine the germicide value of this agent are wanting. The writer has tested it upon vaccine virus, and found that exposure for six hours, in an atmosphere containing one per cent., destroys the virulence of this material dried upon ivory points. Oil.-Anthrax spores germinate after having been im- mersed for ninety days in pure olive-oil (Koch). Oil of Mustard.-According to De la Croix, 1 to 40 de- stroys the bacteria of broken-down beef-tea. Koch found that ten days' immersion in an aqueous solution of this oil is not fatal to anthrax spores, but that in the propor- tion of 1 to 33,000 it restrains their development. Oil of Peppermint.-A five per cent, solution in alcohol failed in twelve days to destroy anthrax spores, but the development of these spores is restrained by 1 to 33,000 (Koch). 325 Germicides. Germ Layers. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Oil of Turpentine destroys anthrax spores in five days, but failed to do so in one day (Koch). Turpentine has no action upon the virus of symptomatic anthrax (Ar- loing, Cornevin, and Thomas). Koch has shown that the development of anthrax spores is retarded by 1 to 75,000. Oleic Acid.-A solution of five per cent, in ether does not destroy anthrax spores in five days (Koch). Osmic Acid.-A solution of one per cent, destroys an- thrax spores in one day (Koch). • No report with refer- ence to weaker solutions. Oxalic Acid.-This acid in saturated solution destroys the virulence of the fresh virus of symptomatic anthrax, but has no effect upon dried virus (Arloing, Cornevin, and Thomas). Abbott reports that this acid in five per cent, solution failed, in two hours, to destroy anthrax spores. But the spores of B. subtilis were killed by a one per cent, solution, and the organisms in broken-down beef-tea by 1.5 per cent. Micrococci resisted exposure for two hours to 1 to 1,000, but were destroyed by 1 to 400. Oxygen.-The experiments of Pasteur upon the attenu- ation of virus show that long exposure to the oxygen of the atmosphere reduces the reproductive activity of the micrococcus of fowl-cholera and of the anthrax bacil- lus, and that, after a time, the vitality of these organ- isms is destroyed. The spores of the anthrax bacillus are, however, unaffected by prolonged exposure. Paul Bert has shown that oxygen under pressure is fatal to bac- teria. Ozone.-The experiments of Chappius show that atmos- pheric organisms, collected upon a cotton filter, are de- stroyed by passing through this cotton filter, placed in a tube, a current of ozonized air. Picric Acid.-The bacteria of broken-down beef-tea are destroyed by 1 to 100 (De la Croix). Potash.-In the writer's experiments, caustic potash in the proportion of two per cent, was fatal to the micro- coccus of rabbit septicaemia in one experiment, and failed in a second ; eight per cent, failed to kill a micrococcus from pus, while ten per cent, was successful; ten per cent, failed to destroy the bacteria in broken-down beef- tea, and twenty per cent, was successful. Exposure to the action of a ten per cent, solution for twenty-four hours failed to destroy the tubercle bacillus in fresh spu- tum (Schill and Fischer). Potassium Acetate.-A saturated solution of this salt failed to destroy anthrax spores in ten days (Koch). Potassium Arsenite (Fowler's solution of).-In the writ- er's experiments this solution, in the proportion of forty per cent., failed to destroy micrococci from pus. Potassium Bichromate.-A five per cent, solution failed in two days to destroy anthrax spores (Koch). Potassium Bromide is without germicidal power. Potassium Chlorate has no germicidal power. In the writer's experiments a four per cent, solution failed to de- stroy the micrococcus of rabbit septicaemia. A five per cent, solution failed in six days to destroy anthrax spores (Koch). Potassium Chromate.-A five per cent, solution was without effect upon anthrax spores immersed in it for two days (Koch). Potassium Iodide.-A solution of five per cent, does not destroy anthrax spores in eighty days (Koch). In the writer's experiments, exposure for two hours to the action of a saturated solution did not prevent the subsequent development of the organisms in broken-down beef- tea. Potassium Nitrate.-A four per cent, solution was found by the writer to be without effect upon the micrococcus of rabbit septicaemia in fresh blood. Potassium Permanganate.-The writer, in experiments with this agent, found that a two per cent, solution was required to destroy AI. Pasteuri in the blood of a rabbit, but that a micrococcus from pus was killed by 1 to 833- time of exposure two hours. This difference depends upon the fact that the permanganate is quickly decom- posed by the large amount of organic material in the blood used in the first experiments, and not upon a differ- ence in resisting power in the two test-organisms. Further experiments showed that, in the absence of or- ganic matter, micrococci are destroyed in two hours by solutions containing 1 to 1,000. Equal parts of a solution of 1 to 250 and of broken-down beef-infusion, proved to be without effect. Anthrax spores were not destroyed by the same solution (1 to 250) in four hours, but in an- other experiment, in which the time was extended to four days, they failed to germinate. The spores of B. subtilis, however, were destroyed in two hours by a solution of 1 to 250. According to Arloing, Cornevin, and Thomas, a five per cent, solution destroys the fresh virus of sympto- matic anthrax, but has no effect upon the dried virus. One per cent, was found by Koch not to destroy anthrax spores in two days, but five per cent, was effective in one day. Quinine.-One per cent., dissolved with muriatic acid, destroys the spores of anthrax in ten days' time (Koch). A ten per cent, solution of sulphate of quinine has no action upon the bacterium of symptomatic anthrax (Ar- loing, Cornevin, and Thomas). The writer has found that in the proportion of 1 to 800 to 1 to 1,000 quinine pre- vents the development of bacilli and micrococci, but its exact germicidal power for organisms of this kind, in the absence of spores, has not been determined. Salicylic Acid.-In the writer's experiments this reagent was dissolved by means of sodium biborate, which, by itself, has no germicidal power. A two per cent, solution was found to destroy a micrococcus from pus and B. termo in active growth ; four per cent, failed to destroy the bac- teria in broken-down beef-infusion. The virus of symp- tomatic anthrax is destroyed by forty-eight hours' expos- ure to a solution of salicylic acid of 1 to 1,000, and by a saturated solution in alcohol (Arloing, Cornevin, and Thomas). Salicylic acid dissolved in oil and in alcohol, in five per cent, solution, does not destroy anthrax spores (Koch) ; 1 to 200 destroys the bacteria of sour milk (Molke) ; 1 to 343 destroys the bacteria in broken-down beef-infusion (De la Croix). Skatol in excess in water has no germicidal action as tested upon anthrax spores (Koch). Soda.-Caustic soda destroys the fresh virus of symp- tomatic anthrax in the proportion of 1 to 5, but has no effect upon dried virus (Arloing, Cornevin, and Thomas). A ten per cent, solution destroys the tubercle bacillus in dried sputum after twenty-four hours' contact (Schill and Fischer). Sodium Biborate.-In the writer's experiments a satu- rated solution was found to have no germicidal power. A twenty per cent, solution does not destroy the virus of symptomatic anthrax, as proved by inoculation experi- ments (Arloing, Cornevin, and Thomas); 1 to 12 failed to kill the bacteria in broken-down beef-infusion (De la Croix). A five per cent, solution failed in fifteen days to destroy the vitality of anthrax spores (Koch). Sodium Chloride.-In the writer's experiments a five per cent, solution failed to destroy the virulence of septi- cseinic blood. A saturated solution failed in forty-eight hours to destroy the virus of symptomatic anthrax (Ar- loing, Cornevin, and Thomas). A saturated solution failed, in forty days, to destroy the vitality of anthrax spores (Koch). A saturated solution failed, in twenty hours, to destroy the tubercle bacillus in fresh sputum (Schill and Fischer). Sodium Hyposidphite.-The writer's experiments show this salt to be without germicidal power. In saturated solution it failed, in two hours' time, to destroy any of the test-organisms. Exposure for forty-eight hours to a fifty per cent, solution does not destroy the virus of sympto- matic anthrax (Arloing, Cornevin, and Thomas). Sodium Sulphite.-The results obtained by the writer correspond with those reported in the case of sodium hy- posulphite, being entirely negative. Stannous Chloride.-Abbott reports that this agent is active in the proportion of one per cent., and failed in 0.8 per cent., the test being the organisms in broken-down beef-infusion, and time of exposure two hours. Sulphuric acid.-In the writer's experiments this acid was found to be fatal to micrococci in the proportion of 1 to 200 ; but a four per cent, solution failed to destroy 326 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Germicides. Germ Layers, the bacteria in broken-down beef-infusion, doubtless on account of the presence of reproductive spores. An eight per cent, solution was, however, found to be effec- tive (strength of acid, 1.480 gramme, H2SO4, in each cubic centimetre). Salmon has found that a solution of 1 to 200 is fatal to the micrococcus of fowl-cholera. A solution of one per cent, failed to destroy anthrax spores in forty days (Koch). Sulphur Dioxide.-Wernich, in 1877, found that the bacteria of putrefaction are not destroyed by the presence of 3.3 volumes of sulphur dioxide in one hundred of air, when exposed upon strips of cotton or woollen goods sat- urated with putrid liquids. But four to seven per cent, was effective in six hours' time. Schotte and Gartner, in 1880, found that strips of thick woollen goods soaked in culture liquids containing the bacteria of putrefaction were not disinfected by exposure in a chamber in which sulphur was burned in the proportion of ninety-two grammes per cubic metre (about six volumes p. c. of SO2). Koch exposed various species of bacilli containing spores in a disinfection chamber for ninety-six hours, the amount of SO2 at the outset of the experiment being 6.13 volumes per cent., and at the end of ninety-six hours 3.3 per cent. The results were entirely negative. The writer has also made numerous experiments which show that this agent is without power for the destruction of spores. Even when liquid SO2 is poured upon the spores of anthrax or of B. subtilis, they germinate freely when transferred to a suitable culture medium. But this agent, especially in the presence of moisture, destroys micrococci and bacilli which do not contain spores. Thus, Koch found that the anthrax bacillus obtained from the spleen of a mouse recently dead, and exposed, while still moist, upon a silk thread, in an atmosphere contain- ing one volume per cent, of SO2, were destroyed in thirty minutes. In one of Koch's experiments the amount of SO2 in the disinfection chamber was, at the outset, 0.84 per cent., and at the end of twenty-four hours 0.55 per cent. An exposure of one hour, in this experiment, de- stroyed anthrax bacilli (still moist) upon silk thread. Four hours' exposure failed to destroy the vitality of Mi- crococcus prodigiosus growing upon potato, but twenty-four hours' exposure was successful. The same result was obtained with the bacteria of blue pus. In experiments with an aqueous solution of SO2, Koch found that five days' immersion in a solution containing 5.718 per cent, by weight was required to destroy the vitality of anthrax spores. A solution containing 11.436 per cent, by weight failed to kill anthrax spores in twenty-four hours, but was successful in forty-eight hours. According to Arloing, Cornevin, and Thomas, sulphur dioxide does not destroy the bacteria of symptomatic anthrax, which contain spores. The writer's experiments show that micrococci are destroyed, even in the absence of moisture, when they are exposed for eighteen hours in a bell-jar contain- ing twenty volumes per cent, of SO2. When the propor- tion was reduced to four volumes per cent, the result was not uniform, the test-organisms-micrococci-were de- stroyed in some cases and in others were not. In ex- periments with an aqueous solution of SO2 the following results were obtained. The presence of 1 to 2,000, by weight, destroyed a micrococcus obtained from the blood of a patient with vaccinal erysipelas, and 1 to 4,000 failed; the same result was obtained with micrococci obtained from a vaccine vesicle, and with another species ob- tained from the blood of a patient having puerperal sep- ticaemia. Sulphuretted Hydrogen.-Bacteria develop readily in the presence of sulphuretted hydrogen (Hamlet). Sulpho-carbolates.-In experiments upon anthrax spores, Koch found that a five per cent, solution of sulpho-car- bolate of zinc was effective in five days, while sulpho-car- bolate of soda failed in five per cent, solution to destroy these spores after ten days' contact. Tartaric Acid.-A twenty per cent, solution was found by Abbott to be effective, in two hours, for the destruc- tion of organisms in broken-down beef-infusion, but the same proportion failed with anthrax spores and with those of B. subtilis. Micrococci did not multiply in culture- solutions, after exposure to 0.25 per cent., but one-half this amount (1 to 800) failed. Tannic Acid.-The writer found, in his experiments, that a solution of one per cent, in half an hour is fatal to M. Pasteuri in the blood of a rabbit. A twenty per cent, solution has no effect upon the virus of symptomatic an- thrax (Arloing, Cornevin, and Thomas). A five per cent, solution failed in ten days to destroy anthrax spores (Koch). A twenty per cent, solution failed in two hours to destroy the spores of B. anthracis or of B. subtilis, but was effective upon the organisms in broken-down beef- tea. Micrococci are destroyed by 1 to 400, while 1 to 800 failed (Abbott). Ihymol.-An alcoholic solution of 1 to 400 was found by the writer to destroy M. Pasteuri in fresh blood. One part in twenty is fatal to the bacteria in broken-down beef-infusion (De la Croix). A five per cent, solution in alcohol does not destroy anthrax spores in fifteen days, but the development of these spores is retarded by a solu- tion of 1 to 80,000 (Koch). Valerianic Acid.-A five per cent, solution in ether failed in five days to destroy anthrax spores (Koch). Zinc Chloride. In the writer's experiments, M. Pas- teuri failed to develop after exposure for two hours to 1 to 200, while a micrococcus obtained from gonorrhoeal pus required for its destruction a solution of two percent. The spores of B. anthracis are not destroyed by two hours' exposure in a ten per cent, solution. A five per cent, solution was, however, found to be effective in the same time in the case of B. subtilis spores, and upon the organ- isms in putrid beef-peptone solution. Koch's experiments are in accord with the above, in showing the superior resisting power of anthrax spores. He found that after being immersed in a five per cent, solution for thirty days, these spores still germinated freely. The develop- ment of M. prodigiosus was found by the same author to be only slightly retarded by exposure for more than six- teen hours to the action of a one per cent, solution. Zinc Sulphate.-In the writer's first experiments with this agent, a solution of twenty per cent, failed in two hours to destroy micrococci obtained from the pus of an acute abscess. In later experiments a micrococcus from the same source resisted exposure for the same time to a ten per cent, solution, while M. tetragonus was destroyed by a 1 to 10 solution. Broken-down beef-infusion, mixed with an equal quantity of a forty per cent, solution, was not sterilized after two hours' contact. In Koch's ex- periments anthrax spores were found to germinate after having been immersed for ten days in a five per cent, so- lution. Bibliography. Abbott: The Medical News, Phila., vol. xlviii., p. 33. Arloing, Cornevin, and Thomas: Compt. rend. Soc. de Biol., Par., 1883, 7 iv., 121-128. Chappius: Bull. Soc. Chim., xxxv., 390. De la Croix : Arch, f, exper. Path. u. Pharmakoi, Leipz., 1880-81, xiii., 175-225. Davaine: Compt. rend. Acad, des Sc., October, 1873. Duggan : The Medical News, Phila., vol. xlvi., p. 147. Fischer and Proskauer : Mitth. a. d. k. Gesundheitsamte, Berlin, 1884, Bd. ii., 228-308. Hamlet: Jour. Chern. Soc., London. 1881. xxxix., 326-331. Klein : Fourteenth An. Rep. of the Local Government Board, London, 1885, p. 188-191. Koch : Mittheilungen aus dem Kaiserlichen Gesundheitsamte, Berlin, 1881, Bd. i„ 234-282. Schill and Fischer : Mittheilungen aus dem Kaiserlichen Gesundheit- samte, Berlin, 1884, Bd. ii., 131-146. Sternberg: Studies from Biolog. Lab., Johns Hopkins University, Balt., 1882, vol. ii., No. 2, 201-212. Am. Jour, of the Med. Sciences, Phila., April, 1883. Rei>ort of Com. on Disinfectants of Am. Public Health Association, Balt., 1885. George M. Sternberg. GERM LAYERS. It has long been known that the bodies of embryos consist of distinct layers, which in many cases are separable from one another, so as to be recognized in gross as discrete membranes. It is now known that all such layers may be reduced to three primi- tive ones, named the ectoderm, mesoderm, and entoderm (by certain writers epiblast, mesoblast, and hypoblast). The ectoderm is a layer of epithelium ; so also is the en- toderm ; the mesoderm is more complex. In the lower 327 Germ Layers. Ginger, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. animals, the mesoderm is less developed than in the higher forms ; in the hydroids the body is constituted mainly by the two epithelial layers, the ectoderm cover- ing the outside of the body, and the entoderm lining the digestive cavity ; there is very little space between them, the space being occupied by the slightly developed meso- derm. As we ascend the scale the mesoderm increases gradually, constantly acquiring a greater predominance, until in mammals nearly the whole bulk consists of meso- derm. But, in spite of this change, the three layers are preserved throughout, and their essential relations are not altered, so that we are able to assert the unity of organ- ization throughout the whole series of multicellular ani- mals, without which it would be impossible to accept the doctrine of evolution. The demonstration, therefore, of the homologies of the germ layers is the most important morphological generalization since the establishment of the cell-doctrine. As we have already discussed these homologies under Gastrula, and also the metamorphoses of the layers under Foetus, it only remains for us to re- view, with precision and brevity, the role of the layers in the construction of the human body. The ectoderm covers the external surface of the body, and persists in adult life as the stratified epithelium (epi- dermis) of the skin ; it forms, of course, all the so-called epidermal structures-hairs, nails, sebaceous and sweat- glands, lens, cornea, etc. It also lines part of the buccal cavity ; and the buccal portion gives rise to the hypophy- sis cerebri, to the enamel organs of teeth, and probably to all the salivary glands. It forms a small invagination to meet the rectum, so that it also lines the anus. It gives rise to the entire nervous system by producing the me- dullary canal, which makes the central nervous system, and from which grow out all the nerves, and probably all the peripheral ganglia, and from which also grows out the evagination which makes the optic nerve, the retina, the choroid, and the epithelial portions of the iris. It forms the epithelium of the olfactory and nasal cavities, and the epithelium of the auditory labyrinth. According to His, the thymus gland first arises from the ecto- derm. The entoderm forms the epithelium which lines the di- gestive tract, including the surface of the tongue; also the epithelium of the trachea and lungs, and of all the glands appended to the respiratory passages, and to the digestive tract, including the thyroid, pancreas, and liver. The liver-cells, it should be remembered, constitute a true though much modified epithelium. The notochord is developed from the entoderm. The mesoderm may be conveniently divided into three portions-the mesenchyma, the mesamoeboids, and the mesothelium (cf. Foetus). 1. The mesenchyma produces all the connective tissues of the body, and includes therefore the cutis, the non-epithelial walls of the alimentary tract, etc.; tendons, cartilage, and bone, the marrow of bones, lymph-glands, and spleen; it produces also the blood- vessels and blood, the entire lymphatic system proper, and the heart. Probably the fat-cells and smooth mus- cles are derived from the mesenchyma also. 2. The mesamoeboids include the leucocytes and wandering cells, and perhaps the embryonic red blood-cells, and the mar- row-cells. 3. The mesothelium is the epithelium of the coelom ; it produces the peritoneal and pleural epithelia, the striated muscles (myotomes), except those of the heart, and all the non-mesenchymal tissues of the entire uro- genital apparatus, except, of course, the external genitalia. (Spee traces the Wolffian duct to the ectoderm.) Now, in classifying organs, it is best to rank them as belonging to that layer from which their functionally essential and characteristic part is derived. Thus, al- though the pancreas, ovary, and spinal cord all contain connective tissue, we do not call them mesodermal, but respectively entodermal, mesothelial, and ectodermal. The gland-cells of the pancreas come from the ento- derm ; the ova and the Graafian follicles come from the mesothelium ; the ganglion cells and nerve-fibres (axis cylinders) from the ectoderm. Adopting this princi- ple, we may classify the organs of the human body as follows : Ectodermal. Skin (epidermis). Epidermal structures: Hairs, Nails. Glands : Sebaceous, Sudorific, (Salivary ?), (Thymus ?). Corneal epithelium, Lens of eye. Centralnervoussystem: Nerves, Ganglia. Eye, optic vesicle: Optic nerve, Retina, etc. Olfactory organ. Auditory organ. Lining of mouth : Teeth, Hypophysis. Anus. Chorion : Placenta. Amnion: (Wolftian duct ?). Mesodermal. 1. Mesenchyma: Connective tissue: Cutis, etc., Tendons, Cartilage, Bone, Marrow. Lymph-glands, Spleen, Blood-vessels : blood (in part). Lymphatic system, (Fat cells ?), (Smooth muscle ?). 2. Mesamoeboids: Leucocytes, Embryonic red blood cells, (Marrow-cells ?). 3. Mesothelium: Peritoneum, Pleurae. Urogenitals: Wolftian body, Kidney, Testis, Ovary, Oviduct : Uterus, Vagina. Striated muscles. Entodermal. Epithelium (of diges- tive tract): Thyroid, Trachea and lungs, (Esophagus, Stomach, Liver, Pancreas, Intestine, Yolk sac, Coeeum, Vermix, Colon, Rectum, Allantois : (Bladder). Notochord. The human body may be defined as two tubes of epithe- lium, one inside the other ; the outer tube, epidermal or ectodermal, is very irregular in its form ; the inner tube, entodermal, is much smaller in diameter, but much longer than the outer, and has a number of branches (lung, pancreas, etc.), and is placed within the ectodermal tube. Between these two tubes is the very bulky meso- derm, which is divided by large cavities (abdominal and thoracic) into two main layers, one of which is closely as- sociated with the epidermis and forms the body wall, the somatopleure of embryologists ; the other joins with the entoderm to complete the walls of the splanchnic viscera, and constitute the splanchnopleure of embryologists. The mesoderm is permeated by two sets of cavities: 1, the heart and blood-vessels ; 2, the lymphatic system. It is also differentiated into numerous tissues, muscle, ten- don, bone, etc., and organs, urogenital system. The nervous system, although developed from the ectoderm, is found separated from its site of origin, and completely encased in mesoderm. As we ascend the animal scale, we discover in all parts an increasing complexity ; especially in the nervous sys- tem is this marked, but it is even more strikingly shown by the evolution of the mesoderm in relative size and dif- ferentiation. This important correspondence between the organization of the mesoderm and the degree of evo- lution of animals has not, to my knowledge, hitherto attracted express attention. Charles Sedgwick Minot. GETTYSBURG SPRINGS. Location and Post-office, Gettysburg, Adams County, Pa. Access.-By the Northern Central Railroad, from Baltimore to Hanover Junction, forty-six miles ; thence by Hanover Junction and Gettysburg Railroad, thirty miles, to Gettysburg ; thence by horse-car or omnibus to the spring. Therapeutic Properties.-This is a calcic water of very superior composition. It is deservedly popular as a remedy for many forms of indigestion, catarrhal diseases of the urinary and respiratory apparatus, and those sec- ondary affections, rheumatism and gout. This spring is situated in a little valley a few miles west of Gettysburg. It flows from a red shale underlaid by the blue. The shale is arrested about two miles east- ward by granite formation, where the country presents a more rugged and picturesque scenery. The Catoctin and South Mountains are within view. In the vicinity of the spring the battle of Gettysburg began. The curative quality of this water was a matter of tradition in the vicinity; but it was not until after the war that it was brought before the public. The water is bottled and ex- tensively sold throughout the country. It is not aerated, but has the property of remaining pure, even when ex- posed to the air for a long time. Hotel accommodations 328 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Germ Layers. Ginger. are amply supplied by the Gettysburg Hotel, erected a few years after the war. Analysis (Professor F. A. Genth).-One pint contains : The springs contain a considerable amount of carbon- ates, particularly sodium carbonate. The principal springs have received the names King Otto, Elizabeth, Franz- Josef, and Loeschner. The analysis of the first three of these is, in one pint: Grains. Bicarbonate of soda 0.70457 Bicarbonate of lime 16.40815 Bicarbonate of magnesia 0.54960 Bicarbonate of iron 0.03585 Bicarbonate of manganese 0.C0669 Bicarbonate of nickel trace. Bicarbonate of cobalt trace. Bicarbonate of copper 0.00050 Chloride of sodium 0.65790 Chloride of lithium trace. Sulphate of baryta trace. Sulphate of strontia 0.00427 Sulphate of lime 0.83145 Sulphate of magnesia 6.77940 Sulphate of potash 0.20836 Sulphate of soda 2.46776 Borate of magnesia , 0.03492 Phosphate of lime 0.00679 Fluoride of calcium 0.00954 Alumina 0.00380 Silicic acid 2.03078 Organic matter, with trace of nitric acid, etc 0.70870 Impurities suspended in water 1.10069 King Otto. Elizabeth. Franz-Josef. Grains. Grains. Grains. Sodium carbonate 9.144 8.263 6.087 Potassium chloride 230 161 983 Potassium sulphate 253 221 353 Calcium carbonate 2 634 1 720 1 866 Magnesium " 1 635 1 02!) 1 296 Ferrous " 023 053 023 Lithium " 076 003 .0007 Strontium " 015 Silicic earth 452 .345 522 Argilaceous earth 015 115 Organic matter .007 007 015 Additional solids .633 8.304 .203 Total 15.398 20.106 11.463 Free carbonic acid (cub. in.) 34.859 27.207 30.297 The waters from these springs are largely exported, but they are also consumed at the springs and used for bath- ing. They are taken pure, or with milk or whey. They are recommended chiefly in affections accompanied by an abnormal production of acids in the organism, as in cer- tain forms of dyspepsia, with acid eructations, in uric- acid poisoning of the blood, and in chronic catarrhs, par- ticularly of the respiratory and urinary organs. It has also been used with apparent benefit in strumous troubles and rickets of children. J. Jf. F. Total 1 32.54272 George B. Fowler. GEYSERS. THE. iMcation and Post-office, Geyser Springs, Sonoma County, Cal. Access.-By the San Francisco & Northern Pacific Railroad to Cloverdale, eighty-four miles; thence by stage to springs, twelve miles. There has apparently been no systematic analysis made of any of the numerous and remarkable springs, about one hundred in number, constituting this group. They are situated along Geyser Canon, which is about half a mile long, and from one to two rods wide at the bottom, with steep sides fourteen hundred feet high, on the Little Pluton River. Near the hotel is a spring containing iron, sulphur, and soda; temperature, 73° F. The first spring in the canon is the Alum and Iron Spring ; temperature, 97° F. Near by is the Medicated Geyser Bath (temperature, 88° F.), containing ammonia, epsom salts, magnesia, sul- phur, iron, etc. Then follow in order the Boiling Alum and Sulphur, with a temperature of 156° F.; the Black Sul- phur, with same temperature; Epsom Salt, 146° F.; Boiling- Black Sulphur ; The Witches' Caldron, seven feet in di- ameter, and of unknown depth, the contents, sometimes thrown up two or three feet, semi-liquid and blacker than ink (temperature, 195° F.); Boiling Alum, 176° F., some- times throwing jets of scalding water fifteen feet into the air; the Steamboat Geyser, resembling a high-pressure steamboat blowing off steam. Near this point the canon divides; up the left or western side are many hot springs, the most important being the scalding steam Iron Bath, with a temperature of 183° F. After passing over the " Mountain of Fire," with its numerous bubbling and smoking orifices, we come to Alkali Lake, and numerous other boiling springs. One is a white sulphur spring, clear and steaming. Then there is the Boiling Eye-water, said to be a remedy for weak and inflamed eyes. * Further down is Indian Spring, a chalybeate water of inky black- ness. The aborigines are said to have brought their sick to this spring to be cured. Near the hotel is Acid Spring, the water of which, when sweetened, makes a palatable lemonade. By enclosing the hot steaming springs, and conveying the steam through pipes, hot vapor-baths have been con- structed, and near by there is a plunge made by damming a mountain stream. The hotel accommodations are good. George B. Fowler. GILROY HOT MINERAL SPRINGS. Location and Post-office, Gilroy Hot Springs, Santa Clara County, Cal. Access.-By the Southern Pacific Railroad (Northern Division) to Gilroy, eighty miles ; thence to springs by stage, fourteen miles. Analysis.-No quantitative analysis is published. The water of the main spring is said to contain sulphur, alum, magnesia, iron, iodine, and traces of arsenic. The temperature is 100° to 150° F. There are numerous other hot springs, and a mud bath. Near by are two cold sul- phur springs, and six miles away is a natural " soda spring," whose waters effervesce and sparkle. Therapeutical Properties.-These have long been popular waters among the inhabitants of the Pacific coast as remedial In rheumatic and skin affections ; and their efficacy is strengthened by the invigorating effects of the mountainous location. The main hotel, a large annex, and nineteen cottages, renovated and refurnished in 1884, have accommodations for over two hundred guests. Facilities for bathing are complete for both sexes. Attractive grounds, and nu- merous delightful walks and drives among spruce and pine groves, afford entertainment and recreation for the guests. G. B. F. GILSLAND SPA. A health-resort and watering-place situated in the northern portion of England. Its situa- tion is well suited to a resort, both in regard to climate and in regard to the healthfulness of the vicinity. The mineral spring possesses no especially curative properties, being classed as a sulphur spring very deficient in salts. The resort is patronized especially by the middle class of English people. J. M. F. GINGER (Zingiber, U. S. Ph., Br. Ph.; Rhizoma Zin- giberis, Ph. G.; Gingembre, Codex Med.). The rhizome of Zingiber officinale Roscoe; order, Scitaminece (Zingi- beraceri). This plant belongs to a remarkable order of tropical perennial herbs with horizontal, fleshy, often lobed and branched rhizomes, more or less developed up- right stems, with two-ranked, alternate, parallel-nerved, sheathing leaves, and, theoretically, trimerous, irregular flowers in various clusters. These consist of a normally three-parted calyx, a three-parted, slightly irregular co- rolla, an andnecum normally of six elements in two GIESSHUBL-PUCHSTEIN. A village of Bohemia, an hour's ride from Carlsbad, noted for its pure alkaline mineral springs. Although situated in a mountainous district, the climate is mild, the air fresh, but not subject to disturbing winds. The mornings and evenings are usually cool, even in midsummer. 329 Ginger. Glanders. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rows ; the two upper stammodes of the outer row, and the two lower of the inner, are slightly developed or petaloid, sterile filaments ; the lower one of the outer row is dilated into a large, showy, spreading labium, the principal feat- ure of the flower ; the upper and inner one is the only normal antheriferous stamen. Fruit a one-celled capsule; placentae three. The ginger plant has a1 tall (one metre or more) sterile stem, partly made up of the very long leaf-sheaths, and a low, scaly, flowering one. Flowers greenish-yellow, variously spotted and striped with violet. It is probably a native of Southern Asia, but is not known wild, having been cultivated for many hundred years. It has also been transplanted to tropical Africa and the West Indies, be- sides many other places, where it is extensively cultivated. It has been used as a spice, even in Europe, almost since the begin- ning of this era, imported from the East by the way of the Red Sea. The plant was carried to the West Indies soon after the discovery of the New World, and a few years later ginger was exported from St. Domingo back to Europe. The finest flavored ginger in the world is now grown in these islands. Description. - Gin- ger is either coated, that is, simply washed and dried without removing the cuticle, or elsescraped when the outer surface is peeled or scraped away. It is in pieces technically called " hands," "about three-fifths of an inch broad, flatfish on one side, lobed or clavately branched ; deprived of the corky layer (peeled ginger), pale buff-col- ored, striate, breaking with a mealy, rather fibrous fracture, showing numerous small, scat- tered resin-cells and fibro- vascular bundles, the lat- ter enclosed by a nucleus- sheath ; agreeably aro- matic, and of a pungent, warm taste." When gin- ger is not peeled it has a grayish or brownish wrinkled surface. Infe- rior and dark-colored grades are sometimes bleached with sulphur, chlorinated lime, etc., or are even " whitewashed " with chalk and water, or some such mixture, to give them a whiter and more salable appearance. The best ginger is coated or unscraped " Jamaica," but the scraped lots are more common. The principal varieties in the order of their estimation are Jamaica, Cochin, and African. Composition.-Ginger contains a pale yellow volatile oil to the extent of about one or two per cent., having its odor and taste without its pungency. The remaining con- stituents are a composite resin, consisting, according to Thresh, of a neutral resin and two others, which he has named a. and 3 resins, besides the real source of its pun- gency, gingerol, which he has not obtained in a state of complete purity. Starch, fat, gum, and various amor- phous and uninteresting substances make up the rest. The oil and resins are contained in cells resembling those of the parenchyma, and irregularly scattered among them. The ethereal extract {Oleoresina Zingiberis, U. S. Ph.) is composed of these resins in combination with the essen- tial oil, fat, etc. Action and Use.-Ginger is a spice more aromatic and less pungent than pepper, and, like others of its class, in suitable doses is gently stimulating to the stomach and intestines, and in its way a carminative tonic. In large doses it is irritating; locally applied to the skin it is rube- facient to a less degree than mustard, and useful where a mild counter-irritation is desired. It is used in colics, atonic dyspepsia, flatu- lence, etc., and is a fa- vorite flavor for cakes, drinks, and preserves. Administration.-In powder the dose may be taken as from half a gram to one gram, usually mixed with other aroma- tics. An infusion, under the name of " Ginger tea," is a favorite prepa- ration in the country. A fluid extract is officinal (Extractum Zingiberis Fluidum, U. S. Ph.), but not much used. The tincture (Tinctura Zingi- beris, U. S. Ph.) is in universal employment ; its strength in this coun- try is twenty per cent. The oleoresin or ethereal extract (Oleoresina Zingi- beris, U. S. Ph.) is a very concentrated form suita- ble to add to pills and boluses. Dose, a deci- gram or so. Allied Plants. - There are about twenty species of Zingiber, sev- eral of which are culti- vated for similar prod- ucts (Z. Zerrumbet Ros- coe, Z. Cassumunar Rox, etc.). The order Scita- minece, including Zingi- beracea and Marantacece, is characterized by the de- velopment of the stamens described above. It con- tains a number of aroma- tic members, but few of which have any Europe- an or Western interest; the following list compri- ses the most interesting: Curcuma longa Linn., Turmeric. Curcuma Zedoaria Ros- coe, Zedoary. Zingiber officinale Roscoe, Ginger. Elettaria cardamomum White et Maton, Cardamom. Amomum Melegueta Roscoe, Grains of Paradise. Alpinia officinarum Hance, Galangal, etc. Maranta arundinacea Linn., Arrowroot. Canna arundinacea, Tow les mois (starch). The relations of Ginger to Calamus are much more re- mote, but their rhizomes have points of resemblance in composition and properties. Allied Drugs.-See Pepper, Black. W. P. Bolles. GLANDERS. A disease found most often in the horse, communicable to man, and manifesting itself by the for- mation of nodules and ulceration, principally in the mu- Fig. 1389.-Ginger Plant about One-third Natural Size. (Baillon.) 330 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ginger. Glanders. cous membrane of the nares, and caused by a specific pathogenic organism. From the fact that the disease ap- pears under two tolerably distinct forms, as it affects the mucous membrane or the skin, each of these has been given a separate name in most languages, and this has caused much confusion. In German the name Rotz is used to designate the typical disease affecting the nares, and Wurm for the skin affection ; in French, num, morte farcineuae, and farcin ; in English, glanders and farcy. Recently the name equinia (equinus, belonging to a horse) has been given it, but, as it seems to us, with no good reason, since the disease is not the only one communicable from the horse to man, and is found in other domestic animals. This name is also in nowise descriptive of the disease, while the name glanders refers to the glandular swelling which is nearly always present. The disease comes, with tuberculosis, syphilis, lupus, etc., under the general head of granulation tumors, and is infectious. It presents many features closely resem- bling both tuberculosis and syphilis, and it has been con- founded with these diseases, many veterinarians regard- ing it as an acute tuberculosis in the horse. For a long time before the communicability of glanders to man was aspiration of the products of ulceration, infection of the trachea, bronchi, and lungs follows. At a very early period the virus is carried along the lymphatics to the sub- maxillary glands, and these become enormously swollen. Like tuberculosis and syphilis, glanders may appear as well-marked nodules, or as a more diffuse infiltration of the tissues. The formation of the nodules is best studied on the mucous membrane of the nares after artificial in- oculation. There first appear an intense swelling and hyperaemia of the mucous membrane, and soon small yellowish-white nodules will be seen projecting from the red and inflamed tissue. These are the characteristic nodules of the disease (Rotz-Knoten), and on microscopic examination they will be found to consist of collections of granulation-cells very similar to the cells of other granulation-tumors. Virchow has pointed out a distinc- tion between the glanders nodule and the tubercle ; in glanders the cells being larger than the tubercle-cells, and more like pus-corpuscles. Giant cells may be found in these nodules, but they do not play so prominent a part here as they do in tubercles. After the nodules have reached a certain size, necrosis takes place in the centre, and the nodule, which was at first grayish-white, becomes Fig. 1390.-Mucous Membrane of the Nares in Glanders. Ulcers and numerous nodules are seen. The blood-vessels beneath the mucous membrane are unduly prominent. (From Virchow.) recognized, it had acquired a certain interest in its bear- ing on human pathology, from the circumstance that Van Helmont sought to refer its origin to syphilis, a view which was much later adopted by Ricord. Virchow has shown that this idea most probably arose from the sup- position that both diseases first appeared during the siege of Naples, toward the end of the fifteenth century. Gland- ers was, however, known and described in the fourth century under the name of naXis and malleus, by Apsys- tus, a veterinary surgeon in the army of Constantine. That it has no relation to syphilis is shown, not only from a careful comparison of the course of the two diseases, but also from the fact that syphilis is not communicable to any of the lower animals. It will be necessary to give some general description of the disease as it appears in the horse, because here its various features are more typical, and can be better studied than in man. In horses, glanders is usually pri- marily located in the nose. From this primary seat other organs are affected, the disease spreading both by con- tact of adjoining parts with the secretions of the nose which contain tlie virus, and by the conveyance of the virus to distant organs by means of the blood and lymph-vessels. In its advance it shows great similarity to tuberculosis. After the nares the mucous membrane of the pharynx becomes next affected, and from here, by more yellow. As a rule, these nodules do not attain a much larger size than tubercles, but when the disease takes a chronic form they may reach the size of a filbert or walnut. Along with the central necrosis, a breaking down of the nodule and the tissue immediately around it takes place, with the formation of an ulcer. The ulcers increase in size by the continuous formation of nodules at the edges and base, and the necrosis and breaking down of these and the intervening tissue. I The virus seems to exert a more irritating effect on the adjacent tissues than does the tubercular virus, and along with the formation of the nodules there is always an intense hyperaemia and small-cell infiltration. The edges of the ulcer are ele- vated above the mucous membrane, they are hard, in- durated, and contain great numbers of the small nodules (Fig. 1390). The infiltration of the tissue frequently proceeds along the lymphatics and results in the forma- tion of cord-like prolongations, which radiate from the ulcer ; in these hard cor3s the yellowish nodules may be seen. At any point these may break down, resulting in the formation of other ulcers which enlarge, and soon come in contact with one another, and in this way the most ex- tensive losses of substance are produced. By the deepen- ing of these ulcers extensive destruction of the cartilages and bones is brought about. In consequence of the hy- peraemia and serous infiltration of the tissue, the dis- 331 Glanders. Glanders. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. charge from the nares is not a thick creamy pus, but a thin glairy fluid, which, from decomposition, soon be- comes extremely fetid. In the more chronic forms this tendency to breaking down and ulceration is not so pro- nounced, and in consequence the nodules attain a much larger size. (The disease may appear in the nose under another form. The purely inflammatory changes which accom- pany the nodular formations may be so pronounced that the nodules play only a secondary role.) Patches of the mucous membrane, varying in size, become livid, swollen, and infiltrated with a gelatinous tissue. Large masses of this swollen tissue become necrotic, and a dirty, grayish slough forms, which is difficult to remove, and presents great similarity to the diphtheritic membrane. The ne- crotic tissue is finally cast off, leaving a large ulcerated surface, which can be easily distinguished from the ulcers caused by the breaking down of the nodules. Even in these cases a careful search will generally reveal some nodules scattered along the edges of the ulcer. Any of these ulcers may heal, leaving behind them hard, dense, radiating cicatrices, which involve much more than the ulcerated area, because the small-cell infiltration, which is also changed into cicatrix, extend- ed so far beyond this. These cica- trices are very similar to those which form after syphilitic ulceration. In the other mucous membranes that are in- vaded, the disease follows about the same course ; there is either a formation of nodules with subse- quent breaking down, or a diffuse infiltra- tion. 4 In the lungs the disease shows itself by the formation of nodules and an extensive infiltration of the lung-tissue around these. The nodules vary in size, and in their his- tological structure greatly resemble tuber- cles. They are produced by an extensive cellular infiltration of the alveolar septa and an exudation in the alveoli J In con- sequence of the changing of the small cells into connective tissue, the nodules can become dense and fibrous like the fi- brous tubercle. In a more acute form of the disease the exudation in the alveoli forms the chief part in the process. The surrounding lung-tissue is infiltrated with a semi-fluid, gelatinous tis- sue, and is solidified. Very often the specific nodule and the inflammatory changes fade so into one another that they cannot be separated. These nodules may break- down and thus cavities in the lung be formed. In some cases nodules are formed in the liver, spleen, kidneys, and testicle. Colin has described one case in which perfectly characteristic nodules were found in the vagina of a mare along with extensive disease of the nose, larynx, and lung. The skin affection in glanders pursues a more chronic course. There is first an infiltration of the subcutaneous tissue of the neck or breast, forming a large diffuse swell- ing. The centre softens, and on spontaneous rupture, or on being opened, a yellowish stinking pus is discharged. These abscesses may be as large as a pigeon's egg or a walnut. They do not always rupture ; the contents may be absorbed and the nodule disappear at one place, and a similar swelling appear at some more remote part, which has given rise to the name " flying farcy." The disease has a tendency to spread along the lymphatics of the skin, and in this way tortuous swellings are formed which may ulcerate at any point, and form long, irregular, sin- uous ulcers. Rabi has studied closely the different forms of these skin affections. He divides them into four groups : first, the affection of the papillary body and the epidermis ; second, affections of the reticular stratum of the cutis ; third, affections of the subcutis ; fourth, affec- tions of tbe lymphatics. The first forms small grayish patches with papillary nodules seated on them ; by ulceration with accompany- ing necrosis and formation of granulation tissue, small circular, lenticular ulcers are formed. All of these ulcers are shallow-some, indeed, represent simple excoriations -and all are formed by the epidermis and papillae. The changes in the second group are either circumscribed or diffuse. In the circumscribed affection there is necrosis, ulceration, and, in places, circumscribed new formations of connective tissue. The diffuse form consists in general of hyperplasia of the connective tissue with thickening of the cutis, and produces the condition known as glanders ele- phantiasis. In the third form, the affection of the subcutis, the changes may be also circumscribed or diffuse; there may be nodules formed in the connective tissue which lead to gangrenous ulcers, or there may be infiltration of the tissue with a gelatinous material and extensive phlegmonous sup- puration, or an elephantiasis. In the fourth form, Rabi thinks that most of the boils that arise are due to a cir- cumscribed perilymphangitis. The interior of these boils is necrotic and suppurative, and the exterior formative. Fig. 1391.-Very Small Nodule in the Lung of a Mouse, after Artificial Inoculation. X 90. Wherever the glanders may be located, whether in mucous membranes or skin, there is always a great ten- dency to attack both the lymph- and the blood-vessels, giving rise to the formation of thrombi, and a periphle- bitis and perilymphangitis. J These vascular changes play such an important part that Valel has designated the whole process as an acute periphlebitis. The lymph- glands become affected at a very early stage, and enor- mously swollen. Those in the submaxillary region are especially prominent. This swelling of the lymph-glands has given the disease its name. The swelling is due to an intense hyperaemia and hyperplasia of the lymphatic elements. Caseation and softening may take place with the formation of extensive abscesses. Unlike tuberculo- sis, glanders does not form distinct nodular formations in the glands. The similarity between glanders and tuberculosis is also evident in the literature of the two diseases. In both the infectiousness has been alternately affirmed and de- nied. One set of experiments would seem to prove in- fectiousness, but another investigator would repeat them 332 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glanders. Glanders. and get contrary results. In both diseases exact methods of experimentation have settled the matter beyond dis- pute. The result of the numerous experiments shows that glanders is communicated from animal to animal, from animal to man, and from man to animals. Among animals there is a great difference in susceptibility to the disease. Rabbits have generally been used in inoculation experiments, but their inoculation is not so apt to be suc- cessful as when horses, guinea-pigs, or young dogs are used. Molkentin (in whose article, " Ein Beitrag zur Sicherstellung der Diagnose des occulten Rotzes," the whole literature on inoculation can be found) affirms that young dogs have a greater susceptibility than any other animals. In the inoculations the nasal secretions, the sputum, scrapings from ulcers, and blood have been used. It is interesting that inoculations with blood have only been successful when large quantites-one to two pounds-have been used. This is evidently due to the fact that the virus is contained in the blood in very small quan- tity, so that there might not be any present in a com- paratively large amount of blood. The inoculations are most successful when they are made in the mucous mem- brane of the nose. The typical nodules are formed around the point of inoculation, and the disease takes a very rapid course. When injections are made into the sub- cutaneous cellular tissue, an abscess and ulcer will follow, which may heal, and then after sev- eral weeks the ani- mal may die with affections of the lungs and nares. Viborg, in 1797, made an extensive series of inocula- tions with various products from a glandered horse, and succeeded in causing the disease. Schilling, to whom belongs the credit of the first descrip- tion of glanders in the human subject, inoculated two rab- bits with the nasal secretions of an in- fected man, with positive results. Although the re- sult of the frequent inoculations proves conclusively that the disease is infectious, the success of an inoculation is largely a question of individual susceptibility in the ani- mal used. Lamirault placed 138 healthy horses among a number of glandered, all being kept under precisely the same conditions, and out of the 138 only 39 became in- fected. (Glanders never develops spontaneously. In every case a careful search will reveal some source of infection. It has long been suspected that it is due to some specific living virus, and various observers have described numer- ous organisms, micrococci, etc., in the nasal secretions. Drs. Loftier and Schultz, working in the German health office, have discovered characteristic bacilli both in the secretions from the ulcers and in the nodules, which are of the same size as, and have nearly the appearance of, tubercle bacilli. They are found in preparations which have been stained in methylen blue and then treated with dilute acetic acid. In order to be certain that these bacilli were the only etiological factor in the disease, pure cult- ures of the organisms were made on sterilized blood serum. These cultures were carried through four gen- erations, and from the fourth culture, which certainly contained nothing but the bacilli, inoculations were made on healthy horses, both in the nasal cavities and in the skin. The most typical glanders was produced in every instance. > Pure cultures of the bacilli were also used to inoculate rabbits, mice, and guinea-pigs. In some of the rabbits the autopsy showed only local ulceration and swelling of the corresponding lymph-glands, in others the autopsy gave the most perfect picture of glanders. The inoculations made on white mice gave negative results, but guinea-pigs proved to be especially susceptible to the disease, f This discovery, which was only made possible by the preceding work of Koch, has been confirmed by numerous other observers, and glanders is now added to the list of diseases in which a specific lower organism is known to be the etiological factor. In view of the high susceptibility of man to the disease, these experiments are not without danger, and one of the most eminent of Ger- man pathologists has lately fallen a victim to his zeal in carrying on. these observations and experiments. Glanders in Man.V-Iu the human subject glanders presents many points of difference from the disease as we have so far traced it. It is remarkable, in spite of the fact that glanders was known so early as the fourth century, and that frequent cases of infection of man must have re- sulted, that it was not until 1822 that the first case in man was described by Schilling.'I Since that time not a year has elapsed without the recording of numerous cases, and now its appearance in man is so well known that a single case does not excite any general attention. The horse is almost the exclusive source of the disease in man, and infection takes place relatively often. This depends on the high susceptibility of man to the virus, and the opportunity for infection to which persons employed in the care of horses are exposed. In 106 cases collected by Bollin- ger the occupations of the subjects show clearly the source of infection. Out of the 106 there were 41 hos- tlers, 11 coachmen, 14 land - owners o r owners of horses, 10 veterinary surgeons, 12 horse butchers, 5 soldiers, 4 surgeons, 3 gardeners, 2 horse dealers, 3 employes of a veterinary school. If further evidence were needed, it is found in the fact that but five per cent, of all cases are women. In 120 cases only six were women, and these were for the most part girls employed in stables where there were glandered horses, or they were wives of hostlers and drivers, the virus being communicated through some intermediate object. Children enjoy great immunity-out of the 120 cases re- ferred to there was but one child, and the father of this was a coachman. The infection generally takes place from wounds on the hands, from the conjunctiva, and from the mucous membrane of the nares and throat. The latter places are infected by contact with the nasal secre- tions of the horse, which are cast a considerable distance in the frequent snorting of the animal. There are a cer- tain number of cases in which it is not possible to trace the place of entry of the virus. It is possible that in these cases the virus may enter the system with the food * Ger- lach has reported a case in which a cat in an anatomical institute became infected from eating the flesh of a horse which had died of the glanders. Semmer has made numerous experiments in feeding animals with flesh and secretions of infected animals, but with negative results in every instance; and Decroix was bold enough and sufficiently imbued with scientific zeal to eat the flesh of a horse which had died of acute glanders, prepared in a number of ways (broiled, fried, and stewed), and Fig. 1393.-An Alveolus of the Lung (same animal as in the preceding figure!, Show- ing the Arrangement of the Bacilli. The cells in the alveolus are not represented, in order to simplify the drawing. J/u hum. immersion X 550. Fig. 1392.-The Bacilli of Glanders ; from scrapings from the liver of a mouse after ar- tificial inoculation, 'A* horn, immersion X '550. 333 Glanders, danders. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seven or eight times ate the raw flesh, without becoming infected. No great weight can be attached to a single ex- periment like that of Decroix, and it is not likely to be repeated. From the fact that in some cases the place of entry of the virus and the mode of infection cannot be made out, many authors have assumed the existence of a volatile virus. Some cases have been known where in- fection has taken place from man to man, presumably from eating from the same vessels, and in one case a whole family, man, wife, and four children, became successively infected, the disease starting in the man. In ail cases the secretions from the ulcers in the nasal cavity contain the bacilli in great abundance, and contact with such secre- tions must be carefully avoided. That classification of the disease in man which is based on its duration and course seems the most advis- able, and is the one which has been generally followed. Tardieu, however, has carried this so far as to make six subdivisions dependent on the duration of the disease. Such a multitude of subdivisions has nothing to recom- mend it, and we shall speak of but two forms, the acute and chronic glanders. The anatomical appearances have some similarity to those found in pyaemia. The nodules are the only char- acteristic lesions. These may be found in the skin, in the subcutaneous connective tissue, in the mucous mem- brane of the respiratory tract, in the submucous tissue, in glands, in muscles, in periosteum, or in the bones; They are single or arranged in groups, are accompanied^by act- ive inflammation, and lead to suppuration and the forma- tion of pustules, which may have some similarity to those of small-pox. In the skin they form in the beginning a firm, hard, yellowish-white mass situated in the corium. A red spot similar to a flea-bite forms over this, and the whole makes a papillary swelling, which finally becomes a pustule. The smaller of these pustules are surrounded by an area of active hyperaemia, and contain a dry, crumbling mass ; the larger are soft, and contain a san- guinolent or puriform fluid, in which, on microscopic examination, pus-corpuscles and large caudate connec- tive-tissue cells are found. These nodules lie immedi- ately beneath the epidermis, or in the corium or subcu- taneous cellular tissue, or all three may be involved. As the pustules become older they are colored a bluish-red from the extravasated blood, and form dark crusts ; when these crusts are removed, an ulcerated surface is seen. The process can be more diffuse and resemble the con- dition found in phlegmonous erysipelas. In such cases there is either an cedematous swelling of certain parts under which larger or smaller purulent foci are found, or a purulent infiltration of the skin and subcutaneous tissue. The latter is most often found on the forehead, the eyelids, or in the neighborhood of the joints. In the mucous membrane of the nose there are nu- merous nodules and ulcers, and a catarrhal inflammation of the entire mucous surface, which gives rise to a bloody muco-purulent secretion. This condition can ex- tend into the antrum, and the frontal and sphenoidal sin- uses. The cavities are found filled with mucus, and when this is removed the mucous membrane is often studded with nodules, which are generally arranged in groups. This condition may extend into the cranium, and an accumulation of pus is often found beneath the dura mater over the orbital plates. The nodules may be found in the dura mater, and the pia in such cases is very hyperaemic, yellow, and cedematous. In the palate, pharynx and larynx, trachea, and bronchi, abundant miliary nodules are found. An extensive sto- matitis may proceed froYn the inflammation of the mu- cous membrane of the nose and pharynx, accompanied by ulcerations on the pendulous palate which can scarcely be distinguished from syphilitic ulcers. Some- times there are abundant large ecchymoses on the mu- cous membrane of the stomach, and a few cases have been reported where nodules were found in this locality In the lungs there are numerous small areas of consoli- dation, which are either confined to a single lobe or scat- tered through the entire lung. They appear to take their origin in the small bronchioles and the lung-tissue imme- diately around these. These areas of consolidation soon soften in the centre, and abscess cavities are formed which may reach the size of a goose's egg. Numerous ecchymo- ses are found in the subpleural tissue, and the pleura it- self may be studded with nodules. The lymphatics over the lung are changed into hard, firm cords, and the lymph-glands belonging to them are swollen and infil- trated. In the muscles there are numerous nodules, which in shape, size, relation to adjacent parts, and course of de- velopment, are very similar to those on the skin. The first step in the formation of these nodules consists in a cloudy swelling of the muscular tissue, and the fibres be- come granular and indistinct. A species of capsule is formed by the infiltrated and thickened perimysium. Nodules of the size of a pea or bean are formed in the perimysium, or abscess-like cavities similar to those in the subcutaneous tissue may be found. These cavities are generally no larger than a pigeon's egg, and consist of firm capsules covered on the inside with cloudy yellow or pale-red granulations, and the cavity is filled with a yel- lowish pus. The abscesses are single, and appear princi- pally in the superficial muscles, being most common in the short head of the biceps. The thickening of the peri- mysium and the other changes mentioned may take place in any of the muscles. They are due to coagulation-ne- crosis, suppuration, productive inflammation, and haem- orrhage. Only connective tissue and blood-vessels take part in the active process ; the destructive and degenera- ative processes attack the connective tissue and blood- vessels as well as the muscular fibres. These foci, which appear in the muscles, often break through the skin, or they may advance in depth until the periosteum or the bone is reached, producing necrosis of the latter. Primary changes in the periosteum may also appear, and affect both the bones of the extremities and the skull. In these cases small, slightly prominent, yel- lowish nodules, either single or in groups, cover the sur- face of the membrane. The periosteum in such places can be easily removed, and the bone beneath it is dry, yellowish, and necrotic. This affection of the periosteum is found most often at the place of insertion of the ten- dons. The synovial cavities often contain an exudation, the lining membrane is congested, and its inner surface covered with the characteristic miliary nodules, and the cartilage may be rough and eroded. The spleen is generally very much enlarged, is red, soft, and contains abscesses. The liver-is enlarged, the cells cloudy and fatty-degenerated. In some cases, nota- bly in one reported by Glaser, it is filled with nodules, some of which are miliary, others of the size of a pea. These are often seated along the gall-ducts, and may pro- duce obstruction from pressure. In the kidney changes similar to those in the liver are met with. There is al- ways cloudy swelling with more or less fatty degenera- tion, and sometimes an abundant eruption of nodules which are most often seated in the cortical substance. Most of the changes which we have described may be- long to both the acute and the chronic form of glanders. In the chronic form the affection of the mucous membranes plays the most important part, and the nodules and ulcer- ation in the nasal cavities are seldom missed. When the disease lasts for a long time and takes a very slow course, some of the ulcerations may heal and leave behind dense, hard, stellate cicatrices with cord-like prolongations run- ning off from them. These chronic affections of the mucous membranes are most apt to be mistaken for syphilitic processes, which they greatly resemble. In the acute forms the changes in the lungs, skin, and paren- chymatous organs are the most prominent, and these may be mistaken for pyaemia. / The first symptoms in acute glanders consist in an in- aefinite feeling of malaise, discomfort, and exhaustion, with pain in the head, and chilly sensations ; very often these symptoms may be combined with vague pains in the muscles and joints. At first there are no pathological changes to account for these rheumatic pains, but later they are explained by the localization of the disease in the skin and muscles. If the virus has entered the sys- 334 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glanders. Glanders. scattered through the lung. ^In some cases there are symptoms of a severe gastro-duodenal catarrh, the patient complains of gastric disturbances, difficulty of digestion, and obstinate constipation which, at a later period, often gives place to a profuse diarrhoea. When the disease is localized in the liver, this viscus is much enlarged, the entire hepatic region is very painful to the slightest press- ure, and jaundice may take place. The pulse is small and frequent, 100 to 120, but in a few cases it has been found abnormally slow. The temperature runs up to 103° or 1041F. There is a feeling of giddiness, headache, ringing in the cars, sleeplessness, and great disquiet; to this may be added nocturnal delirium, and, when ulcers and abscess in the muscles appear, frequent chills. /Under the influence of the local phenomena, which may appear without following any regular order, the fe- ver assumes an adynamic character. The heart-beats be- come weaker, the pulse thready, easily compressed, and very much quickened up to 110 to 140 and more, the fe- ver increases up to a temperature of 105° F., the skin be- comes covered with a cold, clammy sweat, and conscious- ness becomes more and more cloudy, until the patient passes into a completely comatose condition^ The evac- uations are passed involuntarily, the temperature of the extremities sinks, the gangrenous ulcers extend and give rise to a fearful stench; finally, with a total abeyance of sen- sibility, with increase of the dyspnoea, stertorous breath- ing, and tetanic convulsions, death from exhaustion takes place. /The chronic glanders is, in its form and duration, often very different from the acute form. It can last months and even years, and many of the changes which have been mentioned may be entirely wanting. ; The patient complains for a long time of an indefinite sense of lan- guor, and? cramp-like pains in the extremities and joints. There are repeated attacks of fever, unquiet sleep, and diminished appetite. /The parts attacked by the local proc- esses become swollen, and the lymph-vessels and glands belonging to them are inflamed.'All these symptoms may diminish in severity, or even completely vanish, and then, after a shorter or longer time, reappear with the same or increased severity.) Livid ulcers of the skin appear which have no tendency to heal, there are abscesses around the joints, and fistulous ulcers which secrete a foul, thin pus, and which do not form good granulations. Tumors on the extremities appear, and on being opened a bloody purulent mass is emptied. Or the eruption appears with all its consequences, just as in acute glanders, but it takes a more chronic course. The nasal affection may be en- tirely absent, but when it appears it runs almost the same course as in the acute form. It does not appear until two or three months after the infection, and shows itself by a stinking, muco-purulent secretion, and swelling of the nose. Gangrene of the root of the nose, or extensive ul- ceration leading to the destruction of the vomer and sep- tum, may develop. Inflammation of the mucous mem- brane of the mouth, with swelling of the tongue and salivation, appears, and ulcers form in the pharynx and palate, just as in syphilis. The affection of the lungs is not as well marked as in acute glanders ; the patient complains of pleuritic pains, although, on physical examination, nothing can be found to account for it; cough is frequent and a bloody sputum is expectorated. There is little difficulty in respiration unless the larynx be involved, when the dyspnoea may be extreme and accompanied by glottis oedema. The tem- perature increases from time to time, going hand in hand with the formation of new abscesses; diarrhoea with pro- fuse sweating appears, and the whole affection has great similarity to chronic tuberculosis with hectic fever. Sometimes the chronic form passes into the acute; high fever then appears, with a small, frequent pulse; there is an eruption of pustules; numerous new abscesses are formed ; in a short time coma comes on, and is soon fol- lowed by death. When the disease takes a favorable course the whole complex of symptoms which we have detailed are not so pronounced. * The abscesses cicatrize ; the skin vesicles and pustules dry up. When the nose is affected the tern through a wound of the skin, this often heals quickly without leaving any trace. After an incubation period of from three to eight days the wound becomes inflamed, swollen, and painful. An eruption of vesicles appears around it, which soon become filled with a haemorrhagic fluid, and there is also a firm, painful, cord-like swell- ing of the lymphatics. Frequently the whole arm swells, and has the appearance of a phlegmonous erysipelas. In other cases the cicatrized wound breaks out again, and an ulcer with a thin purulent secretion is formed, which after a long course may heal without further consequences, or it may lead to a general fatal illness without the forma- tion of any other foci. ' All these conditions may pass away gradually and complete recovery take place, but in the great majority of cases the general affection develops further. In addi- tion to the general sense of discomfort, weakness, loss of appetite, and pains in the head, gastric disturbances with obstinate diarrhoea appear, and the pains in the joints in- crease in severity. An outbreak of fever follows these symptoms, beginning with a sharp chill and followed by sweating. These attacks of fever may be periodic and similar to intermittent, or they may be irregular. After a few days the fever becomes continuous, is accompanied by severe headache, great hebetude, and a dry skin and mouth. The pulse is full and 90 to 100 in the minute. In the course of the fever epistaxis often appears, and severe tetanic pains in the muscles and joints are almost constantly present. At first nothing abnormal can be found in the painful places, and when there is no exter- nal mark of infection the disease may simulate a begin- ning typhoid fever or, when the pains in the joints are very pronounced, an acute articular rheumatism. Later, in the painful places in the muscles, there may be cir- cumscribed oedematous swellings and boils. After the fe- ver has lasted one to two weeks, an eruption of spots similar to roseola appears on the face, trunk, and extrem- ities, accompanied by an increase of the fever and of the nervous symptoms. This eruption soon becomes pustu- lar, or pemphigus vesicles appear which open and dis- charge a thick, slimy, very offensive pus mixed with blood. In other cases great furuncular tumors and ab- scesses appear, which are at first hard and painful; later they become doughy and fluctuating, and after opening form extensive ulcers with irregular borders. In many cases the ulceration is so deep that the bones are laid bare. These large abscesses and ulcers form most fre- quently on the extremities. / The affection of the mucous membrane of the nose is hot so frequent in man as in the horse. The nasal affec- tion begins with a dryness of the mucous membrane, pain and a feeling of tension over the root of the nose, which becomes the seat of a diffuse erysipelatous swelling./ The mucous membrane becomes intensely swollen, and a fetid secretion appears, which is at first thin, tough, and yel- low, but later is more copious and purulent, and often accompanied by haemorrhage. ' This secretion often does not appear until the second or third week from the begin- ning of the disease, and with its appearance the whole face swells considerably and vesicles appear. The eye- lids are swollen and oedematous; they completely close the eye, and the conjunctiva secretes a purulent fluid similar to the nasal secretion/ If the patient lies on his back, a part of the secretion flows into the pharynx, and is either swallowed or expectorated. Inflammatory processes appear in the mucous mem- brane of the mouth, pharynx, palate, etc., ulcers are formed, the gums bleed easily, the mouth is extremely fetid, swallowing is difficult, and the patient becomes hoarse. The submaxillary and sublingual glands are swollen, painful, and form abscesses which often break through the skin. When the lungs are affected, there will be severe pleuritic pain and cough with expectoration of bloody muco-purulent matter. The breath is fetid and, upon at first a slight difficulty of respiration, a profound dyspnoea, with oedema of the glottis, supervenes) The physical examination of the lungs at this period gives the evidences of bronchial catarrh, and does not lead to the suspicion of the smaller and larger nodules which are 335 Glanders. Glaucoma, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. swelling of the mucous membrane diminishes, the flow ceases gradually, and the general condition of the patient is slowly bettered. In case the affection of the respira- tory organs has been very pronounced, complete recov- ery never takes place ; the patient always complains of a difficulty in respiration, and is profoundly cachectic. In other cases recovery takes place rapidly and nothing re- mains of the pathological processes, except the stellate cicatrices. The following cases have been selected at random from the abundant literature of the disease,, and serve to illustrate the variety of symptoms and the forms under which the disease appears. Case 1.-The patient skinned the carcass of a horse which had died of glanders, and in the operation cut himself slightly on the left forefinger, under the nail. This was on September 27th. After three days the wound became swollen and painful, and in thirteen days the skin in the neighborhood of the wound became gan- grenous. On October 17th there was great prostration, with fever, and intense pain in the extremities. On the 20th the face had an earthy color, the skin was hot, and the right cheek, eyelids, and conjunctiva were swollen. On the 21st there was delirium, a bloody mucus flowed from the nose, erythema appeared on the lips, and an eruption of pustules over the whole body, and death from asphyxia resulted. The autopsy showed that the cellular tissue was principally involved. The nasal mu- cous membrane and that of the ethmoidal and frontal sinuses were thickened and inflamed ; beneath the pleura were numerous nodules, and large abscesses in the lungs. Liver and spleen were much enlarged. The whole course of the disease lasted twenty-six days. Case 2.-A stableman, while engaged in the care of in- fected horses, had a slight abrasion of the skin of the cheek. Shortly after he received the abrasion inflamma- tion of the parotid on the same side appeared ; the swell- ing became fluctuating, and was opened. On the 14th, two weeks after the abrasion took place, the patient be- came for a short time very somnolent. The swelling of the gland gradually disappeared, and on the 28th the man was discharged from the hospital. Three weeks later, more than a month and a half from the date of the in- fection, three fluctuating tumors developed on the clav- icle, and were accompanied by frequent chills. In March, boils developed on the left elbow and over the tibiae, and, following these, erysipelatous tumors appeared on the hands. In April, hard, round, isolated tubercles ap- peared on the forehead, the scalp, cheeks, and lips, a bloody fluid flowed from the nose, and shortly before death a pemphigus eruption appeared over the whole body. The duration of the sickness was four months. The autopsy showed the lesions characteristic of the dis- ease in the skin, muscles and mucous membrane. Case 3.-In May, some of the nasal secretion of an infected horse was ejected into the face of a stable at- tendant. Shortly after this the cervical glands became swollen, and abscesses appeared at various places over the body. In June he had chills, followed by fever, with an extensive inflammation of the cervical glands, and in August abscesses in the legs. In September these abscesses were as large as goose-eggs, and healed completely on being opened. The patient then became convalescent. This lasted until January, when boils broke out on the left forearm. In February there was a purulent dis- charge from the nose ; in March pleuritic pains and diffi- culty of respiration, with cough. A large phlegmonous swelling developed on the cheek, stupor followed, and the man died on April 12th. The autopsy showed exten- sive ulceration in the nasal cavity and other characteristic lesions in the lungs, skin, muscles, etc. Case 4. - The patient, while tending a glandered horse, ran a thorn under his thumb-nail. A pustule developed, which disappeared in six weeks. During this time a lymphangitis appeared on the hand and arm with fistulous passages, which secreted a sanious pus. After about a month and a half a large boil developed in the thigh. Three and a half months from the date of infec- tion this disappeared, and numerous fistulous passages formed which again healed. On July 6th the fistulous tracts reopened, and there was general malaise, with swelling of the right parotid, and an eruption of small, hard, elevated nodules all over the face. A deep ulcer, which had formed on the arm, gave rise to considerable suppuration. The nodules in tlie face became smaller, and the fistulous passages healed, but broke out again during the following October. On December 10th the patient left the hospital completely recovered, the disease having lasted eleven months. The horse was killed and found to have a typical case of glanders. The skin affection may be so pronounced that all other symptoms sink into insignificance. Case 5.-A farmer passed his finger into the nostril of a horse in order to be certain that the animal had glanders. This was on August 30th. On September 20th he had severe chills followed by fever, sleeplessness, thirst, etc., and the lymphatics of his arm swelled up to one and a half centimetre in diameter. On October 7th an abscess, which had formed on the forearm, was opened, and dis- charged blood and pus ; on the 18th a new abscess ap- peared which healed after opening. The patient became apparently well, but on November 9th he was again at- tacked with chills, fever, pain in the head, and furious delirium. On the 11th abscesses appeared between the biceps and deltoid which gradually healed, and three months from the date of infection complete recovery had taken place. In making the diagnosis, the first thing to be consid- ered is the occupation of the patient. In ninety-five per cent, of all cases the patients have been engaged in the care of infected horses. The diagnosis may be con- founded with putrid intoxication, especially when it ap- pears in students or employes of a veterinary school. The period of incubation, three to eight days before the first local symptom, should distinguish it from putrid in- toxication. Glanders may resemble also the anthrax car- buncle, but the tendency to inflammation of the lymph- vessels, forming hard, cord-like swellings in the vicinity, does not exist in anthrax. The greatest difficulty is often in the differentiation between glanders and syphilis. In some cases, when the disease takes a very chronic course, and ulcers appear in the mouth and pharynx, it is almost impossible to differentiate the two diseases. The cicatri- ces resulting from the healed ulcerations of glanders are similar to those left by syphilitic ulcers. The safest way of making the diagnosis is by the dis- covery of the characteristic bacilli. A small amount of pus from an ulcer or the nasal secretion is spread over a cover-slip, which is then passed a few times through the flame of a spirit-lamp, or Bunsen's burner. It is then stained in a solution of methylen blue (1 part to 100 dis- tilled water), washed in dilute acetic acid, dried, and mounted in balsam. The bacilli will then be of a deep, dark-blue color, and the cells and nuclei a pale blue. The bacilli may also be found in the blood in acute cases which run a very rapid course. Although this is the most expeditious and certain way of making a diagnosis, it is not available in all cases, for not every physician is provided with a sufficiently power- ful microscope, nor have all the small amount of technical skill which is necessary. When the diagnosis cannot be made in any other way, recourse may be had to inocula- tion. Young dogs and guinea-pigs are the best animals to use for this purpose. The inoculation had best be made in the mucous membrane of the nose by abrading a small area, and placing in contact with this a pledget of cotton or lint which has been soaked in the pus or secre- tions. Several animals should be inoculated at once, because some may have so much power of resistance that the inoculation turns out unsuccessful, or the disease in the inoculated animal may take a chronic course. In general, enough may be learned in a few days to make the diagnosis certain. All recent authors are agreed that the prognosis in glanders is very bad. Kosanye denies that there is a pos sibility of recovery in any form of the disease, and thinks that the cases of recovery reported were due to a false di- agnosis. The prognosis, however, is not as bad as this. 336 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glanders. Glaucoma* It is always more unfavorable when the weight of the disease falls on the mucous membranes; it is more fa- vorable when the skin affection alone appears, because the local treatment can be more thorough, w hen both affections are combined, the disease almost always takes a fatal course. The acute forms are much more fatal than the chronic. Prophylaxis can effect much more in glan- ders than treatment. Great stress shouldbe laid on the importance of at once killing any animal that is infected. All persons whose calling brings them in frequent con- tact with horses should be warned of the dangers of in- fection. In acute cases of glanders treatment seems to accom- plish nothing ; the few cases of this form which have recovered have done so by virtue of their powers of re- sistance, and not in consequence of any special line of treatment. If infection has taken place from a wound, this should be at once cleaned and cauterized, in order that the virus may be destroyed. If the wound is fresh and made in the course of an examination, it should be allowed to bleed freely, washed in a strong solution of corrosive sublimate, and cauterized either with the hot iron or with some strong mineral acid. According to Virchow and Bollinger, when small wounds and excoria- tions are treated in this manner, there is little danger of a general infection. If these precautions have not served to ward off the general infection, then the treatment should be directed to the symptoms. All means directed against the disease itself, after it has once been established, have, up to the present, proved to be of no avail. In the beginning the fever should be treated with quinine, cold wraps, and purgatives. Some good may be accomplished with calomel if the bowels are constipated. When the nasal affection comes on, the mucous membrane should be treated locally by cleanliness, and washing out the cav- ities with solutions of carbolic acid, 1 to 200, or of corro- sive sublimate, 1 to 4,000. Iodoform may be applied to the ulcerated surfaces. In the typhoid condition the gen- eral state of the system should be treated by quinine, tonics, and stimulants. All abscesses should be opened as soon as possible, and washed out with solutions of car- bolic acid. Permanganate of potash may be used to cor- rect the foul odor. In the chronic forms the iodide preparations, sulphur, and sulphur-baths may be used. The abscesses and ul- cers should be treated in accordance with good surgical principles. The treatment, on the whole, can be resolved into good treatment of each symptom that arises. Along with the local treatment, the powers of the organism to resist the virus should be raised as much as possible, and this is best done by good nutrition, tonics, and judicious stimulation. W. T. Councilman. glaucoma, the first of which is called the prodromal stage, the second is that of the glaucoma evolutum, and the last that of the glaucoma absolutum. What are usually described as the prodromi of glau- coma are observed in a large majority of the cases, and are in reality a series of slight attacks of acute glaucoma. This prodromal stage may last many months, even years, until the attacks and their consequences become more se- rious. The prodromal attacks are neither equal in dura- tion nor in degree ; yet they are not serious enough, as a rule, to cause cupping of the optic disc, nor to reduce the visual acuity lastingly. On the other hand, their early recognition is of grave importance to the patient, as the disease in these early stages is more tractable than later on. The symptoms which characterize this prodro- mal stage are the following : There is an appearance of a mist before the eye or eyes which may change in density. Rainbow colors are seen, especially in the shape of a ring around a candle-flame. These rainbow-color rings do not touch the flame, but are separated from it by a dark space. The range of accommodation is reduced, and the eye appears prematurely presbyopic. This symptom is probably due to the hyperaemia of the ciliary body. In some cases the eye becomes myopic, which fact can only be explained by the assumption that the crys- talline lens in toto is pressed forward toward the cornea, and that, moreover, in this manner the zonule of Zinn is being stretched, and an applanation of the lens is taking place. There is pain, which may be slight or even ex- cjuciating, and which is located in and around the eye, in the forehead, the eyebrows, the cheek-bones, the nose, and the temple. There is an increase of the intra-ocular pressure, which may vary from a barely perceptible to a stony hardness. The intra-ocular pressure is tested by directing the patient to look downward, and then gently laying the tips of the forefingers upon the upper lid and alternately pressing them upon the eyeball, as we do when we are searching for fluctuation elsewhere. By comparing the amount of impression we are able to make on a diseased eyeball with that which we can produce on its healthy fellow, or on the healthy eye of a third person, we can form an estimate of the increase of intra-ocular tension in the given case. According to the degree of hardness, we speak of it as +T. (tension) 4- Tn -f- T2, and + T3. Several instruments (tonometres) have been in vented to give an exact measurement, but they do not seem to be altogether reliable. The prodromal stage passes over into that of the glau- coma evolutum as soon as the visual acuity is lastingly reduced. The Glaucoma simplex acutum is, if ever, very rarely observed. It would seem to have existed in a few cases in which sight was lost within a few hours without any inflammatory symptoms, and with barely increased pres- sure. Glaucoma simplex clironicum is one of the most frequent forms of this disease. It is characterized by the fact that externally the eye shows no marked signs of disease. The cornea, anterior chamber, iris, and pupil appear nor- mal. The main symptoms are : the loss of vision, the excavation of the optic papilla, and the increase of the intra-ocular pressure-the latter symptom may, however, always or at times be imperceptible. An increase of the intra-ocular pressure is generally accepted to be the cause of the glaucomatous excavation of the optic papilla. The normal optic papilla has a central depression (physiological excavation) which may, in rare cases, reach so far toward the periphery of the optic pa- pilla that at first sight it will strike the observer as a glau- comatous excavation. I have seen several such cases, in which the absence of all other symptoms alone could con- vince me of the fact that I had not to deal with a chronic glaucoma. Such a physiological excavation may have a sloping or a sharp edge, and appear quite deep, yet it can never reach farther back than the anterior surface of the normal lamina cribrosa. In our judgment of the width as well as of the depth of such a physiological excavation we must take into consideration the fact that the optic nerve-fibres, after they have passed through the lamina GLAUCOMA. The name of this affection of the eye has been bestowed on it on account of a greenish appear- ance of the pupil, which, although present only in rare cases, may be observed as one of its symptoms. This name is a misnomer. It is, however, generally ad- hered to. More recent names, which were adapted to special theories regarding the character, of the affection, as, for instance, ophthalmia arthritica, choroiditis serosa, etc., have never been universally adopted. The chief characteristics of glaucoma are a slowly or rapidly progressing diminution of the acuity of vision, combined with an occasional or continued increase of the intra-ocular pressure, and an excavation of the optic-nerve papilla. Around these chief symptoms we find grouped a number of other symptoms, which characterize the dif- ferent varieties of the disease. These varieties are known as glaucoma simplex acutum, glaucoma simplex chronicum, glaucoma inflammatorium acutum, glaucoma inflammato- rium chronicum. When any of these forms of glaucoma occurs in an eye which has not previously been affected in a manner so as to cause the development of glaucoma, we speak of the glaucoma as being primary ; when, on the other hand, a previously diseased eye is, in consequence of this former disease, attacked by glaucoma, we call it a secondary glaucoma. We can furthermore, as a rule, recognize three stages in the development of all forms of 337 Glaucoma. Glaucoma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cribrosa, lose their marrow, become non-medullated, and are then diaphanous. Thus, a physiological excavation of the optic papilla is likely to appear much larger than it find that here we have to deal with an actual and deep hollowing out of the optic papilla. We furthermore see, in this figure, that the actual excavation has for its floor a thin layer of atrophic nerve- fibres and the compressed lamina cribrosa. The nerve- fibre layer and the lamina cribrosa are together pressed out of the sclerotic, and behind it into the trunk of the optic nerve. The walls of the excavation are also lined Fig. 1391. actually is. The illustrations, figures 1394,1395,1396, and 1397 will give a more palpable illustration of this fact. They are taken from specimens of a very short (hyper- metropic) eye. Fig. 1394 is a transverse section taken from the optic nerve just behind the lamina cribrosa. Fig. 1395 is taken from near the anterior surface of the Fig. 1398.-Glaucomatous Excavation. with a very thin layer of atrophic nerve-fibres. These fibres follow very closely in their course the indentations and projections of the surrounding scleral tissue, and finally pass over into the atrophied nerve-fibre layer of the retina. From the foregoing we understand that the physiologi- cal excavation in the normal eye may appear as having a sharp edge, but usually has none, and cannot, for obvious reasons, reach to the periphery of the optic papilla ; that the typical glaucomatous excavation, how- ever, has always a sharp edge, and can reach to the very periphery of the optic papilla (when all nerve-fibres are Fig. 1395. lamina cribrosa, and Fig. 1396 just from the anterior as- pect of the lamina cribrosa. Fig. 1397 is a longitudinal section of the optic nerve entrance of the same eye. The eye from which these specimens were taken proba- bly showed during life an apparently very large physio- Fig. 1396. logical excavation, while the central (actual) excavation, caused by the manner in which the nerve-fibres pass over into the retina, is but very small. The condition illus- trated by these drawings is chiefly found in hyperme- tropic eyes, while in myopic eyes the double-contoured Fig. 1399.-Glaucomatous Excavation as seen with the Ophthalmoscope. (From Mauthncr.) destroyed), and always comes very close to it. Moreover, in the typical glaucomatous excavation the lamina cri- brosa is pressed backward and out of its normal position. It can, therefore, not well be confounded with a simple atrophic excavation, since this is always very shallow, and the lamina cribrosa is found in its normal position and of normal appearance. nerve-fibres reach farther forward and end in a straight, or even slightly convex, line. If we now compare with this physiological excavation the typical glaucomatous excavation (sec Fig. 1398), we Fig. 1397. 338 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glaucoma. Glaucoma. By the aid of these anatomical facts we shall now easily understand the ophthalmoscopic picture of a glaucoma- tous excavation (see Fig. 1399). The most striking phenomena of a glaucomatous exca- vation pertain to the retinal blood-vessels. Just before reaching the optic-nerve papilla these blood-vessels are seen to pass over a yellowish ring, which corresponds neither to the normal scleral nor to the normal connec- tive-tissue ring as seen around the normal optic papilla. On the inner margin of this yellowish ring the blood- vessels are seen to bend inward, then they disappear par- tially or altogether, and reappear dimly in the depth of the excavation, but in a parallactic distortion. If the excava- tion is very deep, it may be impossible to see the part of the blood-vessels at its floor, while their retinal portion is distinct, and vice versa. The depth of the excavation may thus be approximately measured by means of the glasses necessary to see the two portions distinctly. The optic nerve forming the bottom of the excavation appears punctated. It has usually a white appearance in the centre, where it is directly illuminated ; the parts which are only indirectly illuminated appear bluish or greenish. By moving the mirror slightly the view may be changed in such a manner as to make a formerly greenish part appear whiter. The punctation is probably produced by the fact that the meshes of the anterior sur- face of the lamina cribrosa are visible on account of the atrophy of the nerve-fibres. The yellowish ring around the optic papilla, or at least what is left of it, is caused by an atrophic condition of the choroid, which is undoubtedly due to the stretching of this membrane during the development of the excava- tion, and is not due, as some authors maintain, to a chronic choroiditis. A further vascular symptom is the spontaneous pulsa- tion of the retinal arteries. This is but rarely seen in recent cases. It can frequently be produced by pressure on the eyeballs. The gradual loss of sight (central visual acuity and visual field) is in a general way in proportion to the size and extent of the excavation of the optic papilla, and the consequent atrophy of the optic nerve-fibres. Yet a number of cases have been observed and reported in which an apparently large and deep excavation was not yet com- bined with a great loss of vision. In some cases the cen- tral vision will be destroyed before the periphery seems to be materially altered, and in other cases the loss of vision at first affects the peripheral visual alone. The contraction of the visual field begins frequently on the nasal side, and gradually extends upward and downward, so that in some cases at a certain stage a perfect hemian- opia has been observed. Gradually the visual field grows smaller and smaller. It often has the shape of an ellipse with the point of fixation lying in the nasal focal point. This form of contraction of the visual field is pre-emi- nently found in glaucoma, while an actually concentrical limitation of the visual field is usually due to diseases of the optic nerve alone, or to retinitis pigmentosa with subsequent atrophy of the optic nerve. All these symptoms are accomplished by a gradual dim- inution of the light-sense. The color-sense is usually well preserved, even when the visual field is reduced to almost nothing. The loss of vision and the reduction of the light-sense are the symptoms of glaucoma simplex which usually bring the patient to seek relief. Generally one eye is then already found to be badly affected, while the trouble is beginning in the second eye. Glaucoma Inflammatorium Acutum.-The attack of acute inflammatory glaucoma comes on suddenly, and probably more frequently during the night than in the daytime. The pain, which is the most prominent symp- tom of this form of glaucoma, is often fairly excruciating. It is seated in the eyeball, the eyebrow, the forehead, and temple, and it may extend even to the occipital region. It, furthermore, may be combined with nausea and vomiting. There is usually a considerable secretion of tears and of watery fluid from the nose, and photophobia. These symptoms are, moreover, accompanied by some oedema of the eyelids, and especially of the upper one. When the lids are separated the conjunctival blood-ves- sels are found to be considerably injected, and the bul- bar conjunctiva to be slightly chemotic. The episcleral vessels around the cornea, too, are hyperaemic, and form a reddish-blue ring around the corneo-scleral margin. The anterior ciliary veins are distended and tortuous. The cornea has a dead appearance, like glass which has been breathed upon. Under oblique illumination its sur- face appears irregular, as if pricked with a needle, and there may be slight deposits of fibrin on Descemet's mem- brane. If the cornea is touched with the end of a probe, a feather, or a thin roll of tissue-paper, it is found to be almost anaesthetic, and4he reflex contraction of the orbic- ularis muscle of the eyelids follows the insult long after it does so in a healthy eye. This anaesthesia may be no- ticeable over the whole area of the cornea or only in por- tions of it. By palpation the eye is found to be hard. This sudden increase of the intra-ocular pressure is the cause of the dimness as well as of the anaesthesia of the cornea. The anterior chamber is shallow, the iris and crystalline lens being pressed forward toward the cornea. The pu- pil is wide, and reacts but very slightly under the stimulus of light. There may be some posterior synechiae. When the attempt is made to get an ophthalmoscopic view of the interior of the eyeball, it is often barely possi- ble to see a reddish reflex, but no details of the fundus. This is due as well to the dimness of the cornea as to a diffuse opacity of the vitreous body. Sight is considerably reduced, and it may be dimin- ished to the bare perception of light. This symptom is most probably due to the pressure exerted upon the optic nerve-fibres, the retina, and the retinal blood-vessels, and to the resulting paralysis of the nervous elements and ischae- mia of the retina. That this is the correct explanation of the symptoms seems to be proven by the pulsation of the retinal arteries, the systole of the heart alone being able to overcome the intra-ocular pressure to some extent, and by the fact that a release of the pressure by operation will restore sight. The dimness of the cornea and the vitreous body, moreover, help to reduce the vision. The attack of acute inflammatory glaucoma may last from a few hours to several weeks, and sight may again considerably improve as the attack passes over. Yet, the eye, although it may look so, is no longer in the same condition as before the attack, and every new attack will leave it in a worse state. Repetitions of the attack are the rule. In the intervals between the attacks, the ante- rior chamber remains usually shallow, the movements of the iris are restricted, and the tension remains some- what increased. In other cases the acute stage passes directly over into the chronic one. When all these symptoms are less marked, the affection is called glau- coma subacutum. There is, furthermore, a limited number of cases of acute glaucoma on record in which sight was absolutely destroyed during the first attack, and in a few hours. These cases have been given the name of glaucoma fulmin- ans (Graefe). Glaucoma Inflammatorium Chronicum.-In the chronic inflammatory form, which may follow an acute attack or begin with a chronic character, all of the glaucomatous symptoms are slowly developed, and the external inflam- matory signs are less marked than in the acute form. The injection of the conjunctiva is there, but there is no oedema of this membrane, nor of the eyelids. The epi- scleral blood-vessels, and especially the anterior ciliary veins, are plainly visible and tortuous (see Fig. 1400). There is a marked injection of the deeper-seated blood- vessels around the corneo-scleral margin, and in the later stages the sclerotic tissue has a peculiar leaden appear- ance. The cornea may be perfectly clear, or it is slightly hazy, and it often shows minute superficial or even deeper points of ulceration. The anterior chamber is, and be- comes more and more, shallow, and the pupil, which is at first of medium size and acting sluggishly, is soon more and more dilated, and becomes immovable. The iris-tis- sue, at first swollen and discolored, is later on attenuated, 339 Glaucoma. Glaucoma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and undergoes a slow process of atrophy. The intra-ocu- lar pressure is increased above the normal, and there is a gradually increasing excavation of the optic papilla with a consequent atrophy of the optic nerve-fibres. The patients suffer at times from considerable pain and neuralgia, especially at night. The visual acuity, the visual field, and the light-sense are gradually more and more reduced. This is the more noticeable after each ex- acerbation of the process. The chronic inflammatory glaucoma seems to be the most frequent form in which this disease is observed. We must state here that the acute inflammatory, as well as the chronic inflammatory, variety may be preceded by a simple chronic glaucoma. When the sight has by one of the different forms of glaucoma been perfectly abolished, or at least so far that merely the perception of light is retained, we speak of glaucoma absolutum. The progress of the disease, how- ever, does not end here, and a further glaucomatous de- generation of the eyeball takes place. In some cases the eye is only at times painful, shows but slight external al- terations, and the media remain for a long period in such a condition that an ophthalmoscopic examination is eas- ily made. In most cases the increased malnutrition leads to the formation of glaucomatous cataract. The anterior chamber becomes so shallow that the anterior lens-cap- sule almost touches the posterior surface of the cornea, or actually does so. The eye remains painful, and the pain is at times very considerably exaggerated. Gradually ulceration of the cornea and the formation of scleral or rhagic retinitis (glaucoma hanwrrhagicurn\ Glaucoma has been furthermore observed in cases of pigmentary retinitis and of atrophy of the optic nerve. In these cases the occurrence of glaucoma was, however, probably a coincidence only, and it would seem to have been a primary glaucoma, not a secondary one. Secondary glaucoma is apt, furthermore, to occur in eyes suffering from staphyloma, and the increase of pressure then helps to the further increase of the staphy- loma. All intra-ocular tumors are likely to cause a glauco- matous condition of the eye during their growth. Hydrophthalmus congenitus (cornea globosa buphthal- mus) must probably be considered as intra uterine glau- coma. The differential diagnosis between glaucoma simplex chronicum and amblyopia caused by a simple atrophy of the optic nerve may be sometimes rather difficult, especially since there are cases of simple glaucoma in which there is no appreciable increase of the intra-ocular tension, and they may come under observation when as yet there is only a partial excavation of the optic papilla. This difficulty is only to be met by repeated carefid exam- inations, until one of the necessary symptoms is marked enough to make the diagnosis secure. In this connection I may mention that the yellowish halo around the optic papilla which is characteristic of glaucoma, though little marked, seems to be but seldom wanting, and may there- fore help in making the diagnosis. Furthermore, a sim- ple atrophy of the optic nerve may at a comparatively early stage lead to diminution of the color-sense, while glaucoma does not seem ever to interfere with the color- perception. The diagnosis of an acute primary inflammatory glau- coma may appear plain from the condition of the eye when it comes under observation ; yet the same general condi- tion might also be a secondary one and due to an intra- ocular tumor. Here the position of the defect in the visual field, the usual absence of the perception of rainbow-rings, and the gradual and continuous loss of vision which is likely to have preceded the glaucomatous condition under consideration, may help to the diagnosis of an intra-ocular tumor, even if it cannot be otherwise demon- strated. To distinguish between a haemorrhagic and a primary acute glaucoma will hardly be possible, except in cases in which the retinal haemorrhages had obscured vision very materially, or in which the observer has had occasion to see the occurrence of such haemorrhages pre- vious to the glaucomatous attack. The acute glaucoma might, furthermore, be confounded with serous iritis. Yet, the deposits on Descemet's membrane w hich are so marked in this affection, the depth of the anterior chamber, and the lowr degree of injection of the visible external blood-vessels (there may be none at all) will usu- ally make it possible to exclude a primary glaucoma in such cases. Glaucomatous, as well as any other complicated, cata- ract may, of course, by a careless observer, be taken for an uncomplicated cataract. The primary chronic inflammatory glaucoma cannot well be confounded with any other eye-affection. Glaucoma is observed in about one per cent, of all eye- patients. It seems to be a little more prevalent among females than among males. It has been seen to occur in children as wrell as in old age. Yet the majority of the cases are observed after the fiftieth year of life has been reached, and it is very seldom seen before the twentieth. Although glaucoma may at first attack only one eye, it is the rule that it will sooner or later attack the fellow-eye. In this connection we may state that the attack in the second eye seems to be apt to make its appearance soon after the first one is operated upon. In the relative frequency of their occurrence the chronic inflammatory glaucoma takes the first, the chronic simple glaucoma the second, the acute inflammatory glaucoma the third, and the (doubtful) acute simple glaucoma the last place. The disease is almost confined to eyes afflicted with hyperopia or hypermetropic astigmatism, although it is found also occasionally to appear in myopic eyes. Fig. 1400.-Chronic Inflammatory Glaucoma. (After Schmidt.) corneal staphylomata may take place. The ulceration may lead to perforation and subsequent shrinkage of the eyeball. All these symptoms may be accompanied by very annoying photopsise. In the foregoing we have considered what is desig- nated as primary glaucoma. We come now to the forms of secondary glaucoma. The secondary glaucoma may appear in the shape of a simple or inflammatory glaucoma. It has been observed to follow various diseases of the eyeball. It may follow a diffuse or sclerosing keratitis, vesic- ular (bullous) keratitis, or that form known as ribbon- shaped keratitis ; yet it is more frequently observed in cases of anterior synechia, with or without leucoma of the cornea. Serous iritis is apt to cause glaucomatous symptoms. Glaucoma may furthermore follow a plastic iritis when it has led to the formation of posterior synechiae, and especially when a total circular synechia has been formed, whether this has led to the seclusion of the pupil alone, or to seclusion combined with occlusion of the pupil. But an occlusion of 'the pupil alone (which can, for in- stance, follow an operation for cataract extraction) may also be sufficient cause for the production of glaucoma. Dislocation of the crystalline lens, or a too rapid swell- ing of the lens-substance after the operation of discission or after an injury to the lens-capsule, may lead to glau- coma. This is one of the bad results which often followed the old method of couching cataractous lenses. Serous choroiditis, although leading more frequently to detachment of the retina, may give rise to glaucoma. The most important one among the diseases of the retina which may be followed by glaucoma is the haemor- 340 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glaucoma. Glaucoma. Some authors maintain that there is an inherited tendency to glaucoma in some families. Where there is a tendency to glaucoma, an attack may be brought on by an extraordinary straining of the eyes, by mental disturbances, by excesses of various kinds, by various diseases, by the stopping of habitual secretions, especially of the menstrual flow in the climacteric period in females, and by the instillation of atropine and homa- tropine into the conjunctival sac. Before considering the nature of this disease we will next see what data the anatomical examination of eyes afflicted with glaucoma gives us to build our theories upon. The most interesting part of a glaucomatous eye has been for a long time the optic nerve papilla, with its exca- vation. In a case which is not very far advanced, we find a comparatively shallow excavation, which is deep- est usually in the centre, sometimes at one side (espe- cially the temporal one). The bottom of this excavation lies behind the level of the choroid, and consists of a thin layer of nerve fibres. Nerve-fibres are, furthermore, seen to line the walls of the excavation, and to join the retina at a more or less acute angle. The retinal blood- vessels lie within this nerve-fibre layer, and come, ac- cording to the stage of the disease, more or less close to the edge of the excavation. The fibres of the lamina crib- rosa appear pressed closely together, so as to render this membrane thinner than in the normal eye, and the whole lamina is bulged outward. Its choroidal portion is no longer in distinct connection with the choroid. The small blood-vessels found in the normal eye in this region are reduced in numbers or wanting altogether, and the nerve- fibres are atrophied. The retinal veins are usually hy- peraemic. All these conditions are considerably exagger- ated in an advanced case like the one from which Fig. 1398 was taken, yet I have never seen a glaucomatous excavation which had not, though ever so thin, a lining layer of nerve-fibres. The portion of the choroid and the retina which sur- round the excavation are drawn to some extent down into it and toward its axis, and the choroid is, even in more re- cent cases, very thin and atrophic. It lacks blood-ves- sels-especially capillaries, its pigment cells have, in a certain measure, or altogether, disappeared, and the pig- ment molecules are found lying in the adjoining tissue of the sclerotic. This condition is undoubtedly the ana- tomical explanation of the glaucomatous halo. In some cases small foci of infiltration are found in this portion of the choroid. The choroid in general shows an anaemic condition of the capillary layer ; while the venae verticosae are usually choked with blood. The retinal nerve-fibre layer in very advanced cases is atrophied, and the blood-vessels of this membrane are partially or altogether obliterated. In more recent times (Knies) the interest of the exam- ination has been centred especially on the condition of the iris-angle. We find here, although not at all in- variably, an adhesion between the periphery of the iris and the posterior surface of the cornea. Thus the spaces which in the normal human eye lie between the fibres of the ligamentum pectinatum, and correspond with the canal of Fontana, are partially or totally obliterated. In recent cases the tissue surrounding Schlemm's canal (corneo-scleral tissue) is infiltrated with round-cells, and the periphery of the iris, being pressed forward, comes in contact with Descemet's membrane, the endothelial coat of which begins to proliferate. In this way a small amount of new connective tissue is formed between Des- cemet's membrane and the periphery of the iris, which glues the two together, and thus the spaces of Fontana are obliterated (see Fig. 1401). It is doubtful whether this agglutination of the iris to Descemet's membrane is due alone to the increased intra- ocular pressure, or to the direct pressure (Weber, Brailey) of the swollen and hyperaemic ciliary bodies. According to Brailey, the blood-vessels of the ciliary region are found to be considerably dilated, and their walls are reduced in thickness. Later on the ciliary bodies and muscles are thin and atrophic, and the smaller blood-vessels are ob- literated. Schlemm's canal is found patent or closed. Cusco stated that the sclerotic coat is always thicker in glaucomatous eyes, and especially near the entrance of the optic nerve. Weichselbaum and others found the epi- scleral veins filled with blood, and dilated and surrounded by foci of round-cells. In some cases a proliferation of the endothelial coat of the venae verticosae has been ob- served. Ulrich examined pieces of the iris which he had excised from glaucomatous eyes when making an iridectomy. He found the tissue of the iris atrophied and thin, and lacking cellular elements. The blood-vessels were par- tially dilated, and the thickness of their walls was consid- erably reduced ;-a part of them (especially of the smaller ones) were totally obliterated. In some cases the vitreous body has been found de- tached, in some the cornea was oedematous. It will be seen from the foregoing remarks that our knowledge of the pathological anatomy is as yet very meagre. This is the more astonishing, as a great many able workers have devoted their study to this interesting, and as yet mysterious, disease. Glaucoma, or at least a similar condition, has been experimentally produced in animals by ligating the venae verticosae, by burning the corneo-scleral margin (Schoeler), and by injecting oil into the anterior chamber (Weber). It is, therefore, evident that even to this day it has been impossible to find a common cause for all the different forms of affections which produce the increase of intra- ocular pressure, as well as the gradual destruction of vision, combined with an excavation of the optic nerve. Fig. 1401. which we call glaucoma. It is, in consequence, not to be wondered at that the number of the theories con structed for the explanation of the nature and seat of glaucoma is legion. These theories may be classed under three heads : those which make the increase of the intra- ocular pressure the main feature ; the theories which deal with the disease as originally due to a strange affection of the optic nerve ; and, finally, those which seek the cause in an inflammation of the choroid. The theories making the increased intra-ocular press- ure the main feature attribute it to a hypersecretion into the vitreous body, consequent upon an active but some- what atypical inflammatory process in the choroid ; or they consider it due to an irritation of the secretory nerves ; or the increase in pressure is thought to be the result of reduced facilities of excretion from the eyeball, or of stasis of the venous blood (passive hypersecretion, Mauthner). Graefe thought that glaucoma was a choroiditis or an irido-choroiditis, with diffuse imbibition of the vitreous body ; this would lead to an increase in volume of the vitreous body, and consequently to increased intra-ocular pressure. Later on he thought this choroiditis to be due to an irritation of the secretory nerves. Arlt and Sattler ad here to the former theory. The latter found inflammatory changes in the choroid, yet his description of these changes is such that it seems hardly possible to attribute a dis- ease of the character of glaucoma to so slight a cause. Why, if it were correct, is glaucoma not caused in every case, or at least in the majority of cases, of exudative choroiditis ? The neurotic theory has been put forth by Bonders, lie says that in glaucoma chronicum simplex we have no 341 Glaucoma. Glaucoma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. signs of an inflammatory character, and, furthermore, the increase of pressure has always preceded the inflam- matory symptoms where they exist. The cause of the increased pressure must, therefore, lie in the irritation of secretory nerves. Graefe, as stated before, partially adopted this theory; but he characterized even the glau- coma chronicum simplex as an inflammatory condition. Schnabel, who also supports the neurotic theory, refuses to acknowledge the inflammatory character of any form of glaucoma. He claims that the glaucomatous ophthal- mia is simply a neuralgia of the sensory nerves, while the increased pressure is a neuralgia of the secretory nerves of the eye. Glaucomatous ophthalmia, then, and anomaly of pressure, spring from the same root. The cause of the secretory neurosis is found in the atro- phy of the ciliary processes, and the consequent enlarge- ment of the diameter of the circle formed by these pro- cesses, which causes an increased tension of the suspensory ligament of the crystalline lens. The intra-ocular irritation of the secretory nerves lies, therefore, in the anterier part of the eyeball, the iris, and the ciliary body (Donders, Schnabel, Roeder), and is a reflex neurosis. It might, however, with the same right be an extra- ocular affection which brings about such a reflex neuro- sis, and thus Hutchinson and Schmidt-Rimpler have con- sidered a neuralgia of the trigeminus nerve as the cause of glaucoma. Mooren finds the cause in affections of the brain or spinal medulla. The most plausible theories yet advanced are those which refer the cause of glaucoma to mechanical obstruc- tions to the drainage of the fluids from the eyeball, either by obliteration of the lymphatic channels or by ob- struction of the reflux of the venous blood from the eye- ball. Such obstructions must undoubtedly cause an in- crease of intra-ocular pressure, if at the same time the afflux remains the same. The present status of our knowledge of the course of the nutritive fluids of the eyeball is chiefly due to the labors of Knies. He found that the fluids are secreted by the choroid, ciliary body, and iris. The fluids coming from the chorio-capillary layer take their course through the retina into the vitreous body, then forward toward the crystalline lens. While a portion of these fluids now penetrates the equatorial portion of the lens, the larger quantity goes through the suspensory ligament and around and through (Ulrich) the iris into the anterior chamber. The aqueous humor is secreted by the an- terior portion of the ciliary body and the iris. In the normal eye no fluid is secreted through the cornea (Leber), or the quantity is very small. The way by which the largest portion of the aqueous humor leaves the eyeball is the iris-angle ; here it goes partially into Schlemm's canal, and partially into the lymph-canals of the conjunctival and episcleral tissue, and Tenon's space. It seems, therefore, evident that an obstruction of the ex- cretory canals will cause glaucoma. Such an obstruction may be due to an inflammation in the iris-angle, which, as wTe saw, brings about an actual adhesion between Des- cemet's membrane and the periphery of the iris, with or without obliteration of Schlemm's canal (Knies), or it may be due simply to the swelling of the ciliary pro- cesses, which will press the periphery of the iris against the corneo-scleral tissue (Priestley-Smith, Brailey, Weber). Furthermore, the obstruction may be caused by the atro- phy of the iris-tissue and the consequent obliteration of the channel by which, in the normal eye, fluids pass di- rectly through the iris (Ulrich). Some authors speak of an obliteration of the lymph-canals near the optic-nerve entrance as the partial cause of glaucoma. The obstruction of the reflux of the venous blood from the eyeball may be due to an increased rigidity of the sclerotic (Stellwag, Arlt); to inflammation, and conse- quent increased thickness of the sclerotic (Cusco); to fatty degeneration of the sclerotic (Coccius), all of which will tend to a compression of the venous blood-vessels. Magni finds that the ciliary nerves are atrophic in cases of glaucoma. This atrophy of the ciliary nerves causes shrinking of the vitreous body and sclerotic, and stasis in the venous blood-vessels. This stasis, according to others, may be due to an infiltration of the tissue surrounding the veins, or to a proliferation of their endothelial coat. All of these theories take glaucoma to be a disease due to a reduction of the area of the channels of excretion, and they consider all other symptoms of the disease, in- cluding inflammatory attacks, anaesthesia of the cornea, and excavation of the optic papilla, as directly dependent on the increased intra-ocular pressure. Most recently Schoen has advanced a new theory of glaucoma, which also refers the cause of the disease to mechanical conditions of the eyeball. Although it does not strictly belong among the " pressure theories," it may find its place here. He says that an overstrain of the accommodation is the etiological momentum in the development of all cases of primary glaucoma. This may act in two ways : by pulling the sheaths of the optic nerve forward (thus causing excavation), and by pressing the crystalline lens forward (thus producing glaucoma- tous increase of pressure). As long as all the fibres of the ciliary muscles act, glaucoma simplex will follow this overstrain. When the inner fibres of the ciliary muscles become insufficient as compared with the outer ones, the lens is pushed forward, and glaucoma, with increased pressure, is the result. The two modes can act combin- edly in various ways. The pathological changes found in the ciliary body are due to subsequent inflammation. The theories which consider glaucoma due to an affec- tion of the optic nerve were inaugurated by Jaeger. He sees the direct cause of the disease in changes in the ring of blood-vessels which brings blood to the portion of the sclerotic surrounding the optic-nerve entrance, to the lamina cribrosa, and to the optic papilla (Haller's ring). He denies that the increased intra-ocular pressure is char- acteristic of the glaucomatous process, although it is an important symptom. Schnabel and Klein support this theory. The theories which take glaucoma to be the result of a choroiditis, and assume that this choroiditis alone (with- out increase of pressure), would lead to the loss of func- tion and excavation of the optic papilla, have found their most urgent advocate recently in Mauthner. He says : Glaucoma is an inflammatory process in the system of the ciliary blood-vessels which may concern the whole area of this system, or leave some portions of it free ; an inflammatory process which (with the exception of the lo- cation of the glaucomatous halo) is distinct from others by the lack of formed elements in its products, and by the faculty of inducing a rapid atrophic process in the tissues involved. This inflammation is often combined with an increase of the intra-ocular pressure. This is less marked when the inflammation concerns only the area of the short posterior ciliary arteries which go to the choroid, but is hardly wanting whenever the area of the anterior ciliary arteries and long posterior ciliary arteries (ciliary body, iris, and cornea) is attacked ; in this latter case the fluid secreted into the vitreous body is exuded from the inflamed ciliary body (Brailey). The increased intra-ocular pressure is not a constant symptom, and it is not the source of the functional trouble. This latter is caused by the fact that the inflammatory process of the choroid exerts its action upon the neighboring layer of the retina (the rods and cones), while the affection of the optic papilla, characteristic of glaucoma and due to the inflam- mation in the area of the arterial scleral ring, plays only a secondary or final role in the total ruin of vision. When the glaucomatous inflammation suddenly attacks the area of the long posterior and anterior ciliary arteries (a kind of kerato-irido-cyclitis), we have the acute in- flammatory glaucoma. The disturbance of vision is only proportionate to the dimness of the media ; the function of the retina does not suffer from the sudden increase of the intra-ocular pressure. In exceptional cases the uve- itis, which is the glaucoma, will suddenly attack the whole area of the ciliary blood-vessels; the attack, then, of course, includes the choroid. The function of the rods and cones may be thus suddenly (and usually forever) de- stroyed by the exudation ; this is the case in glaucoma fulminans ; or these organs may at least suffer consider- 342 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glaucoma. Glaucoma. ably and lastingly ; this is the case in glaucoma acutum inflammatorium. Whenever the inflammatory process creeps slowly and in a chronic manner from in front backward, or vice versa, we have the glaucoma chronicum inflammatorium. In the former case the excavation will be developed at a late period only, while in the latter case the excavation will exist before any inflammatory changes appear in the an- terior portion of the eyeball. When the affection is a chronic choroiditis posterior, we have the glaucoma chronicum simplex ; and the glau- coma acutum simplex is that rare form in which this pos- terior choroiditis appears acutely ; a form of glaucoma, however, which is very soon followed by the anterior choroiditis in such a manner that the painless increase of intra-ocular pressure and blindness are soon succeeded by inflammatory changes in the anterior portion of the eye- ball. The writer may here state that it seems to him impos- sible to adopt such a theory, as the choroiditis on which it hinges does not seem to exist. Careful examinations of many glaucomatous eyeballs have not revealed the pres- ence of inflammatory changes in the choroid which would be important enough to be taken as a cause of the series of symptoms constituting the disease which we call glau- coma. It seems to /the writer that the theories which seek the cause of glaucoma in a mechanical obstruction of the outlets of blood- and lymph-fluids from the eye- ball are the most plausible ones, and there can, it seems, be no doubt but that a number of different influences may bring about such an obstruction. That the once in- creased pressure can easily cause an excavation of the op- tic papilla in hyperopic eyes, at least, seems to be plain from Figs. 1394, 1395, 1396 and 1397. The prognosis of glaucoma, unless its progress is inter- fered with by therapeutical or operative measures, is ab- solutely bad. In the medical treatment of glaucoma an important step forward has been made since the myotics, and espe- cially the sulphate of eserine (physostigmine, Laqueur) and the muriate of pilocarpine have been found to re- duce the intra-ocular pressure. The value of these reme- dies in glaucoma is, however, a rather limited one. They do not and cannot cure glaucoma, but by their tension- diminishing influence they act beneficially during the prodromal stage, and they may well serve to stave off a threatening attack of glaucoma. They are, furthermore, of value before and after an operation for this disease. The instillation of these remedies generally also eases the pain of an inflammatory attack. A cure of glaucoma or, at least, an arrest of the pro- cess, is only to be accomplished by operative measures. Among these the iridectomy (Graefe) as yet holds the first place. Its value is greatest in the acute inflammatory and then in the chronic inflammatory forms, least in the chronic simple glaucoma. An early iridectomy in a case of acute inflammatory glaucoma is likely to bring vision again up to the normal. If performed at a later stage it may not be able to restore more than a part, or even noth- ing, of the lost vision. In the chronic inflammatory form the iridectomy usuallyrestores a part of the lost vision ; the quantity of this, however, depends very much upon what pathological changes the optic papilla and the nerve- fibres had already undergone at the time of the operation. In the chronic simple glaucoma the iridectomy generally arrests the progress of the disease, and may produce an improvement of vision, although it does so but rarely. Gn general principles we may state that the earlier the operation is performed the greater may we expect its ef- fect to be. It is as yet an unsettled question why an iridectomy will lastingly reduce the intra-ocular pressure, although the fact is undoubted. It seems to be most likely that the explanation lies in the fact that the removal of a piece of iris-tissue not only lessens the quantity of the blood-vessels, and, therefore, of blood within the eyeball, but also takes away a part of the obstacle to the draining of the fluids from the anterior chamber. It has been stated by Exner that a direct communication between the arteries and veins, without intervening capillary net-work, would take place in the parts of the iris directly wounded by the iridec- tomy. The writer, when reporting his studies on the process of healing after an iridectomy, had occasion to state that he had never been able to see such a condition. Arlt, in his recent book on glaucoma, takes pains to say that the writer's statements in regard to this question are of no value, since he had not injected the blood-vessels. The writer's paper on the question, however, states plainly that he injected most of the animals experimented upon with Berlin-blue, and for the truth of the matter it is necessary to state here again that he was, and is to this day, unable to verify Exner's observations. A number of authors maintain that the scar in the corneo-scleral tissue is of more importance even than the excision of a piece of iris-tissue (Wecker), and they consider this scar a means of continued filtration of fluids from the anterior chamber. No direct proof for this opinion has thus far been given, but there is no doubt that scar-tissue, when consolidated, is, as a rule, more compact than normal tissue. It would, therefore, seem that we had a right to expect an effect just oppo- site to the one here given as an explanation of the action of an iridectomy in glaucoma. Whatever the explanation of the healing influence of an iridectomy in glaucoma may be, one thing is certain, that we have occasion to see cases in which a typically and lege-artem performed iridectomy has not been able to stay the progress of glaucoma, as well as cases in which a very imperfect operation has had the desired effect. This would seem to show that science will some day find a procedure which will supersede the empirical operation of iridectomy for glaucoma. At present, however, it is as yet the safest and the most satis- factory measure in our hands. Based on the theory that the corneo-scleral or scleral incision necessary to perform an iridectomy was the main feature of this operation in glaucoma, and that the excision of a piece of iris-tissue was wholly unim- portant to the end in view, besides, of course, hav- ing other disagreeable features (Quaglino, Wecker, and others), simple sclerotomy has been proposed and in- troduced in place of iridectomy. The efforts which have been made to supersede the iridectomy by the sclerotomy have, however, failed. This failure is not only due to the danger arising from prolapse, or in- carceration of the periphery of the iris in the corneo- scleral wound, but also to the fact that the combined experience of many observers has shown this operation to be insufficient, and especially so in the inflammatory forms of glaucoma. It may be performed with perfect success in chronic simple glaucoma, and in cases in which an iridectomy has not been able to cut short the progress of the disease altogether, and in which a second iridectomy has by some authors been advocated. It may, furthermore, be considered of value in cases of glaucoma absolutum, when the pathological changes of the iris-tissue no longer allow of the performance of an iridectomy. Several authors have tried to replace iridectomy by an operation which aims at cutting the ciliary muscle (Han- cock) or the tendinous portion at its insertion into the corneo-scleral tissue. These procedures do not only seem to be of doubtful value, but to be fraught with danger from subsequent sympathetic ophthalmia. The latter ob- jection has, however, also been urged against sclerotomy. Aside from the operation, the general condition of a pa- tient suffering from glaucoma ought to be attended to. He ought to be especially restrained from everything which may in his case be apt to act as an occasional cause for a glaucomatous attack. If there is-and this is the rule-an error of refraction or accommodation, or of both, it must be corrected. Glaucoma not always being easy to recognize, it will be always well to examine a patient carefully with re- gard to it who comes to his physician complaining of, and seeking relief from, neuralgia of the eye and head, combined with obscurations of sight and nausea. Adolf Alt. 343 Gleichenberg. Glioma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. GLEICHENBERG. A village in Steiermark, Austria, noted for its pure alkaline-chloride springs. Access.-From Vienna, via Gratz, to the railroad sta- tion Feldbach ; thence one hour by stage. Situation.-Gleichenberg is situated in a narrow, fer- tile valley, at the base of the Sulzkogel, nine hundred feet above the level of the sea, open to the south, but sur- rounded on the north and west by mountains, on the east by forest-laden hills. Climate.-The climate of this region is mild and even, without sudden changes of temperature. The air is pure and exhilarating. The average temperature and per cent, of humidity for each of the summer months is expressed in the following table : Danville Railroad, thence by stage to the Springs, twelve miles. Analysis.-(Professor C. W. Shepard, Jr.) One gal- lon contains : Grains. Sulphate of lime 91.501 Carbonate of magnesia 3.324 Chloride of sodium 2.216 Chloride of potassium 0.325 Therapeutical Properties.-The proportion of lime sulphate in this water is unusually large, and theoreti- cally would suggest its indigestibility; but it has, never- theless, proved very efficacious in constipation, torpid liver, and catarrhal diseases of the urinary tract. Glenn Springs is situated in the Piedmont region of the State. The Blue Ridge Mountains shelter this section from the cool westerly and northerly winds. The mean elevation above the sea is 560 feet. The climate is said to be similar to that of the South of France and the val- leys of Switzerland, and is free from sudden and extreme variations. The hotel, situated on an eminence, in a grove of live-oaks, is capacious, and, in addition, there are a number of cottages. Billiards, ten-pins, croquet, etc., afford amusement. History.-The virtue of this water, like many others, was discovered by the early settlers observing that the spring was a resort of the wild animals, and later on of their own domestic cattle. They were induced by this fact to bathe in and drink the water, and thus its curative qualities in many diseases were established. George B. Fowler. Temperature. Humidity. (Celsius.) (Per cent.) May 16" 72 June .. ... .15" July 19" August 18° 75 September 13" 82 October 6° 85 Average temperature for the entire period, 16" C. (60.8° F.) The mineral springs are known by the names, Con- stantins, Emma, Werle, Johanns (Old and New), Romer, Carls, Bach, and Klausner. The Johanns and the Klaus- ner are located a few miles distant from the village. All except the last contain considerable quantities of sodium chloride and sulphate. The subjoined table indicates the solid constituents in one pint of water from each of the five principal springs. Constan- tins. Emma. Klausner. Johanns. Old. Johanns, ' New. Grains. Grains. Grains. Grains. Grains. Sodium carbonate 19.292 17.233 0.007 14.876 15.160 Potassium carbonate 0.430 0.929 0.56(1 0.414 Lithium carbonate 0.030 0.015 0.015 0.007 Baryta carbonate 3.532 0.007 0.007 Calcium carbonate 2.718 0.176 3.978 3.806 Magnesium carbonate .... 3.640 3.717 0.038 3.532 3.194 Ferrous carbonate 0.023 0.537 0.076 0.107 0.124 Sodium chloride 14.215 12.969 0.092 3.901 4.093 Sodium sulphate 0.605 0.814 0.007 0.015 Potassium sulphate 0.046 Sodium phosphate 0.007 0.007 0.015 0.007 Aluminum phosphate ... Silicic acid 0.483 0.460 0.545 0.168 0.176 Potassium iodide. 0.007 0.107 Sodium nitrate 0.053 - - - ■ - - Total 41.436 40.213 0.987 27.226 27.110 Free carbonic acid in cu- bic inches 18.025 11.405 13.177 13.518 15.036 Temperature (Fahrenheit) 61.6° 54.2° 51° 53.8° 54° • - GLENWOOD SPRINGS, COLORADO. Location and Post-office, Glenwood Springs, Garfield County, Col. Access.-From Denver to Leadville, via Rio Grande Railroad, thence by stage, via Aspen to Glenwood Springs, or Denver to Red Cliff by railroad, thence by stage. Analysis.-None has apparently been published. Iron, common salt, and sulphur are strongly perceptible to the taste. These springs, about one hundred in number, throw out a copious supply of water, varying in temperature in the different springs from 130° to 150° F. There are many natural curiosities in the neighborhood, notably numerous caves, containing boiling springs, filled wit h hot vapor, thus forming natural vapor baths. The property is owned by a land company, who pur- pose forming a town and a health resort. Railway connec- tion with Denver is now in process of construction. The invigorating air, beauty of scenery, fine hunting and fish- ing, and mineral wealth of the surrounding region, should eventually render Glenwood Springs a flourishing place and attractive resort. G. B. F. The waters of these springs are employed both for drinking and bathing. They are recommended especially in catarrhal affections of the respiratory organs and stom- ach, and on this account Gleichenberg is much frequented by patients recovering from pneumonia and pleurisy, as well as by those suffering from chronic catarrhs of the pharynx, larynx, or bronchial tubes, the early stages of phthisis, and dyspepsia. Milk and whey treatments are also employed. It is probable, however, that much of the benefit experienced in many of these cases is derived from a change of residence and climate. The bathing facilities are excellent, and there is an apartment for the inhalation of the extract of pine-needles. James M. French. GLIOMA. The glioma is a tumor which is found in the central nervous system or in the physiological exten- sions of this, as the retina, the optic and auditory nerves. Virchow was the first to separate the gliomas, as a special class, from the sarcomas and other tumors which appear in the central nervous system. He regarded them as con- nective-tissue tumors originating in the neuroglia, and in their general histological structure conforming to the type of this tissue. Virchow regarded the neuroglia as the connective tissue of the brain, supporting and protect - ing the nervous elements (ganglion cells) which were em- bedded in it. This neuroglia in various portions of the brain differs somewhat in its structure, in some places being firm and fibrous like connective tissue, in others being very soft and granular. Where most characteristic he considered its tissue to be composed of branched cells, lying in a soft and easily altered ground substance. After hardening in various reagents and making fine sections of the brain, a delicate net-work is seen in the neuroglia, so fine that it looks most like a net-work of fibrin in which white corpuscles are entangled. The cellular elements are so fragile that in ordinary methods of preparation the cell body breaks up and an appearance of free nuclei is given, but on more careful preparation the pells are seen to have numerous very fine branches, which usually con- nect with the net-work in the tissue around the cells. The GLEISWEILER. An institution for the administration of the cold water, milk, and whey cures, in the Rhenish Palatinate of Bavaria, one hour's ride from the railroad station, Landau. The climate is mild and regular, the northern and northwestern winds being obstructed by the hills, rendering the resort well suited to delicate invalids. J. M. F. GLENN SPRINGS. . Location arid Post-office, Glenn Springs, Spartanburg County, S. C. Access.-To the city of Spartanburg, via Richmond A 344 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Oleiclienberg. Glioma. neuroglia is firm and fibrous in character around the ven- tricles. These differences in structure, Virchow says, are not greater than the connective tissue in other parts of the body shows. According to him there could be either a diffuse hyperplasia of this tissue, or tumors could form in it. The differences in structure of the tumors which formed in it might be due either to different steps in the development of the tumor or to its place of origin, the tu- mor partaking more or less of the structure of the mother tissue. These views of Virchow have been generally followed, but other investigators have arrived at very different con- clusions both as to the neuroglia and as to the gliomas. There is scarcely any tissue in the body about which the results of histological investigation are so vague, and the conclusions formed so various, as is the case with the neu- roglia. There should be in the brain an epithelial tissue derived from the epiblast, comprising the ganglion-cells of the gray matter, and a connective tissue derived from the mesoblast, comprising the nerves, the blood-vessels, and the supporting tissue. Such a distinction of parts cannot be made out from microscopic investigation, and so com- plicated are the structures that the most carefid study of embryonic development has failed to give any certain conclusions regarding it. Schwalbe regards the support- ing framework of the brain and cord as composed of two different tissues. One consists of the coarse bundles of con- nective tissue which pass into the cord from the pia mater and form the septa between the nerve-bundles ; in the brain there are similar prolongations which pass into the tissue with the blood-vessels. This tissue must be sepa- rated from that which lies between the nervous elements. This tissue Schwalbe regards as an epithelial structure which originates in the ectoderm ; it consists of a glue-like material which binds the different elements together. The cells found in this are star-shaped, with long, thin, branch- ing processes, and have no essential relation with the nerve-tissue proper, bearing about the same relation to it as the cells of Langerhans bear to the epidermis in which they are embedded. A special form of this tissue is found in the substantia gelatinosa of the cord, and on the surface of the brain ; it consists of a net-work with narrow meshes, and, according to the investigations of Kuhne and Ewald, consists of horny material. Schwalbe thinks that it has developed from the melting together of horny cells from the germinal layer, and the nuclei found scattered through it represent the remains of these cells. It seems to the writer that we are not justified in denying to the branched cells {Spinnenzellen of Deiters) in the neuroglia a place in its essential structure. In the general paralysis of the insane, where there is a general diffuse sclerosis affecting principally the convolutions of certain districts of the brain, these cells are found in great numbers, both in the cortex and in the white substance immediately beneath it. In one case, where there were circumscribed hyper- plasias of the gelatinous tissue of the brain, occurring in the form of small elevations little larger than the head of a pin, scattered over the frontal and parietal lobes, the new formations were composed of tissue, apparently fibrous in character, in which numerous branched cells were embedded. Virchow did not deny that the glioma differed consid- erably from its mother tissue, the neuroglia, in being more vascular, in having a greater abundance of cells which differed very much in form and size, and in the various characters which the intercellular substance offered. He compared these differences with the differ- ent appearance which the neuroglia in several parts of the brain presented, and divided the tumors into several forms-the medullary (soft), the fibrous (hard), and the telangiectasic (characterized by the abundance of its vessels). He described also combinations of the tumor with fibromata and myxomata, with gradual transition to the various species of sarcoma. Simon found in the gli- oma, cells with numerous processes, which appeared very similar to ganglion-cells, but he did not doubt their con- nective-tissue character ; he therefore formed another division of the tumor, the spider-cell glioma. The in- vestigations of Flcischl. Klebs, Gerlach, and Golgi ef- fected a complete change in the ideas which had been held concerning the glioma. Fleischl showed division in the nerve-cells in a gli- oma of the brain, and proved that most of the cells of the tumor were of nervous origin. Klebs described more particularly the various changes which the nerve-cells underwent in the formation of the tumor-cells. According to him, not only did the tumor cells arise from the ganglion-cells, but also from the nerve-fibres. He called the tumor neuroglioma, and held that the principal factors in its pro- duction were the true nervous parts of the brain, the ganglion-cells, and nerve-fibres. That the branched cells of Deiters took part in its for- mation he did not deny, but ascribed to these structures a very subordinate place. The tumor represents a hyper- plasia of all the elements of the tissue, and stands in the same relation to the brain as elephantiasis does to the soft parts of the extremities and body. Klebs describes three stages of development of the gli- oma, which correspond to the three types of structure which are described by other authors. In the first stage the tumor is very vascular, and composed principally of small round-cells, with large nuclei and refractive nucle- oli. The blood - vessels are wide, with thick proto- plasmic walls. In addition to the round-cells, gan- glion-cells in pro- cess of division can be seen, and. other cells with irregular processes, evident- ly of nervous ori- gin. The second stage corresponds close- ly to the type of the tumor which Vir- chow described. In this the nerve- cells which were present in the first stage have become similar to lymph- cells by their con- stant division. In the third stage the cells are princi- pally star-shaped, with long branch- ing processes. Sometimes the cells correspond to the spider-cells of Deiters ; there is a cell-body with but little protoplasm around the nucleus, and from this nu- merous long, hair-like processes are given off. The nerve- Fig. 1403.-From a Spider-celled Glioma of the Brain. Cells isolated by teasing. (After Zieg- ler.) 345 Olioma. Glottis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cells found in the glioma depart in some respects from the type of nerve-cells ; they are without pigment, but can be distinguished from connective tissue cells by the length of their process, which sometimes shows distinct fibrillation, and by the large nucleus with a shining refrac- tive nucleolus. They often have the distinct triangular shape of normal nerve-cells, one process being extremely long, and the others short; they can be distinguished from normal nerve-cells by their thick heaping together and their irregular distribution. When the tumor is very rich in cells, these may assume a spindle shape in conse- quence of pressure, and the tumor will then appear strikingly similar to a spindle-cell sarcoma. Besides the blood-vessels there are numerous large open spaces, which evidently are lymphatics, as has been shown by staining with nitrate of silver. Their great vascularity led Klebs to regard this as the exciting cause of the origin of this tumor, as he regarded lasting hyperaemia as the cause of tumor formation generally. The gliomas are subject to all manner of degenera- tions, particularly the fatty. We find almost constantly the large, pale, granule cells, due to the heaping up of the products of fatty degeneration in the white blood-cor- puscles, and the presence of these cells may cause diffi- culty in differentiating the glioma from apoplexy and softening of the brain, in which conditions they are also constantly found. Sometimes the fatty-degenerated por- tions are absorbed, leaving a cyst with firm w'alls, which may be mistaken for an apoplectic cyst, or the degener- ated portions may be- come changed into a dry, necrotic, caseous material. When this form of degeneration involves a large area of the tumor, it may read- ily be mistaken for a tubercle. There is one form of degeneration which points clearly to the nervous nature of this tumor-this is the sclerosis first described by Fleischl. In this the cells become very large, of a pale-yellow color, firm and refractive. The nucleus is the last part of the cell to un- dergo this transforma- tion, and, until it takes place, appears as a clear space in the cell-body. The cells finally melt together into a firm, brittle mass, which lies principally along the blood-vessels. Lime salts may be deposited in this, and large concretions be found in the tumor. Virchow gave as the type of the fibrous glioma the small granulations found in the ependyma in chronic hydrocephalus and in general paralysis. These granula- tions Klebs does not regard as belonging to the gliomata, but considers them to be pure fibromata. Haemorrhage is common in gliomas, as might be sup- posed from their vascularity and soft structure. It is often very extensive, and when the tumor is cut open the similarity of it to a cerebral haemorrhage is so great that it is often impossible to distinguish between the two by the eye. The difficulty is increased in the case of old tumors with repeated haemorrhages. The locality of the haemorrhage will assist somewhat in making the diagnosis, because the glioma is most often found in the white sub- stance of the brain, where cerebral haemorrhage is of less frequent occurrence. The firm gliomas are usually of small size, seldom reaching that of the fist, and are less common than the soft. Their growth is slow, usually without symptoms, and they are found most often in old people. They are often multiple. The soft glioma is not sharply separated from the brain-substance, and in prep- arations hardened in alcohol it is impossible to say where the tumor begins. Often the only thing to lead to the supposition of the presence of a tumor is the enormous increase in one side of the brain. From the abundance of the vessels these growths have a pinkish hue, and an opaqpe bluish color, not unlike that of cartilage, is more or less characteristic. From sarcoma the glioma is chiefly distinguished by its imperfect differentiation from the surrounding brain-structures. When the glioma is situated near the thalamus opticus, and in the posterior lobe, it often causes internal hy- drocephalus by pressing on the vena choroidea, the vena magna Galeni, and the sinus transversus. The gliomas seldom reach any large size without giving rise to symp- toms which will vary accord- ing to the seat of the growth. The symptoms may run for a long time, or, without any premonitory symptoms, there may be suddenly a paralysis, a coma, or other symptoms similar to an apo- plectic attack. This is most often seen in children. Hu- ber reported a case where a child, after vaccination, was suddenly seized with paraly- sis in the vaccinated arm ; coma and death soon followed. The autopsy revealed a glioma in which a recent haemorrhage had taken place. Next to glioma of the brain in importance and fre- quency comes glioma of the retina. The nervous origin of this is also undoubted, and elements which closely re- sembled rods and cones have been found newly formed in the tumor. Virchow held that here the tumor pro- ceeded from the granular layer, but it is evident that the FfG. 1405. - Section of the Eye from a Case of Glioma of the Retina. 1. Cornea; 2, sclerotic ; 3, sheath of the optic nerve; 4, optic nerve; 5, unaltered cho- roid ; 6, unaltered part of the retina; 7, retinal tumor; 8, shrunken vitreous. (After Hirschberg.) Fig. 1404.-Section of the same Tumor, after Hardening in Mueller's Fluid. (After Ziegler.) Fig. 1406.-Section of Apparently Normal Retina in the Neighborhood of a Large Glioma. At I a microscopic glioma nodule. (After Hirsch- berg.) new formation of cells does not proceed from this tissue alone. The cells of the granular layer produce a great quantity of cells, the connective tissue also increases with the production of spindle-cells, forming a net-work in whose meshes the round-cells frequently lie, giving an appearance similar to an alveolar sarcoma or carcinoma. 346 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glioma. Glottis. The internal limiting membrane is pushed up before the growth, and often retains its structure for a long time. The retina remains attached to the choroid, or, in conse- quence of an exudation, is thrust away from this, and only remains attached by the optic papilla and ora ser- rata. Finally, the eye-bulb becomes swollen, and the lens and iris are pushed forward against the cornea, which be- comes reddened, stretched, and finally broken through. The tumor then protrudes from the eye, grows very rap- idly, and bleeds easily. In some cases the growth takes place in the contrary direction ; the tumor breaks through the sclera and advances along the optic nerve. Foci of the tumor not connected with the main growth, but ap- parently true metastases, may be found in the choroid. Any of the degenerations which are found in the brain- tumors may also be found here. Metastasis takes place more often in glioma of the eye than in glioma of the brain. Metastasis is not confined to the nervous structures, but may extend to the liver, lungs, and other organs. Those tumors in which the cells are small and round, and repre- sent either an earlier stage of development or a closer ap- proach to the embryonic character, are most apt to form metastases. Most authors suppose that this takes place along the lymph-sheaths of the optic nerves or the peri- vascular lymphatics. The cases in which metastases are found in the liver and kidneys would denote that the blood-vessels may also serve as the carriers. In many cases both eyes are affected, often almost simul- taneously. In these cases it is probable that the tumor had an independent origin in each eye. The right eye, in a small majority of cases, is more often attacked than the left. The tumor may arise from the optic nerves; in the 45 cases of glioma of the orbit which Lemcke has col- lected the optic nerves were twice the starting-point of the growth. In the brain the cerebrum is more often the seat of the tumor than the cerebellum. In 38 cases which Lemcke has collected, where the glioma was seated in the cere- brum and its connections, it was seen eleven times in the frontal lobes, and four times in the occipital. There is no difference in the liability of the different sexes to glioma. There is an essential difference in regard to the age at which these tumors appear in the eye or in the brain. Glioma of the eye belongs to an early age of childhood. In 45 cases, Lemcke gives the age in 34 be- tween six months and five years, in 6 between five and ten years, and only in 3 was a higher age than this reached. He was not able to find a single case in which the tumor developed in the brain at this early age. Nothing is known as to the cause of this tumor. Trauma could hardly be assigned a high place in its pro- duction. William T. Councilman. ized in severe cases by orthopnoea, stridulous breathing, and dysphonia or aphonia. This condition, imperfectly recognized by the older writers, was first scientifically de- scribed by Bayle in 1815. Sestier, in 1852, published a standard treatise upon it, in which the observations of previous writers were collated and much valuable infor- mation given. According to his statistics, the influence of age and sex is marked. It is rare before eighteen, but prevails from that time to fifty, its maximum being be- tween eighteen and thirty-five. Of 187 adults, 131 were men and 56 women. Acute oedematous laryngitis may be either primary, attacking a healthy person, or secon- dary, occurring in the course of other disease. It is called typical w'hen it originates in the larynx, contigu- ous when it spreads from the pharynx or other parts, and consecutive where it occurs as a sequel to disease of the cartilages or other structures of the larynx. Typical oedema is rare. Sestier's statistics show that it occurred in but six per cent, of all his cases ; that among 245 cases, but two were children, and in the fifteen ex- amples of simple oedematous laryngitis occurring among adults, fourteen were men, and only one a woman. Morell- Mackenzie believes that, in nearly all cases of so-called simple inflammation, the disease is due to blood-poison- ing, and states that in every case which has come under his notice ample opportunity for acquiring septicaemia was present. Contiguous oedematous laryngitis is the most common form of the disease. Of the cases recorded, the greatest number have been between the ages of twenty and fifty, and the proportion of men to women as two to one. The pharyngeal inflammation was not necessarily severe, and the laryngeal oedema generally supervened during the height of the attack. Sometimes it is apparently of an erysipelatous nature. Very rarely contiguous oedema may begin in the trachea and ascend to the larynx. It may also complicate aneurisms of the aorta or vessels of the neck. Consecutive oedematous laryngitis generally follows dis- ease of the cartilages or perichondrium, or, more rarely, deep or extensive ulceration. Acute oedema is sometimes secondary to tonsillitis, erysipelas, small-pox, typhoid fever, and even scarlet fever. It may occur in tubercu- lar and syphilitic inflammation of the larynx, although chronic oedema is more common in these latter affections. It may be found also in the anasarca following scarlet fever, and sometimes in Bright's disease. The symptoms of laryngeal oedema are dyspnoea, more or less dysphagia, and aphonia, the latter increasing until the voice is almost extinct. There is little cough or expectoration, the latter being confined, as a rule, to the expulsion of small quantities of frothy mucus. The dyspnoea is marked and very distressing, and inspiration is accompanied by a whistling sound, which indicates a narrowed condition of the glottis. Although usually more or less constant, the dyspnoea may occur in paroxysms, in any one of which a fatal result may ensue. " In these attacks the patient sits up in bed, with his mouth open, and gasps for breath. His eyes start from his head, and his whole body often trembles with an intense convulsive movement." In short, the symptoms are those of acute asphyxia. General cyanosis commences and, unless re- Fig. 1407.- General (Edema of the Larynx. (Browne.) GLOSSY SKIN. A term applied to a peculiar cutane- ous change which occurs as an occasional symptom of certain organic nervous diseases, and is found in associa- tion with other trophic disturbances. The skin of the lower extremities usually becomes tense, shiny, and like morocco, and may present a vivid red color, resem- bling erysipelas. There is no pain nor inflammatory dis- turbance. This condition may last for months or years. In one' case, that of a negress suffering from posterior spinal sclerosis, while the skin of the rest of the body was rough and of natural aspect, that of both legs from the ankles to the knees was shiny, and appeared to be tightly drawn. A form of trouble of peripheral origin, due to trauma- tism, and accompanied by neuralgia, has been described by Gull and Mitchell. The redness resembles erythema, the skin is thin and atrophied, and the folds are effaced. Ar- nozan has compared the appearance to that which would result from the application of a coat of varnish. Occa- sionally there are areas of sensitiveness, corresponding to the ramifications of the diseased nerve. A. McL. H. GLOTTIS, (EDEMA OF ((Edematous Laryngitis, Phlegmonous Laryngitis, Submucous Laryngitis). An acute infiltration of a serous, sero-purulent, or purulent fluid into the areolar tissue of the larynx, and character- 347 Glottis. Gm mi den. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lief be afforded, death rapidly follows. Physical exami- nation by the finger or, far better, by the laryngoscope, may show the epiglottis and also the ary-epiglottic folds to be much thickened. As seen in the illustrations (Figs. 1407,1408, and 1409), the normal outline of the larynx may be entirely lost, and instead of the leaf-like epiglottis and the sharp, well-defined edges of the ary-epiglottic folds, we may see nothing but three large, rounded, red, semi- translucent eminences, which occupy the glottis so fully that there is left between them but a small, triangular space. Or the epiglottis may be the principal seat of the tumefaction, and appear as two rounded, thickened prominences. Or, again, the ary-epi- glottic folds may be principally involved, acting as valves and ef- fectually shutting off the inspiratory current of air. The vocal bands themselves are rarely involved, but the oedema may some- times be subglottic. Pathologically, the condition is found to be an infiltra- tion of a serous, sero-purulent, or purulent fluid in the sub- mucous connective tissue. The infiltration is generally sero-purulent, pure serum being found only in acute and rapidly fatal cases. The pus is always diffused, and ab- scess never occurs in acute cases. Blood is sometimes found in the tissues, and denotes inflammation of a rapid and severe course. It will thus be seen that the swelling, in the great majority of cases, is not caused by a simple watery exuda- tion, for, as appears post mortem, upon cutting into the diseased parts little.escape of fluid takes place, while sometimes even firm pressure between the fingers fails to empty the cede- matous structures. The epiglottis, from its situation near the pharynx, more commonly the ary-epiglottic folds, by reason of the laxity of their submucous areolar tissue, and, finally, the ventricular bands, are the parts usually affected. The muscles themselves are often infiltrated. Later in the course of the disease the tissues present a shrivelled and sodden appearance. In contiguous cede- not be demonstrated. Blood and pus are occasionally poured forth from spontaneous rupture of the mucous membrane. Often the swelling migrates, decreasing on one side and increasing on the other. The prognosis is either recovery or else death by asphyxia or pneumonia. He considers the disease erysipelatous for the following reasons: 1, Its rapid development and its tendency to wander, as well as its predilection for parts in which the lymphatics are abundant; 2, the constitutional symptoms, which resemble those of erysipelas; 3, its want of resemblance, from its migratory character, to the ordinary forms of laryngitis ; 4, the tendency of the disease to extend to the lungs; and, finally, its occur rence during the course of epidemics of erysipelas. He concludes that: 1, There is a primary erysipelas of the larynx ; 2, many cases reported as primary oedema of the larynx are really cases of erysipelas-this occurring more commonly than is generally supposed ; 3, there are two forms: in the first the local manifestations precede the general; in the second they close the scene. The analogy between the so-called oedematous and erysipelatous laryn- gitis is thus seen to be strongly marked. In the diagnosis of this dangerous affection the laryngo- scope is an invaluable resource. Palpation is most un- satisfactory, owing to the great indistinctness in outline of the parts and the wide departure from their normal re- lations which has often taken place. It is extremely un- comfortable and even painful to the patient, and most serious of all, is liable to induce dangerous attacks of glottic spasm. The conditions with which oedematous laryngitis may be confused are laryngismus stridulus, polypus, retro-pharyngeal abscess, and foreign bodies in the larynx. Laryngeal diphtheria may be excluded by the absence of false membrane in the pharynx, or in the Fig. 1408.-(Edema of Epiglottis and Right Ary-Epiglottic Fold. (Browne.) Fig. 1410.-Gurdon Buck's scarificator for (Edema Glottidis. expectoration, while other causes of dyspnoea may be excluded by the history and by a laryngoscopic examina- tion. The prognosis is bad, excepting in slight cases, or when the oedema is partial. Septicaemia, asthenia, or pneumo- nia is apt to supervene, even when the laryngeal ob- struction has been relieved. Sestier states that death resulted in 158 out of 213 cases, although tracheotomy was performed 30 times. In 58 recoveries tracheotomy was performed 20 times. Bayle reports 17 cases with 16 deaths. Mackenzie says that " secondary oedema is more fatal than primary." The prognosis also depends on the kind of oedema, as well as on the age and sex of the pa- tient. Typical oedema is almost always fatal, while the contiguous form generally does well if the inHammation start from the pharynx. When, however, it spreads from the neck or chest, it is always fatal, and nearly always sowhen it begins in the external areolar tissue. In consecutive oedema the prognosis depends upon the nature of the original disease. It is more serious in men than in women. The highest proportionate rate of mor- tality occurs between ten and thirty and between fifty and seventy years of age. Prompt treatment directed to the relief of the con- dition must be adopted. While a certain amount of relief may follow the use of derivative remedies, it is upon local measures that reliance must be placed. Local bleeding, by means of leeches applied upon the neck over the sides of the larynx, is sometimes useful in mild cases. Astringent inhalations, together with the frequent swallowing of cracked ice, may also be tried, and a seda- tive, such as bromide of potassium, may be administered. In cases of any severity much more active measures will be necessary. Of these, scarification, the method so ably advocated, many years ago, by the late Dr. Gurdon Buck, of New York, stands pre-eminent. The operation may Fig. 1409.-Sub-Glottic CEdema. (Browne.) matous laryngitis the neighboring tissues are often found to be distended with fluid. Massei has endeavored to prove that the so-called prim- ary oedema of the larynx, or phlegmonous laryngitis, corresponds clinically to a localization of erysipelas in the larynx. He describes the objective symptom of the disease as being a marked swelling, which, beginning at the epiglottis, extends to the mucous membrane of the ary-epiglottic ligament and the inter-arytaenoid space, causing dyspnoea, dysphagia, and aphonia. The onset is generally sudden, and the laryngoscope shows such intense swelling that the interior of the larynx can- 348 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Glottis. Gmunden. be performed with a curved bistoury, guarded through- out all but the last quarter-inch of its length by adhe- sive plaster, with the excellent scarificator of Dr. Buck (see Fig. 1410),* or by means of a guarded laryngeal lan- cet. Although the operation may be successfully per- formed by using the linger as a guide, it is far more safely, accurately, and thoroughly accomplished when done by the aid of the laryngoscope, so that through the medium of distinct vision the instrument may be applied to the exact location desired. Several incisions may be made, and it may be necessary to repeat the operation at short intervals a number of times. After scarification, much can be done to assist in the reduction of the parts by means of hot inhalations and gargles. Should scarifi- cation not produce the desired results, an early tracheot- omy must be performed. In fact, in the experience of the writer, the greatest danger lies in the failure to recog- nize in time the necessity for this operation. Violent inflammation of the larynx, involving the-sub- mucous areolar tissue, may result from scalds, corrosive poisons, or the impaction of foreign bodies. This sub- ject will be treated of under the head of Surgical Injuries of the Larynx. ence, oily to the touch, hygroscopic, without odor, very sweet and slightly warm to the taste, and neutral in re- action. It is soluble, in all proportions, in water and in alcohol, also in a mixture of 3 parts of alcohol and 1 part of ether, but insoluble in ether, chloroform, benzol, or fixed oils. Its specific gravity should not be less than 1.250, corresponding to the presence of at least ninety-five per cent, of absolute glycerin. In solution with water it is slowly vaporized, with steam, at 100° C. (212° F.); exposed alone to higher temperature, it yields acrid de- composition vapors of a characteristic odor, with a little glycerin vapor, and at 290° C. (554° F.) it boils and is de- composed."-U. S. Ph. In its medicinal relations glycerin is unique, from its possession of the following combination of qualities: It is at once viscid, non-volatilizable, unalterable on exposure, antiseptic yet non-poisonous, and has an unusual range of solvent powers, dissolving bromine, iodine, sulphur iodide, the fixed alkalies, lime, tannic and other vegetable acids, many vegetable organic principles, such as salicin and santonin, sugar, gum, and pepsin, and very many inor- ganic salts. Upon the living animal organism glycerin, in concentrated condition, is somewhat irritant to very sensi- tive parts, probably because of abstraction of water from the tissues; but upon ordinarily circumstanced surfaces it is perfectly bland. Swallowed by the human subject in quantities of an ounce or more, glycerin produces no other derangement than a very mildly laxative action, but, ex- perimentally administered to the lower animals, it proves toxic, producing tetanus in the frog, apparently from direct action upon the muscular tissue (Amidon : Archives of Medicine, October, 1881), and varied signs of nervous derangement in rabbits and dogs, even to death by con- joint failure of respiration and heart-action. The uses of glycerin are, pharmaceutically, as a solvent, preservative, and sweet-tasting viscid addition to fluid preparations, or pill-masses ; and surgically, as an anti- septic, bland and unalterable viscid application to wound surfaces and sores. Medically, glycerin has been used as a laxative in cases of haemorrhoids, as a preventative of the development of flatulency, pyrosis, and the fermenta- tion of the ingesta in the alimentary canal (Ringer and Murrell), and as a harmless sweetening addition to foods in cases of diabetes mellitus. A reputation which the substance once enjoyed, of directly tending to oppose the morbid process of diabetes, is now no longer credited. Glycerin may be given internally in quantities varying from a teaspoonful to a tablespoonful. Edward Curtis. Bayle : Nouveau Journal de Medecine. Janvier. 1819. Gurdon Buck : The Treatment of (Edema of the Larynx by Scarification, Med. and Surg. Review, 1850, vol. vii., p. 281. Sesticr: Traite de 1'Angine laryngee oedemateuse. Paris, 1852. Morell Mackenzie: London, 1880. Charazac, J. : ktude sur I'CEdeme du Larynx. Paris, 1885. D. Bryson Delavan. Bibliography : GLYCERIN. Glycerin (CsILOs) is, chemically, an al- cohol-propenylic alcohol (C3H5(OH)3), and results from the decomposition of natural fats by alkalies. The U. S. Pharmacopoeia recognizes under the title Glycerimtm, Glycerin, " a liquid obtained by the decomposition of fats and fixed oils, and containing not less than ninety-five per cent, of absolute glycerin." Glycerin can be obtained as a by-product in the making of lead-plaster or of soap, but is derived in purest condition by acting on fats with water at a high temperature, under pressure. Under those con- ditions the fats break up into glycerin and fatty acids. Glycerin so prepared is known as distilled glycerin, and the famous Price's Glycerin is of such kind. Glycerin appears as " a clear, colorless liquid, of syrupy consist- * The author's description of the procedure is quoted here in full: " The following is the mode of performing the operation of scarifying, as employed in the cases about to be related. " The patient being seated on a chair, with his head thrown back and supported by an assistant, he is directed to keep his mouth as wide open as possible ; and if there be any difficulty in this respect, a piece of wood an inch and a fourth in width, and half an inch in thickness, is to be placed edgewise between the molar teeth of the left side. The forefinger of the left hand is then to be introduced at the right angle of the mouth, and passed down over the tongue till it encounters the epiglottis. " But little difficulty is generally experienced in carrying the end of the finger above and behind the epiglottis so as to overlap it and press it forward toward the base of the tongue. In some individuals the finger may be made to overlap the epiglottis to the extent of three-fourths of an inch. "Thus placed, the finger serves as a sure guide to the instrument to be used, which is represented accurately in the accompanying plate. The knife is then to be conducted,with its concavity directed downward, along the finger till its point reaches the finger-nail. By elevating the handle so as to depress the blade an inch to an inch and a half farther, the cutting extremity is placed in the glottis between its edges ; at this stage of the operation the knife is to be slightly rotated to one side and the other, giving it a cutting motion in the act of withdrawing it. This may be re- peated two or three times on either side without removing the finger. The margin of the epiglottis, and the swelling between it and the base of the tongue, may be scarified still more easily with the same instrument, or scissors, curved flatwise, may be employed for these parts, guided in the same manner as the knife. " Though a disagreeable sense of suffocation and choking is caused by the operation, the patient soon recovers from it, and submits to a repeti- tion after a short interval. In every instance the operation has been performed twice, and in some, three times." (Edematous Laryngitis, successfully treated by Scarifications of the Glottis and Epiglottis, by Gur- don Buck. Jr., M.D., Surgeon to the New York Hospital. From vol. i., p. 136, of Transactions of the American Medical Association, 1848. See also "Six additional cases of (Edematous Laryngitis, successfully treated by the Scarification of the Epiglottis," etc., by Gurdon Buck, M.D. Transactions of American Medical Association, vol. iv., 1851, p. 277. The small knob shown in the illustration was added at a later date, and is intended to serve as an aid to the operator in estimating, by the sense of touch, how far down the cutting end of the instrument has been introduced. GLYCERITES. The following so-called glycerites are officinal in the U. S. Pharmacopoeia (revision of 1880): Glyceritum Amyli, Glycerite of Starch, Amylo-glycerin. This is a ten per cent, starch-paste of a glycerin basis, made by mixing ten parts of starch with ninety of gly- cerin, and heating, with stirring, till a smooth, translucent jelly is formed. The preparation is used as a basis for medicated ointments when it is desirable that the same shall be miscible with aqueous fluids. It keeps well. Glyceritum Vitelli, Glycerite of Yolk of Egg: Glyconin. This preparation is compounded of forty-five parts of fresh egg-yolk and fifty-five of glycerin, intimately mixed. The mixture forms a permanent emulsion that keeps in- definitely, and may be used as a protective dressing, or may be prescribed as a basis for medicated emulsions. It is much used as an emulsifier for cod-liver oil. Edward Curtis. GMUNDEN. A village in Upper Austria, on the Elis- abeth and Western Railroad, at the origin of the Traun River from the lake of that name, at an elevation of 1,350 feet above the sea. The situation is rendered attractive by the lake, which is nine miles long and a third as wide, and the surrounding hills. The climate is mild, the tem- perature averaging from 13° to 14° C. (55° to 56.8° F.) dur- ing the summer. During the forenoon the wind generally blows from the south ; in the afternoon from the north, shifting again to the south in the evening. The Gmunden hospital is provided with a drink-room, where mineral waters, whey, and the juices of herbs are 349 Gm linden. Goitre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dispensed, and with a bathing department. In the latter are found peat-baths, containing twenty-four per cent, of salts from the saline lake Eben; as well as vapor-baths and pine-needle extract baths. There is also a swimming school for cold bathing in the lake. J. M. F. flainmatory, non-malignant enlargement of the thyroid body. Classification.-Goitres may be acute or chronic, en- demic or epidemic. According to their pathological characteristics they may be divided into : 1. Hyperaemic. 2. Parenchymatous. 3. Fibrous. 4. Vascular. 5. Col- loid. 6. Cystic (Lucke). This classification, like all others, is an arbitrary one. It is difficult to draw the lines which separate the several varieties. The differences are of degree rather than of kind. The primary pathological changes are hyperaemia and hyperplasia of the gland, to which are superadded the fibrous, colloid, cystic, amyloid, and calcified varieties as a result of the continuance of the original cause, the preponderance of increased growth in one tissue or the other, or the retrograde metamorphoses to which all hy- perplastic tissue is liable. Clinically, it is useful to dis- tinguish three varieties, viz., the vascular, parenchyma- tous, and cystic. Pathological Anatomy.-See next article. Causes.-The etiology of goitre is involved in much doubt. Certain facts, however, relating to its appearance, have been established. Goitre is more frequent in females than in males ; this difference is most marked before pu- berty, the proportion varying from 2 to 1 (Baillinger) in some localities, to 44 to 1 (St. Sager) in others. The ten- dency to goitre in both sexes is most marked at the time of puberty. The commencement of a goitre can often be traced to repeated congestions of the thyroid body, occurring at the time of menstruation or during pregnancy (Liicke). Goitre is hereditary and congenital. Violent efforts cause acute goitre (cases collated by Welch). Goitre is endemic in certain localities. These are situ- ated for the most part in the temperate zone, are found most numerously in the Alps-Italian and Swiss, and in the Pyrenees; in France ; in certain portions of England, especially Derbyshire and Nottinghamshire ; among the Himalayas ; in certain portions of North America, and in the Andes. The classical situation is one of the deep and narrow Alpine valleys, that is exposed to the sun's rays but for a few hours daily; where the ground is damp and saturated with the salts of lime; where the in- habitants are of a low order intellectually and morally ; where intermarriage is common, the means of subsistence meagre, and the dwellings bad and unhealthy; and where cretinism is prevalent. It would seem that by studying the general conditions- social, atmospheric, and telluric-with which those hav- ing goitre are surrounded, the cause or causes of thyroid enlargement could be definitely determined. Such, how- ever, is not the case. As seen above, certain factors re- garding the time of its appearance, the sex most often attacked, and its geographic distribution, have been es- tablished. The cause or combination of causes is still shrouded in uncertainty. Those circumstances most often accused of implication in the etiology of goitre are : the drinking of snow and glacier water ; of water impregnated with chalk ; the as- cent of high mountains ; the carrying of heavy loads upon the head ; bad air and bad surroundings. But no one of these causes prevails in all the places in which goitre is found, and hence no one of them is indispensable in its formation. The often-quoted observations of Humboldt regarding the prevalence of goitre in South America, in places differing from each other most markedly in atmos- phere, temperature, and the formation of the earth's sur- face, show how varied may be the conditions under which these tumors appear, and how difficult it is to point to one condition of which it can be positively asserted, this is the exciting cause. Especially interesting, in this connection, are the epi- demics of goitre which have occurred from time to time in soldiers newly arrived in barracks situated in a goi- trous district. During one of these epidemics, about thirty per cent, of the members of the regiment were at- tacked with swelling of the thyroid body, which only disappeared, and that slowly, after removal from the dis- trict. GNAPHALIUM. Cudweed (Pied de chat, Codex Med.), the flowering heads of Gnaphalium dioicum Linn. (Anten- naria dioica), order Composita. The plants of this genus, of which there are quite a number, are low, herbaceous weeds, usually gray, with an abundance of woolly hairs on their stems and leaves, and small, often inconspicu- ous composite flowers. G. dioicum grows abundantly in the pastures and mountains of Europe, and is a house- hold "herb" for coughs, colds, etc., among the common folks. Several other species there, and one or two in this country, have been put to the same service. Their properties are similar, but inferior, to those of Chamo- mile. TE P. Bolles. GOCZALKOWITZ. An institution for the administra- tion of peat-baths in Prussian Silesia, about one mile from the railroad station Pless, at an altitude of 650 feet. The peat which is employed is characterized by the presence of a considerable amount of iodine and bromine, in com- bination with magnesium. One pound of it contains : Grains. Magnesium iodide 0.952 Magnesium bromide 0.696 Sodium chloride 252.364 Calcium chloride 41.930 Magnesium chloride 24.222 Ferrous chloride 0.921 The baths are given at a temperature of 15.25° C. (nearly 60° F.), the entire body being immersed. The peat is usually diluted with pure or mineral water. Ar- rangements are present also for the administration of va- por-baths and inhalations from the peat, and the milk and whey cures are practised, either cow's or goat's milk being used. Indications.-The diseases for which the water and baths of Goczalkowitz are recommended are scrofula, rickets, rheumatism, gout, paralyses, and exudative affec- tions of the pelvic organs. The peat that is used at the baths is prepared for exportation in the strength of 1.2 per cent. Bathing salts are also prepared, of which about three pounds Troy are dissolved for a bath. J. M. F. Total 321.085 GODESBERG, a village near Bonn, in one of the most picturesque regions of the Rhine, is of interest on account of its well-equipped water-cure and bathing establish- ment. The mineral springs from which these are sup- plied belong to the alkaline chalybeate class. These are well represented in the analysis of the Old Spring by Mohr, which shows in one litre : Grammes. Sodium chloride 9.960 Potassium sulphate 0.301 Sodium sulphate 3.526 Calcium phosphate 0.008 Silicic earth 0.378 Sodium carbonate 10.396 Magnesium carbonate 4.342 Calcium carbonate 2.('>79 Ferrous carbonate 0.210 Total 31.800 Cub. in. Free carbonic acid gas 9.852 The water which is exported is said to be free from iron. The New Spring contains a somewhat larger amount of iron (0.42), but is weaker in the total amount of salts (20.28). J. M. F. GOITRE (Lat., Guttur, the throat). Synonyms.-Bron- chocele, Wex. Derbyshire neck (Eng.); Kropf, Struma (Ger.); Gozzo (Itai.); Guttur Tumidum (Pliny); Thyreo- cele(P. Frank); Thyreophraxia (Alibert); Botium Trache- lophyma (Sagar); Gongrona, Grosse Gorge, Gros Cou. Definition.-Goitre is a term applied to auy non-in- 350 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gmiinden. Goitre. Symptoms.-The symptoms of goitre depend upon two circumstances, the presence of a tumor and the amount of pressure which it exercises upon the cervical structures. The tumor is connected with the trachea. During deglu- tition, if it be not too large, it moves vertically. The in- tegument over the tumor is normal and freely movable. One lobe only of the thyroid gland may be enlarged, or both, with the isthmus, may be included in the common hyperplastic change. The size of the tumor may be so small as to cause only a gentle fulness of the neck, or it may weigh many pounds (ten), overhanging the sternum and reaching from the ears to the umbilicus. The most common variety, the fibro-cystic, presents an irregular outline, is firm in consistence, and has scattered through it firm nodules and large fluctuating portions, the cysts proper. As the goitre enlarges, it presses upon the organs in its vicinity, and it may be here remarked that the apparent size of a goitre is no criterion of the amount of pressure which it may exert, as a tumor which causes but a slight deformity may send prolongations backward and down- ward, compressing most seriously the parts on which it impinges. The trachea is first to suffer from the invasion of the tumor, giving rise to tracheo-stenosis. The symptoms of this affection are, in the milder cases, slight change of voice, and slight embarrassment in respiration. In the severer cases, which appear suddenly and are due to a severe catarrh superimposed upon a narrowing of the trachea, the respiration is much embarrassed, dyspnoea is extreme, and a peculiar noise {bruit cornage tracheal) ap- pears, and death often occurs quickly from asphyxia. If the patient pass through the paroxysm, he is extremely liable to others, during which the danger of succumbing is imminent. The change in the voice cannot always be satisfactorily explained, but is often supposed to be due to pressure upon the thyroid cartilage, preventing its pronation upon the cricoid. If the tumor grow suffi- ciently to involve the recurrent laryngeal or pneumogas- tric nerves, the voice symptoms are more marked and aphonia may result. Pressure upon the phrenic nerve and upon the sympa- thetic nerve has been mentioned. The brachial plexus sometimes suffers in growths of large extent, giving rise to pain or numbness, and par- tial paralysis of the arm. Pressure upon the veins of the neck causes turgescence not only of these, but of those of the face, giving to the individual a peculiar dusky appearance, and leading to a passive hypersemia of the brain. Dysphagia is sometimes a symptom, though rarely. The oesophagus suffers less from pressure of the tumor than do any of the structures of the neck. Its comparative remoteness from the growth, its length and distensibility, allow of an adaptability, not possessed by the trachea, to the encroachments of the tumor, and relieve it from the danger of stenosis. When dysphagia does occur it is prob- able that some inflammation of the oesophagus has taken place, or that the tumor is malignant in nature and in its growth has invaded the oesophagus. Tkeatment.-In the treatment of goitre it is essential to remember that endemic causes play an important role in its etiology ; and to prevent further growth, and to ren- der means of treatment efficacious, it is necessary to re- move the individual affected from their influence. Hence, change of air, locality, manner of life, food, and social conditions, are not only essential, but imperative. Es- pecially has prolonged residence upon the sea-coast proved serviceable in those cases which originated in a mountain- ous district. If the tumor be small, internal remedies may be tried with some hope of success. The only med- icine which has proved of much service is iodine, in its different forms. Discovered in 1815, in 1819 it was in- troduced into medical use by Corindet, of Paris, for the cure of bronchocele. The success which followed its in- troduction was marked. Later, burned sponge became a fashionable remedy, but was discarded upon the discov- ery that its curative powers were due to the iodine con- tained in it. The amount of iodine to be used should be small, but its administration should be long continued, particular care being taken to avoid iodism. The dose is from three to five grains of the iodide of potassium t.i.d. This internal administration of iodine may be com- bined with its local application directly to the tumor, the combined treatment leading to a more rapid reduction in the size of the tumor. But in many cases internal medi- cation proves to be unavailing, and more radical measures are necessary. Injections of different liquids have been used with good results-and here, again, iodine holds the first rank. The method of procedure varies, according to whether a cyst be or be not present. When there is a cyst the con tents are first evacuated with a trochar, and an amount of fluid equal to the contents is injected into the cavity through the trochar. At this point the practice of differ- ent surgeons varies ; some allow the fluid to remain for some time within the cavity of the cyst, while others allow it to flow away immediately. The result of this treat- ment is an inflammation of the walls of the sac, causing their union, and thus obliterating the cavity. The ra- tionale of the treatment is the same as in the cure of hydro- cele. One part of iodine to two of alcohol is a good mix- ture to use, but red wine, perchloride of iron, or any astringent may be employed. Welch gives the results of this practice in 92 cases, as follows : 53 cured, 8 dimin- ished in size, 19 failures, 10 suppuration of sac, 2 died. The method therefore is not entirely free from danger, is not always successful, and oftentimes results in pro- longed and dangerous suppuration. If there be no cyst, injections may be made directly into the substance of the tumor. These parenchymatous injections are especially useful in the softer forms of goitre. In 48 cases treated by this method 32 were cured, 12 improved, in 1 there was return of the tumor, in 2 there was relapse, in 2 there was no result (Levegue quoted by Welch). The employment of the seton was at one time in vogue, but has fallen into disuse, being superseded by better methods of treatment. The same may be said of electrolysis, cauterization, and ligature en masse. Division of the sterno-mastoid muscles has been per- formed in cases in which their rigidity has pressed the tu- mor upon the trachea, with a consequent stenosis of that structure. J. Duncan Gibbs has divided the isthmus of the thyroid body in cases of impending asphyxia as a result of adhesions between the isthmus and the trachea. To reduce the size of the tumor, the ligation of the thyroid arteries has been practised. The operation is to be preferred in cases of vascular goitre upon which iodine has had no effect. If possible, both superior arteries are to be tied at the first operation, and if necessary, the in- ferior arteries may be secured at a subsequent operation. Again referring to Welch's tables : Out of 39 cases col- lected, in 22 there was diminution of the tumor ; in 8 cases there was no diminution of the tumor; in 3 cases the operation was followed by death some time after ; in 6 cases death took place as the result of the operation. The objections to this mode of treatment are, that in the majority of cases the ligature of the arteries necessi- tates the enucleation of so much of the tumor that it is paramount to its removal; the danger of secondary haemorrhage is great, and the results do not justify its adoption except in extreme cases. The only method of treatment which remains to be considered is the extirpation of the goitre. Respecting no operation has there been such a revulsion of feeling in the surgical world as that which has taken place in regard to this during the last few years, especially as a result of successes obtained during the years 1881, 1882, and 1883. Dieffenbach prophesied that it was an operation that would soon belong to the history of surgery. In 1864 Gross called it " horrid butchery," but in 1882 he admits its justifiability, although reserving the operation for those cases in which life is threatened. It is interesting to compare the mortality which formerly took place with that of the last few years. In the first fifty years of this century Susskind gives 351 Goitre. Goitre. REFERENCE HANDBUCK OF THE MEDICAL SCIENCES. 44 cases of extirpation of goitre and 18 deaths, or a mor- tality of 40.9 per cent. From 1850 to 1877 he gives a mortality of 19.4 per cent. From 1771 to 1875 Welch gives 143 cases ; out of these 34 died, or 25.48 per cent. In 203 cases published by Le Bec, the extirpations oc- curring in the years from 1850 to 1883, the mortality was 12.3 per cent., while in a list of cases published by Lieb- recht in the spring of 1883, the mortality is reduced to 8.3 per cent. Gross gives the results of the operations from 1871 to 1882, with a mortality of only 6.93 per cent. This great improvement in the statistics of this opera- tion has been due to several causes. The employment of antiseptic principles in the dressings of the wounds has done away with the most fruitful of all the causes of death-pyaemia and septicaemia. In Le Bec's tables septicaemia heads the list, as in Welch's tables pyaemia and septicaemia together stand first among the causes of death ; while in 31 cases published by Juillard in 1883, no death is due to either of these causes. Haemorrhage during the operation was formerly very frequent, proving a great source of difficulty to the operator, and of danger to the patient. This has been avoided in the later opera- tions by a greater attention to the controlling of each bleed- ing point as it presents itself, and by improved methods of stopping the haemorrhage. Then, again, the class of cases operated upon has been less desperate. Many oper- ations have been performed for the cosmetic effect, and less often than formerly have the patients been in ex- tremis when the operation was undertaken. The method of operating is capable of several modifi- cations. The incision over tjie tumor may be in the shape of a cross, a V, an H, or a T, or may be a single vertical incision in the median line of the neck, or over the most prominent portion of the tumor. Juillard rec- ommends the vertical median incision as giving better ac- cess to the tumor, rendering drainage easier and more complete, and favoring union by first intention. The incision includes the integument and fascia. The muscles covering the tumor are drawn aside, and the cap- sule of the gland is now exposed and incised ; the fingers are introduced between the capsule and the tumor, and adhesions are broken up ; if possible, no cutting with the knife is to be done after the capsule has been incised. Whenever a blood-vessel is to be cut, two ligatures are placed around it, and it is divided between them. This precaution is imperative to prevent haemorrhage during the operation, which is greatly to be dreaded, and to pre- vent the entrance of air into the veins. When the base of the tumor is reached the thyroid ar- teries, if seen, are to be ligated, and then the pedicle is included between two ligatures, and is divided, and the en- tire tumor is removed. The capsule is allowed to remain. There now remains a cavity corresponding to the size of the tumor. -At the upper part the walls can be brought together by pressure, and union is insured, but the infe- rior portion lies behind the sternum, where rigidity pre- vents its approximation to the posterior wall, and conse- quently this dependent pocket is a reservoir for all discharges from the wound. Union by first intention is imperative, for, if suppuration occur, this pocket in the anterior mediastinum fills with pus, good drainage is im- possible, and blood-poisoning occurs from the absorption of the pus. To avoid this result the strictest antiseptic precautions must be taken in the dressings, allowing, if possible, the original dressing to remain until union is complete. William L. Wardwell. up into small stems, which penetrate the gland and sur- round the alveoli. The capillaries are short and anasto- mose freely with one another. The intermediate veins are of small calibre, like the corresponding arteries have a very short course, and soon enter the large venous trunks on the surface. This condition allows of a very rapid circulation in the gland, and a dilatation of the ar- teries which may not exceed the normal limits, makes a considerable increase in the size of the gland. Such an increase in the size of the gland occurs as the result of various emotions, and is particularly often seen in women during the menstrual period and at times of sexual excitement. The hyperaemia may become permanent, producing a marked increase in the size of the gland, and closely simulating the enlargement due to a hyperplasia of gland-tissue. The increase in these cases is principally due to an enlargement of the veins, which pursue a very tortuous course on the surface of the gland, and make deep depressions in it. Almost always in such cases there is some hyperplasia of the gland-substance, but this plays a very subordinate role. According to Virchow (to whom we are indebted for the first close study of the different pathological conditions met with in goitre) there are two distinct forms of vascular goitre ; in one the arteries being principally involved, in the other the veins. The arterial form, the struma aneurysmatica, is the most important. In this the arteries do not form circumscribed aneurisms, but there is a general increase in their calibre, principally seen in those which run on the outside of the gland. Not only is the calibre increased, but there is also an increase in length, giving them a tortuous, and, in some cases, an actual corkscrew character. The walls of these dilated arteries are not thinned, but in many cases they are very much thickened. The small arteries and the capillaries are slightly dilated ; the veins, however, are larger and have thicker walls than normal. The other form is the varicose goitre, which has not so much pathological importance as the aneurismal, but is met with very much oftener, and complicates in many instances the ordinary forms of adenoma. The soft varieties of adenoma are almost always complicated by varicosities along the veins. In the varicose goitre the veins on the surface of the gland are principally involved ; they become enormously widened, tortuous in their course, and are frequently provided with circumscribed ampulla- like dilatations along their sides. In the interior of the gland they have all manner of saccular dilatations, which occur at regular intervals, giving the vessel the appear- ance of a rosary. Both of these forms may occur only in a circumscribed portion of the gland and simulate the nodular form of adenoma. The vascular goitre may be congenital, or may be acquired at any time of life. Goitre, due to a hyperplasia of gland-substance, has been divided into numerous forms, the division being made dependent on minute differences in histological structure in many cases; in others, on the macroscopic appearances. Before entering into the consideration of these forms it will be well to briefly go over some of the histological characters which are met with in all forms. The thyroid gland is a true glandular structure, and is formed in the embryo like all other glandular structures, by an involution of an epithelial-forming layer of the blastoderm. The two components of the gland, the epi- thelial elements and the stroma which surrounds these and carries the vessels, must be considered. The gland- ular parenchyma is made up of groups of epithelial cells, which are arranged both as a true glandular acinus and in solid masses, which may be either long in shape or round. All of these masses of epithelial cells are surrounded by a structureless hyaline membrane. Inside of the masses, which are arranged like the glandular acini, lies a mass of substance which gives to the gland its peculiar char- acter. This is the colloid material, a transparent yellowish or grayish substance which is tough and sticky, and can easily be squeezed out between the fingers. When the gland is pressed between the fingers this material emerges from the spaces in which it was confined, and appears on the surface in the shape of fine transparent drops like drops of honey. When examined microscopically it has, as a GOITRE; PATHOLOGICAL ANATOMY. Under this term is understood an enlargement of a part or the whole of the thyroid gland. This enlargement may be due to a variety of causes, and is often congenital. One of the causes is hyperaemia, which may be temporary or per- manent. Under normal circumstances the thyroid re- ceives an enormous supply of blood, its combined arteries being several times greater than those which supply the brain. Both the arteries and the veins form numerous anastomoses, and the great arterial branches quickly break 352 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Goitre. Goitre. rule, the same glassy homogeneous appearance that it offers to the naked eye, but in some cases a very slight granu- lation may be seen in it. It stains slightly with most of the reagents used in microscopical work, but the staining is much more intense with some of the aniline colors than with carmine or haematoxylin. Although this material is always met with in the thyroid gland, both in its nor- mal state and in all pathological conditions, it is not con- fined to it, but is met with in other glandular organs under certain pathological conditions. The small cysts in the kidney, found in many of the forms of Bright's dis- ease, are often filled with a substance which in all respects seems quite identical. In some cases the colloid material is soluble in a large quantity of water, in others it is not soluble in any quantity either of cold or hot water. In solution it has all the properties of an alkali albumen. Virchow has shown that a substance in all respects iden- tical with the colloid may be made artificially, when a large quantity of chloride of sodium is added to a solution of alkali albumen. It is unknown how this colloid sub- stance' is produced. According to Virchow, whose opinion in this has been followed by other observers, the epithelial cells are not changed directly into this substance, but a fluid is at first secreted which afterward becomes thick and converted into colloid. According to a recent article by Gutknecht, it may also be formed by a direct metamor- phosis of the stroma. Masses of it are sometimes seen which contain remains of connective-tissue bands, and blood-vessels whose walls have undergone a hyaline de- generation. The epithelial cells vary much in size and shape : those surrounding the colloid masses are usually short and cy- lindrical, and in the solid masses they may be cuboidal or more or less cylindrical. The stroma is very slight in amount, and, as a rule, poor in cellular elements. It contains here and there small masses of embryonic cells, which may present some similarity in appearance to the epithelial structures ; they can, however, be distinguished from these by differences in degree of staining, and by the absence of the hyaline membrane around them. There may be a true hypertrophy of the thyroid gland which embraces all parts of the gland, with an exact repe- tition of the normal structure. Such enlargements hardly come under the head of tumors in the narrow sense of the word, and they are due most often to miasmatic influ- ences. In some cases the alveoli of the gland are very much enlarged, with but a slight amount of stroma. Such tumors have a soft, doughy feeling, are easily in- dented by pressure, and the indentation in some cases re- mains for a short time. The tumor is made up in great part of the alveoli with their colloid contents, and the solid glandular parenchyma is present in very small quantity. Such tumors are known as struma gelatinosa. In other cases the follicles are smaller, and the bulk of the tumor is made up of the solid masses of cells. These forms produce a large, smooth swelling of the gland. The cornua and the isthmus of the gland are both en- larged, and the whole anterior portion of the neck may be occupied by the growth, which covers entirely the larynx and trachea. The new formation of glandular tissue proceeds chiefly from the solid groups of cells in the stroma. The follicles increase in size by a new for- mation of cells and increased production of colloid matter. The new follicles are formed in the cell-groups by aggre- gations of cells in the periphery which gradually become separated from the main body. The colloid material be- gins to be formed in the middle of one of these groups, the cells become arranged around it, and in this way a new follicle is formed. They may also be formed from the old follicles by a budding out of the cells into the stroma, and by the formation of colloid in the middle of these. Wolfler distinguishes from such tumors the true adeno- mata of the gland, which occur chiefly in the form of cir- cumscribed nodules, or as an increase of the entire gland. These are epithelial new formations which develop from embryonic glandular tissue in which the arrangement of blood-vessels is atypical, and they either retain this type of embryonic tissue, or in the course of their growth change into tissue of a normal character. According to Wolfler, four forms of adenoma can be distinguished : the foetal, the gelatinous, the myxomatous, and the cylinder- cell adenoma. The foetal adenoma arises from the remains of embry- onic tissue in the gland, begins its growth usually at the time of puberty, or during the first pregnancy, and ap- pears in nodules which may vary in size from the head of a pin to that of the fist. According to the degree of vascularization it has a whitish, or dark-brown color, and is hard or soft. The formation of the nodules takes place in the same way in which the embryonic glandular tissue is formed, and consists of small, irregular masses of cells, in which the individual cells are not clearly separated from one another. The cells are round or oval, and the masses are surrounded by wide vessels which frequently show ampullar dilatations. In the further growth of the tissue the vessels become differentiated into narrow capillaries, and wide vascular branches, which finally assume the typical arrangement of the vessels in the normal gland, and the epithelium becomes arranged into typical masses of cells and alveoli, with colloid contents. The nodule does not necessarily attain this typical structure, but may remain permanently at any of the steps leading from the embryonic condition up to this. The adenomata, which are of a dark-brown color from the abundance and dilatation of the vessels, are prone to haemorrhages, which may be considerable in amount. The histological struct- ure of the tumor is rendered more complicated by these haemorrhages ; the blood thus escaping may change into a hyaline mass which later becomes vascular. The adenoma gelatinosum appears in the form of rough, uneven tumors of various size, which may com- prise the entire gland or be seated only in one portion. On section the tumor has a gelatinous appearance from the masses of colloid matter enclosed in the stroma. The development proceeds from the groups of cells lying be- tween the alveoli, and the tumor is related both to the hypertrophy of the gland and to medullary carcinoma. According to its origin and growth, Wolfler distinguishes two varieties, the interacinous adenoma and the cysto- adenoma. The interacinous adenoma is the most fre- quent, and forms very large tumors ; it consists chiefly of gland alveoli with colloid contents. The alveoli are lined with cuboidal or round epithelial cells, and be- tween them, in the stroma, lie masses of embryonic cells and beginning vesicles. The tumor arises by a growth of the embryonic gland cells between the gland alveoli, and by the further formation of cell masses and vesicles from this. The growth is accompanied by a strong vas- cularization of the interacinous connective tissue. This form of tumor may be found in the gland along with the foetal form. The cysto-adenoma is characterized by the formation of cysts, from the size of a pea up to that of a hen's egg, and within these the formative cells undergo a fatty and colloid degeneration. The connective tissue between the cysts, as well as the blood-vessels, undergoes atrophy. In places the solid masses of epithelial cells may grow into the cysts, and there undergo colloid degen- eration. It is in this way that the presence of the cells which are sometimes found in the middle of the colloid masses may be accounted for. They may not break into the cysts, but by their growth push in the wall, and the cells of the cyst covering this portion frequently change into long cylindrical cells. In some cases there is a growth of the epithelium of the old cysts in the form of papillae and coral-shaped formations, which also become covered with cylindrical epithelium. Nodules with such forma- tions are known as proliferating cysto-adenomata, and form the bases of very large goitres, into whose formation the entire thyroid may enter. These forms are relatively seldom met with in man, but in dogs and monkeys such papillomatous growths are found in the normal thyroid. The myxomatous adenoma appears in both young and old individuals, and forms soft and haemorrhagic nodules of variable size. The tumor consists of a hya- line, structureless, or, in some cases, striated ground sub- stance, in which solid round masses and bands of cells, which may be of various shapes, are embedded. This form is secondary, and proceeds from the foetal and in- 353 Goitre. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. teracinous adenoma. The conditions for its development are found in the haemorrhages which often take place in these forms at the time of puberty, during menstruation, and during pregnancy. A hyaline tissue is formed in the haemorrhagic foci, which becomes fibrous, fatty, and some- times calcified if the vascularization is feeble, and, if the vascular formation is more abundant, becomes filled with newly-formed masses of cells and alveoli. The cylinder-cell adenoma is characterized by the for- mation of vesicles, which are lined with high cylindrical cells, and of solid masses and rows which are composed of similar cells. According to Wolfler, this is one of the rarest forms of goitre. Although, in general, the stroma is slight in amount, and forms but a small portion of the goitre, a form is met with, known as struma fibrosa, in which the formation of connective tissue makes up a considerable portion of the- tumor. This form of goitre was supposed formerly to be composed largely of cartilage, and was designated as en- chondroma by Marquart, who found chondrin in the tis- sue. The fibrous tissue is not formed throughout the gland in great excess, but ordinarily the centre of the tumor is occupied by a dense, firm connective tissue, which sends processes toward the periphery of the gland. On section this tissue cuts with a creaking sound, and has often the bluish tint of cartilage. On microscopic examination, it is found to be composed of hyaline con- nective tissue, which contains very few cells and blood- vessels ; the walls of the latter are hyaline and thickened. It proceeds from a growth of the connective tissue of the stroma, but is probably composed in part of degenerated epithelial formations. Such formations may be small, and several may be found, all having the same character and often joined by their processes. This fibrous form is chiefly met with in the nodular tumor formations. Cyst formation is very common in all the forms of goi- tre. The more abundant is the deposit of colloid mate- rial, the more does the connective tissue between the masses suffer. In consequence of the pressure from the growth of the vesicles it is thinned, its vessels are com- pressed, atrophy and fatty degeneration take place, and the connective tissue gives way between adjoining vesi- cles, so that several may coalesce, forming one large cyst. The septa between the cysts are subject to the same influ- ences as those which affect the septa lying between the alveoli, and they undergo the same fate. Several cysts break into one another, just as the alveoli did, to form the single cyst, and finally a portion, or nearly the whole gland, is changed into a large cyst. As a rule, the con- tents of these cysts have not the same character as that of the alveoli, but consist of a tenacious, ropy, albu- minous fluid, which has all the characters of alkali albu- men. Haemorrhage into the cyst often takes place, re- sulting either from spontaneous rupture of one of the thin varicose veins, or from traumatic influences. The blood coagulates and forms firm, brownish coagula, which in course of time become decolorized and soften, forming a whitish fluid somewhat similar to pus, or it becomes changed into a yellowish or brownish smeary mass. In most cases, the haemorrhage is not sufficient to form ac- tual thrombi, but the blood mixes with the fluid, giving it various shades of color. In many cases the contents of these cysts have a striking similarity to the contents of the multilocular ovarian cysts, both in consistency and in color. On microscopic examination of the contents of these cysts, irregular masses of fatty detritus, fatty degen- erated cells, and cholesterin are found. The development of cysts in a goitre may also take place when there has been but a slight development of colloid masses. The follicles can be distended by the ex- udation of a great quantity of albuminous fluid, in which the cells undergo all manner of changes, but especially the fatty degeneration. The change of this form into the cystic takes place from the increase in size of the single follicles ; the intervening walls atrophy, the follicles be- come confluent, and thus large cavities may be formed in the midst of a purely hyperplastic nodule. In most cases there is a multiple cyst formation, in that smaller or larger cavities are formed in different places, which are scattered at intervals through the tissue or are separated from one another by small partition-walls. The cavities sometimes have perfectly smooth walls, at other times they show all sorts of diverticula. When the cavities are once formed, their increase in size is not limited to the co alescence of adjoining cysts. Their increase takes place chiefly by means of an exudation from the walls, which can be either entirely serous or haemorrhagic in character. The rapidity with which this exudation takes place is best seen from the rapid tilling of the cyst after puncture. It often takes but a few hours for a large cyst to till again. It can be readily understood from this that this form of goitre makes the largest growths. Many of these are of truly enormous size, and from the force of gravity they descend lower and lower. Cases have been seen in which they hung down to the lower extremities. In the development of the thyroid gland, auxiliary glands, which have no connection with the main organ, but frequently lie at a considerable distance from it, often are formed. These may lie in almost any portion of the neck, and frequently are found within the thorax along the aorta. Tumors may also form in these, and from their situation are often peculiarly dangerous. The goitre, in its growth, does not follow the course of a malignant tumor. It has no tendency to extend into sur- rounding parts, is limited to the tissue in which it origi- nates, and does not often produce metastases. Cases of metastasis have been seen by Cohnheim and Heschl. It is possible that these may have proceeded not from a simple adenoma of the gland, but from a medullary carcinoma. Wolfler has shown that metastases may form from a tu- mor which has all the characteristics of a medullary car- cinoma, and the secondary nodules will present the most typical adenomatous structure. When the extirpation is complete, there is no tendency to a return of the growth. Still, the goitre is a dangerous tumor, the danger arising principally from the pressure which it may exert on the important parts around it. There may be circulatory dis- turbances, caused by pressure upon the jugular veins and carotids ; disturbances of innervation from pressure on the vagus, sympathetic and brachial plexuses ; disturb- ances of deglutition from pressure on the oesophagus; and respiratory disturbances from compression of the trachea. Danger most frequently arises from the pressure upon the trachea. This does not depend so much upon the size of the tumor as upon its position and form. The most ordinary form of compression is lateral, which takes place when one or both cornua of the gland are involved, and the isthmus is comparatively free. Compression from both sides takes place principally from the congeni- tal gelatinous form, which often extends a great distance, both upward and in a posterior direction. This form may even entirely surround the trachea and compress it on all sides. The development may take place in the form of an isolated nodule behind the trachea, and be- tween this and the oesophagus, with danger to both organs. William T. Councilman. GOLD. So far as determined, the action of gold upon the animal system resembles that of mercury more nearly than that of any other of the well-known heavy metals. Locally, soluble gold salts are powerfully irritant, and, con- stitutionally, gold compounds affect nutrition. In thera- peutic doses they tend, like mercurials, to improve nutri- tive tone, but in poisonous quantities to derange it, with the development of stomatitis and fever, and, in continued dosage, of emaciation and progressive general eufeeble- ment. Gold is said to possess peculiar medicinal virtues in correcting disorders of the genital apparatus, particularly of the ovaries. Therapeutically, it has been used in ova- rian inflammation and irritation, in amenorrhoea, in loss of virility, and in various conditions of impaired nerve- power, and also as a substitute for, or adjuvant of, mer- cury in the treatment of constitutional syphilis. In none of these applications can gold be considered a medicine of first-rate, nor possibly even of second-rate power. The sole compound of gold officinal in the United States Pharmacopoeia is that entitled Auri et Sodii Chlor- 354 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Goitre. Gonorrhoea. idum, Chloride of Gold and Sodium. This is " a mixture composed of equal parts of dry chloride of gold (Au Cl3) and chloride of sodium (Na Cl)." The compound is easily obtained by mixing in proper proportion solutions of the two salts and evaporating to dryness. It crystallizes in elongated prisms, but is commonly found as " an orange- yellow powder, slightly deliquescent in damp air, odor- less, having a saline and metallic taste, and slightly acid re- action. The compound is very soluble in water: at least one-half of it should be soluble in cold alcohol " (U. S. Ph.). It contains 32.4 per cent, of metallic gold. This preparation is locally irritant even to causticity, and con- stitutionally exerts the virtues of gold as already set forth. The dose is about 0.005 Gm. (about one-twelfth of a grain) three times a day, in lozenge or pill. Edicard Curtis. GOLDTHREAD (Coptis trifolia Salsbury, order Ranun- culacea), is a pretty little evergreen bog-plant, with long, yellow, thread-like roots ; bright-green and shining ter nate leaves, and white, solitary, star-shaped flowers. Calyx of from five to seven white, petal-like segments, deciduous, corolla of as many small club-shaped petals, stamens rather numerous, pistils several, stalked. It grows rather abundantly in the cold bogs of America, Europe, and Asia. The whole plant is generally collected, although the root is undoubtedly the most efficient part. The description above-given of the plant is sufficient for the drug, which has an intensely bitter taste, but no odor. The color, taste, and medicinal value of Gold- thread are due to a salt of the alkaloid berberine, which it contains in considerable quantity. A second alkaloid, coptine, is described by Gross as also present. Goldthread is a simple bitter. It is frequently used in the country as a mouth-wash for aphthous and her- petic ulcerations, etc. Allied Plants.-The root of Coptis Teeta Wallich, of Asia, is a classic remedy for sore eyes, and still used in the Orient. Its properties are similar to those of Gold- thread. W. P. Bolles. GOLD, POISONING BY. The most important prepara- tion of gold is the trichloride. Our knowledge of its physio- logical action upon the system is not wholly satisfactory. According to Magendie, six and one-half milligrammes (0.1 grain) has produced symptoms of gastric irritation. Orfila's experiments show that its action is very energetic when injected into the veins. Six and one-half centi- grammes (1 grain) killed a dog in four minutes. One and three-tenths decigrammes (2 grains) caused death in three minutes. The heart, in both cases, was filled with black blood. Given internally, 0.194 Gm. (3 grains) killed a dog in three days. Six and one-half decigrammes (10 grains) caused death in seven days with symptoms of gastro-enteritis. The mucous membrane of the stomach was ulcerated in many places. Chloride of gold appears, therefore, to be an irritant and corrosive poison. It coag- ulates albumen. In contact with many organic sub- stances it is reduced with separation of metallic gold. For this reason, living tissues, to which it is applied, as- sume a brownish-red or violet color. Dragendorff states that the mucous membrane of the mouth, oesophagus, and stomach is colored brownish-red in cases of poison- ing by chloride of gold, owing to the reduction of the salt. It has been asserted that chronic poisoning results from the repeated administration of chloride of gold in doses of three to six milligrammes. The most prominent symptoms are headache, salivation (which differs from the mercurial salivation in the absence of tenderness and ulcer- ation of the gums), gastro-intestinal irritation, and febrile disturbance. Baudelocque and Velpeau, however, ob- seryed no bad results from doses of 0.77 to 1.3 Gm. (12 to 20 grains) daily. According to Rabuteau, albuminuria and hyperaemia of the kidneys result from the continued administration of small doses. Elimination takes place chiefly through the kidneys. Treatment should be similar to that which is required in cases of poisoning by corrosive sublimate. Vomiting should be encouraged. Albumen, in the form of white of egg, should be administered. This should be followed by an emetic in order to remove the compound of gold and albumen formed. In the absence of white of egg, milk or wheat flour may be given. Ferrous sulphate has been recommended on account of its property of reducing the chloride of gold to the metallic state. The after- treatment depends upon the symptoms. The action of the remaining preparations of gold has not been sufficiently investigated to render any positive statements possible. Orfila quotes cases from Plenck and Hoffmann, from which it appears that fulminating gold is a highly poisonous preparation. The principal symp- toms attributed to it were colicky pains, vomiting, diar- rhoea, convulsions, salivation, and fainting. In one of Hoffmann's cases 0.388 Gm. (six grains) caused the death of a child six months old. The action of the double chloride of gold and sodium is probably similar to that of the trichloride. The double cyanide of gold and potassium is an important prepara- tion which is used in the process of electro-gilding. There can be very little doubt that it is an active poison, though no case of poisoning by it is recorded. William B. mils. GONORRHCEA. Syn. : Clap. ; Fr., Blennorrhagie, Conor rhee, Chaude-pisse; Ger. Tripper. Gonorrhoea is the term applied to an acute inflammation of the mucous membrane lining the urethra in the male, characterized by a discharge of pus ; and in the female to a similar inflammation of the vulva, vagina, or urethra. The dis- ease is most frequently the result of contact with a simi- lar discharge from the genitals of the opposite sex. Gonorrhoea in the Male.-As in all diseases, the symptoms vary in intensity in different cases : some are subacute from the first, others act as though possessed of a peculiar virulence ; there is often a difference in viru- lence between the first and subsequent attacks. The course of the disease is usually divided, for the sake of clearness in description, into three stages: the first, or in- creasing stage; the second, or inflammatory stage ; the third, or stage of decline. These stages are not of defi- nite duration, nor are they distinctly separated from each other ; but the division is one of great convenience in the discussion of the disease and its treatment. The time within which the first symptoms appear varies from a few hours to ten or twelve days. Intelligent men usually notice something within the first two or three days. Ordinarily, the attention of the patient is first drawn to his meatus by an uneasy sensation, which is hardly definite enough to describe : it is the merest little feeling of weight, heat, itching or tickling, or a sensation as though a hair were drawn across the meatus. With the first sensation appears also a slight moisture at the meatus, and a drop of thin and translucent fluid can be pressed out from the urethra. A sensation of burning during the passage of urine is felt first at the meatus, but with each succeeding micturition the sensation becomes more and more marked, till the urine itself seems to be scalding hot and to burn the whole urethra. Meanwhile the discharge has increased in quantity, lost its translu- cency, and become decidedly purulent. These symptoms gradually increase for three or four days, when the first stage reaches its height and the second stage begins. At this time there is a constant feeling of weight and tension about the genitals, the lips of the meatus are red, swollen, and everted, sometimes even eroded ; in the most severe cases the discharge may be even streaked with blood, and may be abundant enough to fall in drops as the patient stands erect. The swelling is not confined to the meatus, but is more or less general. The whole glans and prepuce are materially increased in size, the course of the swollen urethra is plainly marked along the under surface of the penis and is tender to the touch ; even the gentlest neces- sary handling of the parts is painful. The passage of urine along the inflamed urethra is attended with great suffering. The patient dreads the necessity of passing water ; he places himself in the most favorable attitude and refrains from using his abdominal muscles and dia- phragm, in the hope of making his water flow more 355 Gonorrlirea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. slowly, and is often unable to restrain a groan during its passage. At night, particularly in the early morning hours, he is weakened from sleep by an erection accom panied by very acute pain somewhere along the course of the urethra. The disease having reached its height, the symptoms remain about stationary for a time, varying from one week to three, when the various phenomena begin gradually to decline. The pain in micturition be- gins to subside, the swelling disappears, and the organ is no longer painful to the touch, the discharge becomes less abundant and thinner, though it still persists until it remains the only symptom. Little by little it changes to a simple mucous discharge, till finally, in favorable cases, it disappears ; or it may persist indefinitely, when it is usually known as gleet. Most cases show a singular readiness to return to an acute state on the slightest or no provocation. The slightest provocation is sufficient to start up, again and again, a clap which has seemed just on the point of disappearing entirely. Such a description is by no means true of all cases of the disease. Patients who experience the disease re- peatedly do not always show such acute symptoms in subsequent cases as in the first. In them the discharge shows itself at a variable, often a very short, period after the exposure, and is almost the only symptom ; the smart- ing during micturition is very little more than a feeling of warmth. In these cases, or at least most of them, the attack is rather a reawakening of an imperfectly-cured disease than a new infection, and patients with these symptoms usually admit a previous disease; and many of them will say that, since the first attack, they have always been conscious of a slight moisture at the meatus, or have occasionally found the meatus glued together in the morning. Mucous or Bastard Gonorrhcea.-A third class of cases is deserving of special mention, because its occa- sional occurrence has so great a bearing in estimating the effect of treatment. These cases are called by Lebert1 slight superficial, sero-purulent, and mucous gonorrhoeo- catarrh, and by Dr. J. William White,2 irritative or abor- tive gonorrhoea. The patient presents himself with a little tingling sensation at the meatus and a slight dis- charge. The discharge becomes muco-purulent, and may even be quite thick ; in point of fact, the disease in its early stages cannot be accurately distinguished from the acute variety, but the inflammation never runs very high, and subsides in from seven to fourteen days. Gonorrhcea Sicca.-Under the name of dry gonor- rhoea cases have been reported in which an inflammation of the urethra following exposure ran its course without discharge. It is characterized by severe pain and other signs of gonorrhoea, which leave no doubt as to the exist- ence of the urethritis. According to Voillemier,3 this con- dition is of short duration and is in no way peculiar to the urethral mucous membrane. The discharge is simply delayed in the same manner as occurs in catarrh of the nasal and bronchial mucous membranes. Gonorrhcea of other Mucous Membranes.-Gon- orrhoea of the anus, mouth, and nose are mentioned by authors, but must be very rare if they exist. There is no reason why the pus brought in contact with these mu- cous membranes should not manifest its effects there as well as on the conjunctiva, where the disease occurs occa- sionally. Gonorrhoeal conjunctivitis will be mentioned again toward the close of this article. Causes and Nature of Gonorrhcea.-That certain cases are the direct result of contagion there can be no question. It is a question whether cases ever occur which are not the result of contagion. Men certainly have gonorrhoea after connection with women who pre- sent no sign of the disease when subsequently examined. For certain authors these cases are simply errors in ex- amination. They suppose the gonorrhoea to have been overlooked in the examination, a very easy matter when the disease has become chronic, and its manifestations at best are very slight; and, probably, the disease es- capes detection in some cases. Few facts in the pathology of the disease are more cer- tain than that a portion of the urethral mucous mem- brane may remain in a chronically inflamed state for years, and yet upon any excitement may develop a purulent discharge. Men, with such an imperfectly- cured gonorrhoea, who believe themselves well, re- awaken the old disease by intercourse with a perfectly healthy woman, and naturally accuse their partners, when they are themselves alone at fault. A latent condition of the disease in one sex explains many of the alleged non- contagious cases. Many of the cases claimed to have oc- curred without contagion are open to the gravest suspi- cions; but it is also true that a certain number of cases oc- cur which are exceedingly hard to explain on the ground of contagion; for instance, those in which a woman lives on terms of intimacy with a lover in addition to her husband. The lover is suddenly affected with gonor- rhoea without other exposure, while neither husband nor wife have any sign of the disease. The alleged causes of urethral discharge in the male are too numerous to mention. The menstrual discharge and various morbid states of the female organs are first in importance. It is a pretty widespread belief that a man may contract disease from the menstrual discharge, a be- lief that seems to be fostered by women who desire to re- lieve themselves of suspicion. Any man who finds him- self infected and upbraids the woman, is pretty sure to be told that she had not quite recovered from her " turns," or that her "turns had just commenced, and she did not know it at the time." The cases that rest on such state- ments are, of course, useless in deciding the question of causation, but cases occur in which the most careful ex- amination by the physician fails to find any better explan- ation. Any non-gonorrhceal discharge, as that from any of the many ills to which women are subject, may, it is highly probable, be occasionally the cause of gonorrhoea in the male. Ricord believed that a man could " give himself the clap," and a very large proportion of venerealists since his day have entertained the same belief. To quote from Fournier: " For one case of gonorrhoea resulting from contagion, there are at least three in which contagion, strictly speaking, plays no part." Over-excitement and over-indulgence, combined with the use of alcohol, are apparently the exciting causes in such cases. The oft- quoted recipe of Ricord for catching the clap illustrates so well the circumstances under which the disease often makes its appearance that one may hope to be pardoned for repeating it: "Take her out to dine; begin with oysters and continue with asparagus; drink freely and often ; white wine, champagne, coffee, liquors, all. are good. Dance after dinner and make your friend dance too. Heat yourself well and drink beer freely during the evening. When night comes conduct yourself valiantly ; two or three times are not too much, and more is better ; in the morning do not forget to take a prolonged hot bath, and by no means neglect to take an injection. This pro- gramme conscientiously carried out, if you do not have the clap, some deity has protected you." The claim that a non-contagious urethritis differs from true gonorrhoea in its milder character and freedom from complications is erroneous. Severe complications follow discharges which are the result of irritation, as after sur- gical operations in the genito-urinary tract, or the mere passage of a catheter. At the present time the believers in the specific nature of the disease rest their belief, for the most part, upon the existence of a micro-organism in gonorrhoeal pus, which was discovered by Neisser in 1879, and called by him the micrococcus gonorrliom, and since known as the gonococcus. His observations have been confirmed by a large number of observers, the coccus has been cultivated, and attempts made to induce the disease in men and animals by inoc- ulating the urethra with the pure culture. Some of these attempts have been followed by urethritis, but not always under conditions that ruled out other possible origins for the disease. Other observers find the same organism in pus from acute abscesses, in normal human saliva, and various other places, and do not believe the gonococcus to be distinguished from other micro-organisms. De Ami- cis 4 has produced a urethritis with injections of ammonia. 356 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea. Gonorrhoea. and found micrococci identical with those found in cases with a clear history of contagion. with the thickening of the submucous tissues, produces a narrowing of the canal. Some interesting pathological facts are given by Voille- mier, based on a series of nine post-mortems. " In sub- jects who have had many inflammations of the urethra the traces of inflammation of the mucous membrane are not very apparent. There is little redness ; the mouths of the foramina are not to be seen ; it is difficult to find any remains of the large follicles. On the contrary, in subjects affected for the first time the traces of the in- flammation are manifest ; the foramina are very appar- ent and very numerous. These facts support the opinion of Morgagni, who attributed their obliteration to an old inflammation. They explain also why the first urethritis is, in general, more acute than the others, because the glandular elements, not being atrophied by a previous in- flammation, play a greater part in the disease. Another fact, not less important, is the manifest narrowing of the canal. Its swollen walls have lost in great measure their suppleness and their elasticity. They are infiltrated, and in places blood is effused in irregular plaques. . . . These are evidently all the alterations proper to an in- flammation which is not limited to the surface of the mu- cous membrane. That inflammation can even go beyond the submucous cellular tissue," and in one of Voillemier's examinations plastic effusions were found even in the spongy tissue. Diagnosis.-It may seem superfluous to write any- thing on diagnosis, but mistakes are not very uncommon. Patients often report that they have been treated for gon- orrhoea without even being inspected by the practitioner, their own diagnosis being accepted without question. Such patients show the most varied lesions, and some have absolutely nothing abnormal, an uneasy conscience hav- ing raised some newly-noticed anatomical peculiarity to the dignity of a disease. Perhaps the most frequent error is to mistake the dis- charge of a balanitis from beneath a tight phimosis for a urethral discharge. Such an error may usually be avoided by carefully retracting the prepuce as far as possible and bringing the preputial opening over the meatus, wiping away the discharge, and pressing gently along the ure- thra, when the source of the discharge will become evi- dent. Sometimes the phimosis is so tight, or the swelling of the prepuce so great, that this cannot be done ; or the discharge may be so abundant that it is impossible to pre- vent its obscuring the view of the meatus. In such a case the patient's sensations during micturition may be of some value, though often misleading. The urine gives rise to a burning sensation when it conies in contact with the in- flamed internal surface of the prepuce, so that a patient with a balanitis will say that his water scalds. As the scalding of gonorrhoea is often felt only at the meatus, it seems to be difficult for a patient to accurately distinguish the seat of the pain. In such a case it may be necessary to reserve the diagnosis for a few days. Even when the discharge comes from the meatus, one must remember that a discharge from the urethra is not necessarily gonorrhoeal. The presence of a chancre within the meatus is an occasional cause of a discharge which may be mistaken for a gonorrhoea. Any other lesion or morbid growth in the urethra may, in the same way, be a source of error. It is a matter of great mo- ment to distinguish a discharge due to an initial syphilitic lesion. Fortunately, a true chancre is seldom found far from the meatus. It may be in sight when the lips of the meatus are separated, and may often be recognized by its induration. The discharge to which it gives rise is thinner and less abundant than that of ordinary ure- thritis, though thicker and more abundant than it would be from the same chancre on an exposed surface. Gruenfeld has recently reported a case in which a ure- thral discharge was due to ulcerated gummata. Prognosis.-It is very common to speak of the disease as though it were a trifling affair. It is undoubtedly true that a very large proportion of cases recover with but little inconvenience, but it is also true that a certain number suffer from very serious complications ; while of the cases not attended by serious complications, a large Interesting as these experiments are, it cannot be con- sidered that the gonococcus has been established as the essential element in a true gonorrhcea, nor has it yet been proved that there is anything specific in the pus of gon- orrhcea that makes it essentially different from the pus of a simple urethritis. In the present state of knowledge we cannot with ab- solute certainty discriminate between true contagious gonorrhoea and urethritis not the result of contagion. Whatever a man's private belief may be in regard to any given case, he cannot positively affirm that the woman with whom his patient has cohabited is necessarily diseased, simply because his patient has acquired a discharge. Every case of gonorrhcea is not necessarily of venereal origin. It is not very uncommon to see the discharge spread from older members of a family to young female children, as in a family recently under my observation, in which father, mother, and a four-year old girl were con- secutively affected. The little girl occupied the same bed with her mother ; an older child, who slept in a differ- ent part of the house, escaped. Similar cases have been mentioned quite recently by Aubert and others. Certain cases in the male are the result of mediate contagion, as in the instance related by Otis, of the physician who be- lieved that he had acquired it by contact with a dirty privy, which he had been obliged to use in too great haste to take the usual precautions against contact. Such a case rests wholly upon the statement of the victim. This physician's case did perfectly wrell, and he com- municated the circumstance to Professor Otis, who places implicit confidence in his word, simply as a matter of scientific interest. A second case of the same sort is given in Dr. Otis' wrork on Genito-urinary Diseases. That such cases are possible ought to be recognized, though there will always exist the strongest probability that a man who claims such an origin for his disease is trying to impose upon the credulity of his medical ad- viser. Lesions. -The result of the observation of a great num- ber of cases, of endoscopic examination of the living, and of post-mortem examinations, shows that the disease com- mences at the meatus and propagates itself backward along the urethra toward the bladder. The disease, in its earliest stages, is confined to the mucous membrane, which is reddened, injected, and swollen. In acute cases the epithelium is stripped off, leaving behind a super- ficial ulceration, which is limited, however, to the epi- thelial elements, and is the same in character as the super- ficial exfoliation to be seen in cases of balanitis. True ulcerations, properly so called-that is to say, losses of substance-occur rarely, if ever, in the acute stage. What one does find is an exfoliation, often greatly accentu- ated, of the epithelium. So slight are the lesions that at post-mortems the urethra may sometimes appear almost entirely healthy. In uncomplicated cases the in- flammation is confined to the anterior urethra, that is, to that portion of the canal anterior to the compressor ure- thrae muscle. The diseased portion, even when the dis- ease has existed for many months, is abruptly limited by this muscle. Such, at least, is the more commonly re- ceived view. When the disease persists it t6nds to locate itself on certain portions of the canal, while the rest of the mucous membrane regains its normal state. Two portions of the urethral tract seem to be most commonly the seat of these persistent lesions, the cul-de-sac of the bulb and a spot within a short distance of the meatus. These are only the most favorite, not the exclusive, seats of this later limited disease. These affected portions of the mucous membrane are deprived of their epithelium, and later ulcerate. These ulcerations persist and granulate, and maintain a slight discharge. The granulations are com- pared to the lesions of granular conjunctivitis. As the disease in growing older limits itself, it gains in depth; it involves all the thickness of the mucous membrane and also the subjacent tissues. The ulcerations finally cicatrize, and the contraction of the cicatrix, together 357 Gonorrhoea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. proportion require many weeks and months before the discharge finally ceases. Unfortunately, no one can tell at the beginning which cases will prove to be serious, so that the prognosis in every case must be a guarded one. Complications are by no means always absent in the cases that commence very mildly. As illustrating this point, a recent case occurs to me where the initial symptoms were so slight that a most intelligent general practitioner, a man of high local reputation, advised his patient to do nothing. His advice was gladly accepted and followed by his patient, who was chagrined to find the discharge grow markedly purulent, a chordee appear, and become so distressing as to make sleep nearly impossible, and fin- ally to see a cystitis and epididymitis supervene, which confined him to his bed or chamber for several weeks. The effects of the disease are not by any means limited to the few weeks in which the discharge is a prominent symptom. Gonorrhoea is the most active cause in the genesis of affections of the genito-urinary organs. Not only the great majority of strictures, but many of the cases of chronic cystitis, and some at least of the cases of pyelitis, acknowledge a gonorrhoeal origin. Possibly cer- tain cases of tuberculous disease of the genito-urinary or- gans are indirectly the result of gonorrhoeal trouble, the local irritation in a tuberculous subject attracting the dis- ease to that spot. No conscientious practitioner can promise a cure within any definite time. From four to six weeks is the time given by most writers as ordinarily required for a cure, but a very large proportion of cases last longer, and in some the discharge seems absolutely incontrollable. Every practitioner hears from his patients of cases that recover in a few days in the hands of other physicians. These remarkable cases occur for the most part in men who have urethras already damaged by previous attacks, in whom any exposure is liable to light up a fresh discharge, which speedily improves under a mild injection. If such cases could be examined, many of them would undoubtedly show some sign of the trouble still existing which the pa- tients themselves disregard. Others are cases of a mucous gonorrhoea, in which the discharge hardly becomes puru- lent, and which subsides in a very short time. These latter cases are not very common, but one occurring in an individual willing to discuss the matter with his friends becomes a standard by which to try other physicians not so fortunate in their cases. Complications.-Gonorrhoea, in uncomplicated cases, is an inflammation of the urethral mucous membrane an- terior to the compressor urethrae muscle. Unfortunately, it is not always confined within the limits of the anterior urethra. It may invade any of the many structures in anatomical connection with it. Proceeding directly back- ward, it may attack the prostate and the bladder, and even proceed up the ureters to one or both kidneys. It may follow along the spermatic cord, and invade the vesiculae seminales and the testicles. There may be swelling of the lymphatics and suppuration of the lymphatic glands. The pus may be conveyed to other mucous membranes, and cause suppuration there as in the ocular conjunctiva ; occasionally it gives rise to phenomena in other parts of the body with which no connection can be traced, as in gonorrhoeal rheumatism and inflammation of the deeper portions of the eye. The number of patients who escape with no other symptoms than those pertaining to the inflammation of the urethra is not easy to determine, for with no disease is a patient more inclined to run about from one physician to another. If any complication arises he is apt to desert his first adviser-who will, henceforth, class him among the cures-and go to another practitioner. The first man believes the disease easily curable, and the second gets an exaggerated idea of the frequency of complications. Complications are very frequent as the result of a ne- glect of proper hygienic precautions. A want of proper cleanliness, indulgence in liquor or venery, unusual and extraordinary exertions, are apt to be followed by an ex- tension of the disease. A long journey in the cars (nearly across the continent and back) was in one case followed by severe epididymitis and cystitis. But complications may and do occur in patients whose conduct is irreproach- able. Complications by no means always come singly, they are very apt to be multiple. Cystitis and epididy- mitis are often associated. In some cases it seems as though the disease was bound to complete the tale of all possible extensions and complications. One symptom is very common with all the deeper- seated extensions, viz., a diminution, sometimes almost a cessation, of the discharge. A sudden diminution should make one suspicious of some additional trouble, and the practitioner should beware how he allows his patient to rejoice over a too early and sudden delivery from his troublesome running. This diminution is only apparent in many cases, in which urination is over-frequent and the discharge is washed away, but in most cases there is a real diminution. It is not certain that we ought to regard the original disease as strictly limited to the anterior urethra, and in- vasions of neighboring tissues as complications, but such a method of treating the subject has the sanction of most writers, and renders its consideration more simple. Two of the so-called complications, but which are incidents of the disease rather than complications, will be considered first, that we may more intelligently study treatment, be- fore proceeding to the other complications, whose treat- ment needs separate consideration. Chordee.-Few patients escape without some pain during the erections, which, from the increased heat and overfilled blood-vessels, are much increased in frequency, and which put the inflamed urethral and peri-urethral tis- sues on the stretch. When the inflammation runs high, it involves the corpus spongiosum in some portions, and its inflamed and partially obliterated cavities are unable to expand. As the cavities of the corpus cavernosum on the dorsum of the penis are usually unaffected, the erec- tion forms a bow toward the under, the affected, side; this phenomenon is known as chordee. Patients frequently refer the pain during erection to a particular point, where examination shows the urethra to be surrounded by an inflammatory mass, tender to the touch, and large enough to make an evident projection beyond the surface. Oc- casionally the erection curves in some unusual direction, which is, of course, the result of some irregularity in the swelling of the peri-urethral tissues. Haemorrhage from the Urethra.-A very slight transudation of blood, sufficient to barely tinge the dis- charge, is by no means uncommon during the acute period. Bleeding also occurs in cystitis of the neck, when it shows itself at the end of micturition. But bleeding from the inflamed mucous membrane is occasionally quite free, and it may be sufficient to cause anxiety on the part of the physician. In such cases it usually follows some known cause, an erection more than usually violent and painful, coitus, " breaking the chordee," a practice which seems to be common in France, though quite rare in America, and which consists in laying the curved organ on some solid substance and straightening it with a blow. Fournier tells of a case of repeated and violent haemor- rhage, in which the patient became blanched and almost pulseless, in which the original cause was the excitement due to the mere presence of a woman. The same cause is mentioned by other writers. The source of the bleed- ing is undoubtedly a rupture of the swollen and engorged mucous membrane. Treatment.-Prophylaxis.-1This is a subject on which American writers have, as a rule, very little to say. There is but one perfectly reliable method of avoiding the disease, and that is, naturally, the avoidance of expos- ure. But the subject cannot be dismissed so abruptly; it occupies the attention of many men, and anyone who treats many cases must hear it discussed. The possession of some infallible means of prevention is the pride of many men. Some are content to pass their urine and wash themselves, but a very large number resort to an in- jection of some sort. Almost every substance usedin the treatment of the disease is also used as a prophylactic, but perhaps carbolic acid, and some of the forms of zinc and lead, are most common. It is very doubtful whether such an injection has the power of preventing the dis- 358 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea* Gonorrhoea, ease. It is common to meet men whose trusted prophy- lactic has at last failed, greatly to their astonishment: and the number who have met with disappointment in the use of a preventive which always works with a friend is legion. It is by no means improbable that the use of an irritant injection occasionally helps to produce the very inflammation it was intended to prevent. Abortion of the Disease.-There can be no question of the desirability of aborting the disease at its very outset. Its possible complications and consequences are far too serious to allow it to go unchecked, if it is possible to prevent its development. Unfortunately, the means at our command are not satisfactory in their working. The means ordinarily used consist in an injection of nitrate of silver sufficiently strong to slightly cauterize the urethral mu- cous membrane. A single strong injection, or repeated injections of a less strength, are used with the idea of sub- stituting a healthy for the specific inflammation, or of "destroying the virus." To have any hope of being success- ful, the attempt at abortion must be made at the very earliest possible moment, "when the discharge is but slight and chiefly mucous, and while as yet there is no severe scalding in passing water."5 At this very early stage no one can possibly prophesy the course of the disease, and the chance of making it worse rather than better is very great. The abortive treat- ment of gonorrhoea seems to me to belong to the old sys- tem of "breaking up" diseases, and should be aban- doned. The opinion of Lebert6 is specially worthy of consideration, as he is a strong believer in the specific nature of the disease. " Theoretically this method is quite satisfactory, since caustic fluids, such as nitrate of silver, often quickly produce a change for the better in acute and recent inflammations of mucous membranes. But this plan is not infrequently followed by deep- seated phlegmonous inflammation of the urethra, severe pain, and sanguineo-purulent discharge-in short, by all the signs of intense urethritis. If, therefore, we can by this means deprive gonorrhoea of its specific character, yet we substitute generally a more troublesome and dan- gerous malady than that which we had to treat. " Attempts have also been made to abort the disease by the immediate use of large doses of copaiba or cubebs. It is not very rare to find patients who have made the ex- periment upon themselves, and the experience of such patients is by no means encouraging. Fournier describes the method only to condemn it. To combine the two methods is not to gain over either of them singly. Curative Treatment.-Treatment, to be effectual, must be carefully adapted to the condition in which the pa- tient presents himself for advice. To proceed systemati- cally, we may first follow an acute case and consider the best method of caring for its different stages. Perhaps the most important of several things of about equal im- portance is the necessity of putting the inflamed organ at rest, and the avoidance of irritation, exactly as we should put any other actively inflamed portion of the body at rest. The patients in whom the active symptoms vanish most quickly and easily are those who, by some other disease or accident, are confined to bed from the very first. Absolute rest is not often attainable by private patients. Social and business reasons make them unwilling to ac- knowledge their disease, and they prefer to attend to their daily duties, unless actually disabled. All men can, however, make some difference in the amount of exercise they take. The doctor may justly insist that all exercise not imperatively demanded shall be given up until active symptoms are past. The patient can go home immedi- ately after business hours. He can ride instead of walk- ing ; he can stay quietly in his room evenings, on the lounge or bed. Such changes in habits are very impor- tant, and should be insisted upon. The entire absence of all genital excitement is also to be enforced. The avoidance of irritation is still further attained by rendering the urine unirritating. The first step to that end is the proper regulation of the diet, and above all things entire abstinence from alcohol. The malt liquors, to judge from the aggravation that almost invariably fol- lows their use, are decidedly more hurtful than the dis- tilled liquors. Occasionally it is necessary to make some concession to persons who are habituated to the use of liquor and are not in condition to give it up, but such cases are not very common, and do not invalidate the general rule. Occasionally it may be necessary to allow a little claret and water on occasions where the patient must drink something, but the less the better. As to food itself, highly spiced dishes, salads, curries, salt food, and articles difficult of digestion, should be avoided. I like to diminish somewhat the amount of meat taken, though vegetables may be freely allowed. Asparagus is supposed to give rise to urethral discharge, and should be avoided. Patients are very apt to inquire about tea and cotfee. Though often forbidden, I can see little objec- tion to their use, especially if taken somewhat weak and in moderate quantity. Tobacco, in moderation, I do not believe to be counter-indicated; on the contrary, its use will assist in keeping the patient quiet, and to deprive a per- son of tobacco who is accustomed to its use is very apt to render him restless and uneasy. A hospital patient should be put upon milk diet. It is more than can be expected of private patients that they should be willing to put themselves on such a regimen, except in extreme in- stances ; but they may well be told of what hospital milk diet consists, and told to approximate their own diet to it. Plenty of milk should be allowed. Patients are very apt to overdo the reducing of their diet, and need to be watched lest they actually injure their health, which is not an assistance to the cure of their disease. The urine should also be increased in quantity, and so diluted, by some diluent. Teas of slippery elm and flax- seed are very commonly used. It is doubtful if they are at all superior to clear water, but if they are agreeable to the patient there is no objection to them. Some of the milder alkaline waters, like Vichy, are often agreeable, and are to be recommended, though the amount of alkali is hardly sufficient to render them actively remedial fur- ther than as diluents. It is also important to render the urine alkaline during the scalding of the acute stage. The administration of an alkali has a marked effect upon the comfort of a patient when so given as to gain its desired effect upon the urine. For this purpose it should be given while digestion is go- ing on in the stomach. This time of giving the alkali will doubtless seem improper at first thought, but is based upon physiological experiment. It is strongly insisted upon by Dr. J. William White, of Philadelphia, who re- fers to an article by Dr. C. II. Ralfe,7 who found that when the alkali was taken on an empty stomach its effect on the urine passed off in two hours, and the amount of acid passed in the succeeding three hours was nearly equal to that passed when no alkali was taken. When taken dur- ing digestion the urine remained alkaline for four hours, and no recovery of acidity was noticed. The bicarbonate of soda is one of the best preparations, because it has very slight irritant properties, and is not disagreeable to the taste. The acetate, citrate, and bicarbonate of potassium may also be used. The real guide to their use is the urine, which should be tested with litmus paper. When once the urine is alkaline the dose may be diminished. A word of caution in regard to the continued use of alkalies may not be out of place. Their long-continued use may give rise to an alkaline cachexia distinguished by anaemia and scorbutic symptoms. Such a condition is hardly likely to occur when the drug is only continued during the con- tinuance of the ardor urines, but when the bladder be- comes involved, and the alkali is continued on that ac- count, patients sometimes suffer from indigestion and its attendant ills, which fall short of the cachexia alluded to, but are its first symptoms. Perfect cleanliness and freedom from constriction are essential not only to comfort, but to recovery. Frequent cleansing, to remove the pus accumulated about the glans, is not only of great advantage in the treatment of the dis- ease, but averts to some extent the danger of carrying the pus to the eyes-an infrequent accident, but of sufficient danger to deserve special warning on the part of the phy- sician, The patient must be taught from the very first 359 Gonorrh«ea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. how to dress himself. It is very common to see a rag tied round the penis in a manner that constricts and irri- tates it. Occasionally a man is able in this way, by the use of a broad strip of cloth instead of a string, to fasten his bit of cloth in such a manner as to secure cleanliness without constriction ; but for one who succeeds ten will fail. The method is faulty, and better methods once learned are no more cumbersome. A method often rec- ommended is the insertion, beneath the prepuce, of a small piece of cloth, perhaps an inch square. The pre- puce is retracted, the bit of cloth placed over the meatus, and the prepuce, drawn forward over it, holds it in place. Such an arrangement is most admirable in the later stages, when the discharge is slight; but when the discharge is great it dams it up and causes it to collect just within and about the meatus, where it forms a fruitful source of irri- tation. A better method, when the discharge is at its height, is to receive the discharge in a little bag which may be made from the foot of an old stocking, a section of an arm from an old undershirt, or from ordinary cot- ton cloth, and suspended by a safety-pin from the under- clothing or from the girdle of a suspensory, if the patient is wearing one, and so arranged that the penis hangs loosely inside of it. Some absorbent cotton or bits of cloth in the bottom of the bag take up the discharge and can be changed as often as necessary. Further protection is secured by a wide strip of cloth pinned with safety-pins to the inside of the underclothing or the shirt. Such a false flap is often the only security needed. The ardor urina is greatly diminished by the diluents and alkalies already advised. In addition, if the pain is great, the penis may be inserted in a bowl of hot water during micturition. This usually gives great relief, though it is not easy to say exactly why it should do so. The injection of cocaine has been tried, but as it needs to be for some fifteen to twenty minutes in contact with the urethra to produce anaesthesia, its use can never be very general. For the relief of chordee many drugs have been ad- vised, particularly camphor, lactucarium, lupuline, hy- oscyamus, and opium. Camphor needs to be given in very large doses. Mr. Milton8 advises half a teaspoonful to a teaspoonful of the tincture on going to bed, to be re- peated every time the patient wakes with the chordee, and he finds the trouble much alleviated by the third or fourth night. Bumstead and Taylor have found the monobromide of camphor to give good results. They em- ploy it in doses of three grains (0.20 gramme), either made into pill or dissolved in tincture of hyoscyamus. Lupu- line and lactucarium are too feeble in their action to be valuable in severe cases. Opium is usually effectual in subduing the pain, but its effects on the whole are not good ; its action on the bowels is particularly prejudicial. No prejudice against this drug, however, should compel the patient to suffer when its use would relieve him. The dis- agreeable symptom should be overcome by any means in our powrer. Rectal suppositories or starch injections con- taining opium are favorite and convenient methods of ad- ministration. Hyoscyamus is valuable as a sedative of the urinary organs, but is seldom used alone in chordee. The bromides are, on the whole, the most reliable, but need to be given in full doses. It will require usually sixty grains (four grammes) to gain the desired effect, and even a larger dose may be needed. It should be given in divided doses, and the administration commenced during the afternoon or early evening, as some time elapses before its effect is felt. Thirty grains at three, six, and nine o'clock,or the middle of the afternoon, after supper, and at bedtime, ought to give good results. I have occasionally added a dose of opium for a night or twro, but prefer to do without it if possible. The bromides appear to be useful aside from their con- trol of chordee, and I often add them to an alkaline mix- ture, or prescribe them at night, when chordee is not a troublesome symptom. Genital excitability is greatly di- minished by the continued dose, but too great an effect must not be expected to follow immediately, before the effect of the continued dose is reached. The system once under their influence, smaller doses than those mentioned above will continue the effect. Hot water, locally, is exceedingly valuable ; it alone will often subdue a troublesome chordee ; to gain this effect the penis and testes should be immersed in a bowl of water, as hot as can be borne, before going to bed, and thoroughly soaked for perhaps fifteen minutes, taking care that the water docs not grow cold. Such a bath is of the greatest service in subduing the inflammatory symptoms and enforcing the necessary cleanliness al- ready insisted upon. It should be looked upon as one of the most reliable remedies in the surgeon's hands. In addition to things already mentioned, the patient's bowels should be attended to. Excessive purgation, which many men seem to think is curative, should be avoided ; but the effect of a single purge at the outset is good, and a daily stool should be induced. The changed condition of life in regard to diet and exercise are apt to cause torpidity of the bowels, and a loaded condition of the rectum favors congestion of the genito-urinary or- gans. A very large proportion of patients are clamorous from the very first for an injection ; but I am more and more convinced by experience that all local meddling during the acute stage is injurious. The occasional suc- cesses I hear of, from medical gentlemen, from the early use of injections, I am persuaded, are either markedly ex- ceptional, or are illusions ; or, what is more probable, the cases belong not to the first gonorrhoeas, but to the sub- sequent attacks. The use of demulcent and anodyne in- jections during the acute period is often recommended. They seem soothing, but equal good may be accom- plished by the means described above, without incurring the risk, at the time when it is greatest, of propagating the disease to the bladder. When the disease has reached its height and begun to decline, as evidenced by a decrease in the smarting and disappearance of the swelling of prepuce and urethra, it is proper to begin the use of the antiblenorrhagics. The substances that have some claim to be classed under this name are very numerous, but three stand easily at the head of the list: copaiba, oil of sandal wood, and cubebs. Other drugs may have equally valuable properties, but the three mentioned have been most faithfully studied and are best known. Of these, cubebs has probably the least in- fluence upon the disease, but has the advantage over co- paiba of being less irritating to the stomach, and its odor is so identified by the public with certain preparations for the throat and voice that it escapes hostile criticism. Copaiba is very unacceptable to a delicate stomach, and is occasionally followed by a very disagreeable rash in the form of a characteristic bright cherry-red maculo- papular or papular efflorescence, which appears suddenly and may invade the whole surface of the body. Sandal- wood is identified with East Indian trinkets, and it is not easy to explain the presence of its characteristic and well- known odor. It seldom disagrees with the stomach, but shows its effect, when a full dose is taken, by a pain in the region of the kidneys, due probably to congestion of those organs caused by the passage of the drug in elimi- nation. Its action is often more marked than that of either of the others, but it is more uncertain. When the antiblenorrhagics disagree with the stomach they must not be expected to do any good to the urethral trouble, and must be stopped. As Keyes9 expresses it, when they are digested they do good, but when they are not digested, they do harm. The odor of these drugs ought to be perceptible in the urine before therapeutic action can be expected. Given at the moment indicated, that is, when the dis- charge is just beginning to decrease, a noticeable improve- ment follows. Of course, that is the natural course of the disease, but the decrease is greater with the antiblennor- rhagic than without it. I usually begin with cubebs, giving from half to a whole teaspoonful of the freshly- powdered berries three or four times a day. If it shows itself useless, or improvement is not continuous, one of the others should be substituted. It is a very good plan to follow with sandal-oil, which should be given in fifteen to twenty drop doses on sugar after meals. If a marked effect is not shown within a week, it is hardly worth 360 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhwa. Gonorrhoea. while to continue the drug longer. The drug itself should be used, and not the capsules said to contain it. Copaiba is most often given in capsules wfliich contain about ten drops. Six to nine should be taken in twenty- four hours-either two or three after meals, or scattered singly through the day. Many individuals take it better in the form of an emulsion, in which form it seems to me hardly more difficult to take than cod-liver oil. Injections may supplement internal medication as soon as improvement ceases, but with first cases it is not best to begin them until all signs of acute inflammation have passed away. The time when local medication seems to be specially indicated is the time when the inflammation tends to localize itself on certain portions of the urethra. No injection of sufficient strength to have a caustic action should 'ever be entrusted to a patient. The charge that injections cause stricture is, generally speaking, untrue, but the strong injections sometimes recommended, ap- parently with the idea of burning out the disease, suf- ficiently strong to cauterize the delicate mucous mem- brane, must cause an actual loss of substance which can only be replaced by cicatricial tissue. An injection of proper strength, though it does not cause stricture, may induce a cystitis, as shown in treating of that complica- tion, and perhaps epididymitis ; a fact wfliich should be kept in mind in prescribing. The ease with wfliich the bladder may be injected in some cases is not always ap- preciated. No more should be injected into the urethra, with a closed meatus, than the urethra is capable of hold- ing. Many syringes are too large to be entirely emptied into the urethra, which holds from a drachm to a drachm and a half (four to six cubic centimetres). The substances that have been used for injections are too numerous even to mention. The sulphate and acetate of zinc, and the acetate of lead, are probably as service- able as any. These substances may be used in a strength of from one to two grains-possibly three grains in rare cases-to the ounce of water, and should be administered twro or three times in twrenty-four hours. If the urethra is still tender, the sulphate of morphia, or the extract of belladonna, may be added in about the same proportions. Many cases fail to recover simply because the urethra has " lost its tone," and the stimulant action of one of these salts is the one thing needed to cause it to take on healthy action ; to overstimulate by too strong an application would be apt to keep up the discharge. Sulpho-carbolate of zinc, one to four grains to the ounce, is thought very highly of by many. If the wished-for result is not attained by these simple solutions, an insoluble substance, like the oxide of zinc, or the subcarbonate of bismuth, should be added. Dr. Otis recommends the addition of lime-water, as in the following prescription : B- Zinci oxidi 3 ss. Zinci acet grs. viij. Aquae calcis § iv. M. Such a method as here recommended will not meet with universal approval nor universal success ; but some similar course will, I firmly believe, show better results than a more heroic one. But few formulas have been given, for gonorrhma cannot be cured by any infallible remedy of universal application. Its treatment requires as much judgment and as careful watching as any disease we are called upon to meet. The most important matter is the careful treatment of the acute stage ; to abridge that is to diminish the damage to the urethral mucous membrane. Mr. Milton seems to hold a similar opinion when he says: " Chordee cannot be cured too quickly, and Boerhaave showred wfliat a sound physician he was when he said that, ' he who is most successful in prevent- ing priapism will be most successful in the cure of the disease.' " The treatment here indicated does not differ very greatly from that advocated by many modern writersi0, some of w hose methods are even simpler. Dr. F. N. Otis discards the antiblenorrhagics and uses no injection until the dis- ease begins to decline. Iii addition to what has already been said on the sub- ject, it is not superfluous to repeat that anything that depreciates the general health of the patient should be avoided, and the vegetable bitters with iron, quinine, or other tonics should often be added to, or even supplant, specific treatment. The method advocated is intended to apply to virgin cases, or those recurrent cases in which the inflammation runs high. The cases w'hich recur so frequently in many men are usually attended by very little inflammation, and in most of them it is advisable to have recourse imme- diately, or at least very soon, to injections. A solution of sulphate of zinc, a grain or two to the ounce, will often cause the discharge to cease immediately. When it fails, the injections containing an insoluble precipitate are often very serviceable. Some of these cases do well with the balsamics, but most of them do best with an in jection. There are many forms of treatment which have been highly praised, and from which great improvement in re- sults was expected. The washing out the urethra with large quantities of hot water before applying a curative injection promised great results and was extensively tried, but has been abandoned. Various antiseptic methods have been put forward as successful by their inventors, but in the hands of others none of them has been better than the older methods. Soluble bougies, and soluble substances mounted on probes, have the advantage of put- ting the medication just where it is needed, but, promis- ing as their use would seem to be, in actual practice they are very disappointing. Their use in subacute cases and cases long past the acute period are often follow'ed by the appearance of acute symptoms in full force. Balanitis.-The mucous membrane covering the glans and lining the prepuce is often the seat of inflammation which may be general or circumscribed. If limited to the glans it is properly called balanitis ; limited to the pre- puce, posthitis ; involving the two, balano-posthitis. So accurate a nomenclature is seldom used, balanitis being applied indiscriminately to any superficial inflammation of glans or prepuce. Balanitis may be induced by any irritation ; it is common in men with congenital phimo- sis, and is then due to the retained smegma which under- goes decomposition. A similar result takes place when a long foreskin is not retracted and the parts beneath kept properly cleansed. It is not very uncommon in boys who have never learned the necessity, or even the possibility, of retracting the foreskin for the sake of cleanliness. The discharge from a venereal ulcer, the gonorrhoeal discharge from the meatus, the saccharine urine of diabetes, if retained beneath the prepuce, may set up a balanitis. Some cases are the direct result of contagion from gonorrhoea in the female, though, strangely enough, such cases are rare compared with gonorrhoea. According to Sigmund, one case of balanitis applies for treatment to seventeen of gonorrhoea ; according to Four- nier, one to twrenty-four. A slight degree of balanitis attends most acute cases of gonorrhoea, in the form of marked redness about the meatus when the discharge is very abundant, especially if the penis is dressed in such a manner as to retain it. In its most simple form balanitis manifests itself by a slight itching or burning sensation, and examination shows a redness more or less marked of some portion of the mucous membrane, usually in the furrow behind the glans, with an increased secretion of smegma. In a higher degree of inflammation one finds a general redness of the mucous membrane with slight swelling. Upon the red and injected base are multiple exulcerations, superficial and variable in extent. These exulcerations are most characteristic, and are simply surfaces deprived of their epithelium, and dark-red in color. They vary greatly in size, are exceedingly irregular in contour, and their outlines remind one of a map of an irregular coast. There is a certain degree of local discomfort, which may amount to positive pain during erection. The secretion is abundant, purulent, and of a nauseating odor. When the preputial opening is small and the swelling great, it becomes impossible to retract the prepuce. With such an acquired phymosis, or when the phymosis is congen- 361 Goiiorrlieea. Gonorrhea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ital, the actual condition of the glans cannot be seen ; the appreciable symptoms are a swollen and reddened pre- puce, and a discharge from the preputial orifice. The in- tensity of the inflammation is seldom great enough to give rise to symptoms of more importance than those described. Occasionally-seldom, unless the inflammation is due to a subpreputial chancroid, or has been subjected to some unusual neglect or irritation-the swelling and discharge become excessive. The prepuce may project far beyond the glans and take on most singular shapes. The passage of the urine over the excoriated mucous membrane of the elongated prepuce may then be very painful. The swelling of the prepuce maybe so great as to cause a ver- itable obstruction to the passage of urine. Balanitis and its acquired phimosis occasionally result in gangrene of the prepuce, which takes place on the dorsum, in such a manner as to allow the glans to escape through a button- hole, the remainder of the prepuce hanging from its lower aspect, like an excrescence. The destruction of the pre- puce may more closely resemble an ordinary circumcision, but the portion about the fraenum is never destroyed, nor does the destruction of tissue extend beyond the furrow behind the glans. Febrile phenomena attend these more serious cases. Paraphimosis also results from balanitis when the swelling is sufficient to diminish somewhat the preputial opening, and results from too energetic attempts to re- tract it to apply lotions, or from curiosity. A frequent result of repeated attacks of balanitis beneath a phimosis is the adhesion, more or less complete, of the foreskin to the glans. Such adhesions are sometimes diffi- cult to separate, and it is still more difficult to keep the two surfaces apart in healing. Another, but rare, result, mentioned by Fournier, is a persistent oedema of the prepuce, which even returnsand persists after circumcision. From what has been said it is evident that balanitis is not necessarily venereal in origin, nor is it possible to dis- tinguish with certainty the cases that owe their origin to contagion. The disease, as it occurs in boys, is often re- ferred to the physician for an opinion as to its cause. The treatment is very simple : cleanliness is the first requisite. In addition a mild astringent should be used, like the dilute lead-water or a weak solution of sulphate of zinc. It may be necessary in some cases to keep the two surfaces apart by inserting a bit of cloth soaked in the astringent wash. Phimosis and Paraphimosis.-Occasionally the oede- ma and swelling of the prepuce and glans are sufficient to prevent retraction of the foreskin and cause a tempo- rary phimosis. The swelling seems sometimes to be in- flammatory when the whole prepuce is red and tender. In other cases it is evidently oedematous. In a similar man- ner, the swelling accompanying gonorrhoea may prevent the return of the prepuce to cover the glans, when once it has been retracted, and cause a paraphimosis. Phimosis and paraphimosis are treated of in separate articles to which reference may be made. Lymphangitis.-In a certain proportion of cases lym- phangitis occurs as the result of the absorption of puru- lent material. It occurs most commonly in cases which have been neglected or irritated by improper dressings or want of cleanliness, but is not confined to such cases. The affected lymphatics are usually found on the dorsum, but occasionally on the side, and they appear like hard cords beneath the skin, running from the glans toward the pubes. These cords are but slightly attached to surround- ing tissues, so that they may be rolled beneath the finger. They may be either of uniform diameter or moniliform, and are about the size of a crow-quill. They may be slightly painful to the touch, and their course is indicated externally by a reddish line. In fact, they resemble exactly the line of lymphatics running up the arm or leg from a wound on the hand or foot. Lymphangitis is generally an accompaniment of oedema and inflammation of the prepuce. Suppuration may occur along the line of in- flamed lymphatics, particularly at the root of the penis. Bubo.-In gonorrhoea, as in any local inflammation, the neighboring glands may be affected. This occurs either with or without evident inflammation of the lymphatics. It is by no means uncommon, during the acute period of the disease, to find a gland in the groin somewhat en- larged and tender. Usually these glands do not go on to suppuration, but subside under the influence of rest and, perhaps, some soothing application ; but if irritated, if the patient is debilitated, and sometimes for no apparent reason, they suppurate. See Bubo. Peri-urethral Abscess and Folliculitis.-Ab- scesses may form in the cellular tissue surrounding the urethra in any portion of its extent. They show them- selves along the under surface of the urethra at any part of it, but are most common in the vicinity of the fraenum and of the bulb. The abscesses near the meatus are nat- urally much less serious than those in deeper portions of the canal; they are said to occur in cases where the ure- thral inflammation is especially intense, but they are not unknown in milder cases. Their beginning is usually quite insidious: A hardened lump is first noticed, ordi- narily on one side, but possibly on both sides of the frae- num. This increases in size, projecting more and more externally. The mucous membrane soon becomes thin and allows the pus to shine through. If the abscess oc- cupies both sides, it is distinctly divided by the fraenum into two lobes, which, on incision, may prove to be two en- tirely distinct cavities. Often these abscesses remain for weeks, if undisturbed, as a curious addition to the penis. They seem to have no tendency to break into the urethra, and should be treated by a little incision. These ab- scesses are due to suppuration in the urethral follicles. The inflammation closes the duct more or less thoroughly, and the purulent secretion of the gland can no longer find exit but collects within the gland, forming an abscess or a purulent cyst. The duct can often be felt like a small cord connecting the cyst with the urethra. When the cyst has been pretty thoroughly destroyed by the suppu- ration it heals after incision, but sometimes the cyst fills again after incision, or a fistulous opening may remain which may communicate with the urethra and prove troublesome to cure. Abscesses with a similar origin may form anywhere along the pendulous urethra ; when first noticed they are little roundish bodies, more or less closely connected with the urethra. They work their way slowly to the surface, when it is necessary to evacuate them. The pus which they contain is mixed with mucus, showing their gland- ular origin. These abscesses always occur on the under surface of the penis. The possibility of suppuration in connection with lymphangitis has been already mentioned. This occurs only on the dorsal surface. The deep abscesses in the neighborhood of the bulb are of much greater importance than those already mentioned. Fortunately, as compared with the universality of gonor- rhoea, they are not very common. They manifest them- selves at first by deep-seated swelling, in which fluctua- tion can be recognized with difficulty, if at all. The local discomfort and constitutional reaction are marked ; with the follicular abscesses of the pendulous urethra there is little if any disturbance. Abscesses may terminate by opening into the urethra or externally, or by finding exit in both directions about the same time. An opening into the urethra exposes the patient to great danger of infiltration of urine. Too much time should not be spent in antiphlogistic measures, nor should the surgeon wait for signs of point- ing before opening a peri-urethral abscess in the peri- neum. An early opening can alone insure against uri- nary infiltration. The patient should be etherized and put in the lithotomy position, as the only satisfactory way of reaching the pus. The rapidity of recovery after incis- ion is truly astonishing. If the abscess opens into the urethra, what is the proper course to pursue ? It is usually advised to make a coun- ter-opening in the perineum to avoid infiltration. Four- nier advises waiting, keeping the patient under close ob- servation. " If there is no reason to suppose that urine enters the cavity of the abscess no surgical interference is needed. At the least sign giving a presumption of 362 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea. Gonorrhoea. such a danger the urine should be evacuated by a cath- eter ; if the presence of urine in the cavity becomes evident, the counter-opening should be immediately made." The surgeon should remember, while waiting, that too early an incision is less dangerous than one made too late. These abscesses in the perineum may have a similar follicular origin to those near the meatus. Some, at least, have their origin in the glands of Cowper. Cowperitis.-The glands of Cowper, or of Mery, are two little rounded bodies about the size of peas, situated behind the bulb of the urethra, below the membranous portion of the canal, one on each side of the median line of the perineum, between the two layers of the subpubic fascia. They are compound vesicular or racemose glands, composed of several small lobules held together by a firm investment. The branched ducts unite to form a single excretory duct for each gland, which runs forward for an inch or more beneath the mucous membrane before en- tering the urethra. Cowperitis is never observed until the urethritis has gained the membranous portion of the canal. Bartels re- ports a case after the gonorrhoea had existed fourteen days, Carlo Giaccomini after eighteen days, Gilbler and Mauriac after a month. The inflammation attacks by preference the left gland, although both may be simultaneously af- fected. In the beginning there is a sense of tension in the perineum, and occasionally lancinating pains. The pain is increased by pressure, by sitting, and by the rub- bing of the clothing. Soon there can be recognized on one side of the urethra a little hard tumor the size of an almond ; the skin of the perineum and scrotum are un- changed. The tumor may remain stationary for a time, or slowly increase; if chills should occur, suppuration would be no longer doubtful. The pus is at first enclosed in the glandular envelope, but its tendency is to break its thin bounds and infiltrate the cellular tissue. English,11 who is the author of a very careful study of the subject, says that there is disturbance and pain in micturition ; as the swelling of the gland and its sur- roundings increases, the stream grows thinner, and at last stops. Disturbance occurs either in the rectum or the urethra, as the gland is situated nearer the one or the other. The symptoms in the rectum are seldom great; at most they consist in an unpleasant sensation, or a con- tinuous desire to defecate. The first symptoms of the trouble should be met by en- forced quiet and a rigid enforcement of the general pre- cautions to be taken during the acute period of the general disease. When suppuration is evident, the pus should be evacuated as advised for any perineal abscess. Prostatitis.-Inflammation of the prostate as a com- plication, or as an event in the course of an acute gon- orrhoea, occurs in all grades of intensity-from a simple congestion, with symptoms so slight as often to escape recognition, up to a suppuration which may involve the most serious consequences. The simple congestive forms are not uncommon. Suppuration is fortunately rare. The same causes-like excesses, suppressive medication, the use of instruments, etc.-which may provoke other complications may also call forth a prostatitis, but it often occurs when no additional provoking cause, aside from the gonorrhoea itself, can be found. When it ap- pears early in the disease, that is, in the first fortnight, it is usually due to some provoking cause. Symptoms.-Sensations of pain and weight are felt in the perineum, with frequent calls to urinate, which are painful, but without the marked vesical tenesmus of cys- titis. Micturition is rendered somewhat difficult by the swollen gland ; defecation is a little painful, accompanied by rectal tenesmus. Sometimes these symptoms become more intense, the urine is ejected only with effort, with a burning sensation in the depths of the canal; there may be actual retention, requiring the use of a catheter ; the rectal tenesmus becomes insupportable with the sensation of fulness, or of the presence of a foreign body. Rectal touch shows the prostate hot, swollen, and tender, actu- ally projecting into the rectum. The general system sympathizes with the local hyperaemia rather more than in cystitis, and we have a febrile condition. Inflamma- tion of the prostate almost always results favorably in resolution. A few cases go on to suppuration, when the symptoms, both general and local, increase in intensity ; chills may occur, and if the pus forms on the rectal por- tion of the gland, it may be possible to recognize its pres- ence. Rectal examination is apt to be quite painful, but should be carefully made if there is any reason to suspect suppuration. Most commonly the abscess breaks into the urethra, the discharge taking place during efforts at mic- turition or defecation, or the abscess may be punctured by the catheter, if its use has been necessary. The evac- uation changes immediately the condition of the patient; the difficulty of micturition and of defecation vanish, and the temperature falls. Such, at least, is the ordinary course, but the abscess may result in the most doleful consequences. When the abscess is large and the pros- tatic parenchyma practically destroyed, there may result a cavity communicating with the bladder and forming a sort of supplementary bladder ; or the resulting cavity, communicating with the urethra, fills with urine at each micturition, and, continuing to secrete pus, proves fatal after a long period of suffering. The abscess may also break into both the urethra and rectum, leaving a urethro-rectal fistula. Pelvic peritonitis, followed by general peritonitis and death, is also one of the possibili- ties. The symptoms are further considered in connection with those of cystitis. Treatment.-The patient should be confined to bed, and all urethral injections stopped. In addition, for the great majority of cases, the simplest hygienic care, with the administration of opium, belladonna, or hyoscyamus to control the pain and tenesmus, will be sufficient. Leeches to the perineum, to the number of fifteen or twenty, are recommended by most writers. Mr. Harri- son knows of " nothing that gives more relief at the out- set of an attack of prostatitis than free leeching of the perineum, followed by hot applications." 12 Hot rectal injectionshave seemed to me to fulfil all the indications; they are very soothing, and seem to hasten resolution. By this means the water, which should be retained as long as possible, is brought into close relations with the swollen gland. Hot sitz-baths have a similar, though not so marked, an effect. M. Paul Reclus 13 speaks very highly of rectal injections. He uses water at 130° F., and applies wet compresses of the same temperature to the perineum. If the symptoms lead one to suspect the formation of pus, it should be carefully looked for-too frequent examinations of the rectum should be avoided, however. An abscess which cannot be felt by the finger in the rectum, may generally be left to nature ; it is usu- ally advised that the abscess, when fluctuation is felt in the rectum, be punctured through the rectal wall. Mr. Harrison's views on the subject, as expressed in the arti- cle mentioned above, seem particularly worthy of repeti- tion : " When fluctuation is detected by rectal examina- tion, a perineal incision becomes imperative." "When the finger detects that suppuration has taken place, there should be no hesitation in giving exit to pus by an inci- sion into the prostate with a long-bladed finger-knife, the finger of the opposite hand being retained within the bowel as a guide. Unless this is done, the matter will most probably find its way into the rectum, and a perma- nent fistula may be the result; or it may burrow in other directions, all of them likely to be more disastrous to the patient than the course the surgeon would afford. Rec- tal puncture I know has been advocated, but I am not in favor of it; a cut in the treatment of an acute abscess is, as a rule, far better than a puncture." For chronic affections of the prostate, see under Pros- tate. Cystitis.-In the compressor urethrae muscle gonor- rhoea finds an obstacle which is usually sufficient to con- fine it to the anterior urethra. Sometimes, however, the inflammation extends beyond the compressor urethrae, and invades the posterior urethra and the bladder. Ordi- narily the inflammation reaches the cul-de-sac about the end of the third week, or a little later, and the most common, one might almost say the normal, time for 363 Gonorrhoea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cystitis to appear is in the third or fourth week. It is occasionally precocious, appearing as early as the third or fourth day, and then owes its existence, almost invari- ably,' to some external mechanical action upon the ure- thra, as the passage of an instrument or the improper use of an injection, or to some infraction of the necessary quiet. The appearance of cystitis may also be greatly retarded. The inflammation may so far subside as to be confined to the region of the bulb, and remain for weeks or months in that locality, and after that long interval, from some cause not always appreciable, pass the sphinc- ter and attack the posterior urethra and the bladder. Many cases of cystitis, occurring so long after a gonor- rhoea has been apparently cured as to seem unconnected with it, owe their existence to a latent inflammation of the deeper portions of the urethra which dates back to the original clap. The additional influence necessary to set up a cystitis in the early period of gonorrhoea is commonly found in an improper use of the urethral syringe. When a syringe holding more than the urethra can contain has its con- tents forcibly injected into the urethra while the meatus is held tightly against it, the injected fluid must find a passage in the direction of least resistance ; if the syringe is a good one, and the hold on the meatus firm, it is likely to pass the compressor urethrae. Naturally, it pushes before it some portion of the urethral discharge, which, coming in contact with the neck of the bladder, sets up an inflammation. The passage of any instrument into the bladder for any purpose may have the same effect, though perhaps less commonly than the injec- tion, as the compressor, hugging it closely as it passes, would detain any extraneous material from entering the bladder. The inflammation is usually said to be limited to the neck of the bladder-that is, the posterior urethra, the portion included between the compressor urethra? or mid- urethral sphincter and the vesical sphincter. The pres- ence of a large amount of pus in the urine shows that it often involves the bladder itself. It manifests itself by marked frequency of micturition. In the slightest cases this is almost the only symptom, and the patient may then be obliged to pass water perhaps every two hours. In the most acute cases the desire is constant, and every few moments a few drops are squeezed out. The desire is imperative and irresistible ; one finds these patients con- stantly in the position for micturition, groaning, with an anxious, congested countenance, bathed with sweat. Even in some of the cases in which the frequency is not most marked the patient must pass water immediately, or it will force its way through, in spite of his efforts to retain it, and soil his clothes. This frequency is somewhat in- fluenced by mental impressions; the desire becomes agonizing when the patient realizes that some circum- stance, like the presence of a visitor, makes it impossible to pass his water at the moment. When he prepares to yield to the desire, the very thought that the water is to be passed increases the pressure, and the patient, with the urinal already in his hand, esteems himself fortunate if he escapes with only the loss of a few drops on his clothing. The pain that attends the worst cases is agonizing. It is only at the end of micturition that the characteristic vesi- cal tenesmus is felt. Thb bladder squeezes down involun- tarily, as if to expel the very last drop, and continues or repeats the spasm one or more times. With the last drops are usually squeezed out a few drops of blood. Some cases are exceedingly insidious in their beginning, with symptoms so slight as hardly to attract attention. The patients have a slightly disagreeable sensation with the last drops of urine, but no blood. A single symp- tom shows the inflammation of the bladder, the presence of a small quantity of pus in the urine. This latent con- dition persists sometimes until recovery is complete, but more often it is only the prelude to the more common form.14 It is very rare, however, according to Guyon, that slight bleeding fails to show itself with the last drops of urine. The blood may be sufficient to tinge the whole of the urine, but, even then, the last drops will show the greatest quantity. The presence of pus may be demon- strated almost at the very beginning, while in some other forms of cystitis, like the tubercular, the appear- ance of pus is delayed to a later stage. The disease is usually accompanied by an apparent diminution in the amount of discharge ; some diminution there is undoubtedly, but the frequency with which the urine washes the urethra makes it difficult to appreciate its true amount. A state directly opposed to the incontinence already mentioned occasionally occurs. The inflammatory state which usually induces the sphincter to relax too quickly may induce a spasm and consequent retention. Fever is certainly exceptional in gonorrhoeal cystitis, and any rise in temperature should cause one to search for further complications. In well-marked cases of cystitis and prostatitis, the symptoms are sufficiently distinctive, but many cases are so poorly marked that it is not easy to discriminate be- tween the two. Moreover, the two troubles are often conjoined. The following table shows the distinctive features of each: Gonorrhceal Cystitis. Micturition increased. Calls to micturate imperative. Vesical tenesmus. Pus and blood in urine. Pain in perineum slight. (Pain may be felt over pubes when the viscus is largely involved.) No rectal tenderness. Usually no hinderance to urination. Retention rare. No fever. Gonorrhceal Prostatitis. Increase less marked. Rectal tenesmus. Very little. Pain more marked in perineum and rectum. Enlarged and tender prostate. Hinderance to micturition. Some- times retention. Fever more common. Treatment.-Rest, anodynes, and alkalies are of about equal importance in the treatment of this trouble. The rest should be absolute and in the recumbent position, and should include the cessation of bougies and injections. The urinal should be taken into bed rather than allow the patient to rise. An anodyne of some sort is indispensa- ble, and is not only an addition to the patient's comfort, but, by preventing the tenesmus, controls the disease. Opiates are often administered in suppositories or starch injections, but can also be given by the mouth. Bella- donna and hyoscyamus are often as effectual as opium. The urine should be rendered mildly alkaline. Diet is of great importance, and in a severe case I prefer that my patient should take only milk at first, gradually adding bland articles-bread, oatmeal, potatoes-as the symp- toms improve. Patients are sometimes treated by wash- ing out the bladder, but that method of treatment is best reserved for chronic cases. When the disease has become subacute, Bumstead rec- ommends the following formula: R. Potassae bicarb ^j. = 30. Tr. hyoscyami, Fl. ext. kavse kavae aa § ss. = 15. Aquae q.s. ad 3 viij.= 240. M. One tablespoonful in a wineglassful of water three or four times a day. The disease occasionally attacks the whole mucous lin- ing of the bladder and becomes chronic ; and it may ex- tend up the ureters and invade the pelvis of the kidney- an unusual course, but much more frequent than was for- merly supposed. Epididymitis.-Epididymitis occurs as a complication of gonorrhoea with great frequency ; Fournier says once in every eight or nine cases. It may occur in any period of the parent disease, but most commonly from the third to the sixth week, the period at which the disease reaches the mouths of the ejaculatory ducts. When it occurs earlier it is almost invariably due to the use of instru- ments or irritating injections, and its later appearances are also apt to follow the action of some provoking cause. There can be little doubt that the disease always proceeds directly along the cord to the testis, though the first com- plaint is often of the testis itself. Attentive and sensitive patients usually notice a pain in the groin before feeling 364 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea. Gonorrhoea. it in the testis. Occasionally, though not often, a chill precedes the disease. A diminution in the flow of pus usually precedes the disease. Within a few hours of the first symptoms a decided pain is felt in the testicle, accom- panied by an increase in size. The gravity of the symp- toms varies greatly in different cases. In an acute case the swelling is first noticed in the epididymis, but soon involves the whole structure, though the testicle itself is probably only distended with blood, and not the seat of pathological processes. The disease attacks chiefly the tail of the epididymis, just behind the body of the testis. Occasionally there is a malposition of the testis bringing the epididymis in front, which may be the cause of error in diagnosis. When the disease occurs in a retained testis the pain is apt to be atrocious. The scrotum becomes cedematous, the tunica vaginalis is slightly distended with fluid, and the cord becomes swollen and painful. The testis increases to the size of the closed fist or a little larger, but the general swelling is seldom so great that the epididy- mis cannot be recognized, by careful manipulation, as sur- passing in hardness the testis proper. The pain may be sufficient of itself to keep the patient in bed, especially as any attempt to move about on the feet is attended with a marked increase in pain. The pain increases for three to seven days, and then remains for a time stationary, but is usually pretty well gone before the end of the second week. Relief from pain is often experienced before the swelling has greatly diminished, but the standing posture will still bring it back. As resolution goes on everything becomes normal except the epididymis, which remains hard for a long time-months, or even years-and in some cases never returns to its proper condition. In such cases it becomes merely a little hardened lump, which causes no uneasiness, and is entirely disregarded except by pa- tients who are by nature anxious about their genital organs, or have informed themselves concerning its pos- sible consequences. Like the parent gonorrhoea, the first epididymitis is usually, not invariably, the most severe. Some attacks amount only to a hardening of the epididy- mis, attended by pain and dragging, which is so far re- lieved by a suspensory as to allow the patient to attend to ordinary business. The inflammation may limit itself at any point and stop further progress. Dr. Otis gives a very interesting case of a man who, after the passage of a bougie, complained of a pain in the perineum, the loins, and the back, which passed off in a day or two. Again, after a bougie, the same pain appeared, but ex- tended down the groin, with a little aching of the testicle. This also passed off with care, but the third time, also after the bougie, the inflammation extended to the epidid- ymis, and the patient suffered from swollen testicle for weeks. In cases which do not recover, the tail of the epi- didymis becomes fused into a solid mass, and a fatty de- generation may afterward set in, when the convolutions of the tubes can no longer be made out. When such a condition is present in both testes, the man is of course, sterile (though not impotent). Treatment.-It is often recommended to wear a sus- pensory bandage from the very first appearance of the discharge at the meatus, as a means of prophylaxis. The danger is very slight until the disease is well down the canal, and a suspensory put on at the end of the second week ought to be early enough, except in cases in which one has reason to expect everything to go wrong from the very first, and in which no precaution can be too great. In recommending a suspensory, the surgeon had best make himself sure by personal observation that it actually supports the testes. A suspensory is the very first req- uisite when the epididymitis appears. If the patient has consulted the doctor at his office, before he starts for home he should have a handkerchief, or some arrange- ment, to support the testicle until he reaches home, where he should go to bed. A suspensory which is good when a man stands is of little service in bed, and the physician should see for himself that the testicles are raised. Pa- tients will carry out to the letter the most careful direc- tions, but, by some ingenious neglect of their spirit, leave the whole weight of the testes to hang unsupported. A very good support can be made, with a little practice, from a handkerchief folded once so as to make it three- cornered ; the centre of the long-the folded-side is put beneath the testes, and the two ends on the folded-side tied to a bandage about the waist. If necessary, a double tape can be sewed to the middle of the long side which is beneath the scrotum, and secured to the bandage about the waist behind. A long towel carried over the thighs close up to the body, and secured below, makes a shelf on which the testicles rest easily. Rest in bed, with the testicles raised, is all the treatment necessary in many cases, but it is not sufficient in the severer cases. Local applications, either hot or cold, may be used. Ice poul- tices are very pleasing to many, but they need to be care- fully adjusted to keep up a continuous cold not extreme enough to do damage or be uncomfortable. Such an ad- justment is difficult for any except a trained and in- telligent attendant. An evaporating lotion is perhaps quite as good when the patient can give it a chance to evaporate, which is very rare, indeed. I know of no means by which those cases may be distinguished that do well with cold ; if it does not relieve the pain somewhat in the first three or four hours it should be abandoned. Hot applications are on the whole easier to manage, and, especially if they contain some narcotic, are quite as ser- viceable. Tobacco has long been a favorite addition to poultices for epididymitis-almost its only remaining function in medicine. It may be sewn in a bag and wrung out in hot water, in the same way that hops are used, or may be added to a poultice. The drug is ab- sorbed to some extent, and appears to leave a deadening effect upon the pain. In persons not accustomed to its use it occasionally causes nausea and the deadly faint- ness so well known as accompanying the first cigar. It should be promptly removed on the appearance of such symptoms. Laudanum fomentations are a very good substitute for the tobacco; or the testicle may be wrapped in a cloth soaked in a lead-and-opium lotion. Puncture of the tunica albuginea is a proceeding strongly recommended by some surgeons as harmless and a certain relief to the pain, but others equally trust- worthy condemn it as being occasionally followed by atrophy, and not giving sure relief from suffering. It would seem best to reserve it for cases that do not yield to gentler means. Strapping the testicle should be reserved until acute symptoms are on the decline. Many drugs have been recommended as possessing rather marvellous powers over epididymitis. Pulsatilla is advised in fraction-of-a-drop doses of the tincture every two or three hours. Bumstead and Taylor were unable to gain good results from it, and observation on my own part has led me to believe it useless. The most that internal treatment can effect, in the present state of our knowledge, is to mitigate the pain and make the patient comfortable. When the epididymis is slow to go down, systematic compression by strapping is of some value. The inunction of mercurial ointment is also use- ful, and should be joined with the internal administra- tion of iodide of potassium and mercury in some form. Inflammation of the Vesicul^e Semin ales.-This is a rare complication of gonorrhoea. Its occurrence is betrayed by an emission in which the spermatic fluid is reddish from the presence of blood. The emission is pain- ful, the pain lasting after the ejaculation and radiating toward the perineum, the anus, along the cord, and to the lower part of the abdomen. Rectal examination may dis- cover the vesicles enlarged and tender. Defecation may also provoke a very decided amount of discomfort. Gonorrhoeal Rheumatism.-The existence of a spe- cial form of rheumatism, having definite characteristics of its own, and owing its existence to a pre-existing gonorrhoea simply, is not universally admitted. The fre- quency with which cases occur in which there is a re- currence of rheumatism with succeeding gonorrhoeas, no rheumatism having occurred previous to the gonorrhoea, nor in the intervals between the attacks, has convinced most observers that there is some connection between the two diseases. Such recurrent cases have been reported 365 Woiiorrlioea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by many different observers, and the opportunity to ob- serve single instances of the concurrence of the two dis- eases is so great that most practitioners have met them. Every large hospital service shows some cases every year. There is no longer any question as to the frequent oc- currence of rheumatic symptoms in connection with gon- orrhoea. The questions in dispute are whether the gon- orrhoea is the sole and sufficient cause of the rheumatism, and whether the rheumatism differs from ordinary rheu- matism. Some predisposing or provoking cause, in the opinion of certain writers, is necessary in addition to the gonorrhoea, as the rheumatic diathesis or exposure to cold. For other writers this form of rheumatism is iden- tical with other rheumatoid affections, as that occurring after scarlet fever ; others believe that rheumatoid symp- toms identical in character occur after any affection of the genitals, and after childbirth, and would speak of genital rheumatism ; by some it is regarded as a reflex manifestation of urethral irritation ; by others as a mild form of pyaemia ; others, still, can be satisfied with nothing short of making gonorrhoea a constitutional disease like syphilis, and the rheumatism an occasional manifestation of constitutional infection. That these rheumatic symp- toms owe their existence to gonorrhoea and would not exist without it, seems incontrovertible. It cannot be a matter of chance that such symptoms attack a certain small proportion of the victims of gonorrhoea, but ex- actly why one person is attacked and others not is, so far, simply a matter of conjecture. Leaving disputed points of etiology and nature without discussion, this article will consider simply the clinical history and treatment of the affection. Rheumatism is an infrequent complication of gonorrhoea. In 1,912 gonorrhoeas recorded by Fournier, there oc- curred 41 cases of rheumatism in 31 individuals, or about one case in 47 gonorrhoeas. It often appears during the acute stage, but not necessarily until after this stage has passed. Rene, of Strasburg, records 56 cases, of which 18 occurred in the third week, and 16 in the fourth week. It first shows itself, usually, by not very acute pains in some one or two joints, the eyes being often affected at the same time with, or even before, the first joint symptoms. Occasionally the rheumatic affection seems to follow, or be aroused by, some extra irritation of the urethra. The joints involved are most frequently those of the knee and ankle, and of the fingers and toes. The fingers are usually involved subsequently to the larger joints, and in the cases which have fallen under my observation but one or two of the fingers or toes have been affected. The disease is described as having a mon- articular character. It certainly attacks fewer joints than the ordinary acute rheumatism, but a more striking peculiarity is the reluctance with which it abandons the first joint. The disease extends, rather than removes, to other joints. Professor Frazer, of Edinburgh,16 describes this pecu- liarity a little differently. He says: "Where only one joint is affected, the inflammation remains there generally for weeks, and frequently for months. Where several joints are affected, the inflammation persists with equal tenacity in one or two of these joints, and long after it has disappeared from the others. This persistency, therefore, in one or more joints, and not the absence of a tendency to pass from one joint to another, or to disap- pear suddenly from an affected joint, is to be regarded as a distinguishing character of the arthritic disease." A single joint only was attacked in twenty-two out of forty-five cases of Fournier and Rollet, but in some of these cases other structures than the joints were involved. While certain joints are most liable to be attacked, no joint can be considered exempt from danger. The following list, taken from Fournier, and includ- ing his own cases and those of Foucart, Brandes, and Rollet, shows the number of times different joints were affected in the cases under their care : Knee, 83 ; tibio- tarsal, 32 ; fingers and toes, 23 ; hip, 16; wrist, 14; shoulder, 12 ; elbow, 11 ; temporo-maxillary, 6 ; medio- tarsal and metatarsal, 5 ; sacro-iliac, 4 ; sterno-clavicular, 3; chondro-costal, 2 ; tibio-fibular, 1. Though gonorrhoeal rheumatism possesses no pathog- nomonic sign, it has certain peculiarities which distin- guish it from ordinary acute rheumatism. These peculi- arities may not be so marked in any single case as to necessarily attract notice, though the observation of a series of cases'could hardly fail to show the distinction. The points of difference are best shown in the tabular form. Gonobrhceal Rheumatism. Occurs during a urethritis. Little fever. Constitutional symp- toms neither severe nor lasting. Usually no sweating. Urine unchanged. Cardiac lesions uncommon. Often associated with some trouble in the eyes, and with inflamma- tion of tendons and bursaj. Few .joints attacked. First joints attacked apt to be the last to re- cover. Local pain less marked. Recurs with a new gonorrhoea. Anti-rheumatic remedies ineffect- ual. Ordinary Acute Rheumatism. Not necessarily occurring during urethritis. Fever often high, and constitu- tional symptoms often prolonged. Sweating a marked characteristic. Urine high-colored and loaded with urates. Cardiac lesions common. Such association very uncommon. Joints affected more numerous. Often entirely abandons the old in attacking new joints. Local pain marked. Recurrence irrespective of gonor- rhcea. Anti-rheumatic remedies evidently useful. One of the points usually included in such a table is the rarity of the disease in women, but experience has modified this opinion. Fournier reported seven cases of the disease in women in about two years. During the same time twelve cases in men came under his observa- tion. It is an important fact that a gonorrhoeal inflam- mation of any part of the female genital tract is sufficient to give rise to rheumatic symptoms. The character of the temperature is shown in eight cases reported by Dr. V. Struppi, of Gratz.16 The tem- perature rose in five cases only the first two days ; morn- ings to 38° (100.4° F.), evenings to 38.4° (101.1° F.). From that time on it varied from 36.9° (98.4° F.) to 37.2° (99° F.). In the other three cases the temperature was always normal. With ordinary rheumatism the tempera- ture rises, especially in the early part of the disease, and with each jump to another joint, very high-40° (104° F.). The number of cases of heart affection observed in gonorrhoeal rheumatism grows constantly. Still, its oc- currence is exceptional. Affections of the cerebral mem- branes have also been reported. In 1868 Fournier had had no complication of heart, pleura, cord, or brain in forty-five cases of rheumatism, but the same series of cases showed ophthalmic complications in seventeen cases. Gonorrhoeal rheumatism is apt to affect many systems, producing at the same time, or successively, lesions of the joints, tendinous synovitis, ocular phlegmasiae, acute hygromas, and neuralgias; in this way becoming even more varied in its morbid expressions than simple acute rheumatism.11 Several cases of sciatica, as one of the manifestations of the disease, have been reported. The disease is very varied in its manifestations. Four- nier makes clinically four classes : 1. Hydrarthrosis ; in which there is great effusion into the joint, with an absence of local or general reaction, and a tendency to chronicity. This form occurs almost ex- clusively at the knee-joint. It attacks either one or both knees. The effusion occurs slowly, and the pain is not very great, even with motion. The muscles of the thigh and calf are apt to become greatly emaciated. 2. Rheumatismal form ; in which the disease involves a greater number of joints, with greater local reaction, and, in short, nearly resembles ordinary acute rheuma- tism. 3. Painful form ; in which the joint shows no external signs of disease, and the symptoms are limited to pain which is often vague but persistent. 4. The " knotty, or pseudo-gouty." The characteristic of this form is the singular deformity that it impresses upon joints. It is observed only upon the hands and feet. The enlargements are similar to those observed in nodu- lar or gouty rheumatism. This form must be very rare. Professor Frazer, of Edinburgh, makes a more simple division into chronic, subacute, and acute forms. 366 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Clonorrlioea. Gonorrhoea. Mr. R. Clement Lucas18 has recently reported an inter- esting, though not a unique, case in which he believes that gonorrhoeal rheumatism occurred in an infant as a result of purulent ophthalmia. The father had a gonorrhoea, and the mother discovered that she was infected about a fortnight or three weeks before the birth of the infant. A day or two after birth the child was noticed to have a purulent discharge from its eyes. When it was about two weeks old the left knee was-found enlarged and pain- ful, and the wrist was, a little later, similarly affected. The knee resembled very closely the gonorrhoeal syno- vitis of adults, and both joints, and apparently the eyes, perfectly recovered. Prognosis.-The prognosis as to time it is impossible to make. Many cases recover promptly, but convalescence is usually prolonged, and even after recovery seems per- fect so far as external symptoms go, the patient is con- scious of weakness and a necessity of favoring the af- fected member. Ankylosis is an occasional result, and suppuration is not unknown, though not common. Mr. Brodhurst19 believes the articular inflammation to be of a more injurious character when a second or third attack occurs. He gives the case of a young man who had gonorrhoeal rheumatism in both knees, from which he perfectly recovered. Two months after recovery from the first attack he again contracted gonorrhoea. In ten days several joints became inflamed-the right temporo- maxillary articulation as well as the hips, knees, ankles, shoulders, and thumbs. The arms and ankles recovered perfectly, but the hips, knees, and the jaw became anky- losed. Treatment. - The treatment may be discussed as re- gards the original discharge, the constitutional treatment, and the local treatment of the affected joints. When the rheumatic manifestations were supposed to be due to a metastasis, it was thought desirable to cause a re- turn of the discharge, which was effected by various means, such as the use of irritant injections. Such a course has little in its favor and may be considered obso- lete. On the other hand, the question may well be asked, can we hope to see the rheumatism recover while the dis- charge remains ? The fact seems to be that the course of the discharge has little effect upon the rheumatic symptoms when once the latter have shown themselves. We should undoubtedly make the best possible use of the enforced quiet to cure the original disease, but should not consider its persistence necessarily a fatal barrier to the recovery of the rheumatism. The ordinary anti-rheumatic remedies are of little, if any, avail. The temptation to try the anti-rheumatics in an obstinate case is almost irresistible, but neither alka- lies, nor salicylic acid, colchicum, nor iodide of potash, have any effect, except perhaps the last toward the close of a chronic case. Quinine often seems to be of service, but not always. In general, in addition to quinine, the diet should be nourishing ; the patient should be encour- aged to live well, and wine or spirit should be given if deemed advisable, disregarding its possible evil effects upon the urethra rather than to allow the general health to suffer in the least. For the same reason it is advisable, in general, not to use the anti-blenorrhagics. The joints should be kept at rest; repeated small blisters seem occa- sionally of service. Extension was evidently of service, or at least, recovery followed rapidly its use, in one chronic knee affection under my care. Lebert sums up his treatment as follows : '' Inunction of fatty material into the joints, cold applications if the pains are severe, hypodermic injections of morphia at night if the pains persist, and rest in the horizontal po- sition, form the chief means of treatment." No means of treatment is perfectly satisfactory. Dr. J. William White,20 of Philadelphia, gives minute direc- tions for a method which has some novel features, and has succeeded well in his hands, and deserves trial by others. His directions are as follows : " On the occurrence of joint symptoms place the pa- tient immediately at rest, and limit the movements of the diseased articulation, which should first be freely painted with iodine, then enveloped in a layer of cotton wadding, and finally confined by means of a splint. Purge briskly with a saline cathartic, and, after its action has ceased, place the patient at once upon full-almost heroic-doses of quinia and small-antiplastic-doses of some mer- curial, preferably the protiodide of mercury. The use of these latter remedies constitutes the essential element of this particular plan of treatment. The quinine should be given in ten-grain powders, three or four times daily, or oftener if the symptoms of cinchonism are not marked, and should be pushed to the fullest degree consistent with safety. The mercurial should be administered in doses of a fourth or a third of a grain, four times daily, until the gums and posterior molars become slightly sensitive, when the dose may be somewhat reduced. At first a hypoder- mic injection of a fourth of a grain of morphia may be given at bedtime, but this will not be necessary for more than a few days. The splint should be removed daily, and after the first three or four days gentle motion should be made in the joint, especially if it be the wrist, after which it should be painted with iodine and immo- bilized again. If the case is unusually obstinate leeches around the joint may be required. The diet should be generous, and great attention should be paid to the condi- tion of the digestive tract. Urethral treatment, if mild in character and not involving instrumental interference, may go on uninterruptedly ; but I have found it better to avoid the passage of bougies, at least during the acute stage of the rheumatism. The disappearance of the swell- ing may be hastened by " strapping" the joint with ad- hesive plaster, something after the fashion of its use in epididymitis. This should not be done, however, until after the acute symptoms have subsided." Gonorrhceal Diseases of the Eyes.-These compli- cations need but the briefest mention here. They are of two entirely distinct varieties : the external inflammation, which is the result of direct inoculation, and the internal inflammations that accompany rheumatism. The reader is referred for their consideration to Diseases of the Eye. Gleet.-When complete recovery does not take place within a few weeks from the inception of a gonorrhoea, the discharge is no longer abundant and purulent, but thin and scanty, in which condition it may persist for years. The number of cases which become chronic is very great, so great, indeed, as to justify the opinion of Dr. Green- ough,21 who is " convinced that, unlike most inflammatory affections, that of gonorrhoea does not, in the majority of cases, tend to resolution and a return to a healthy and normal condition." To this slight but long-standing dis- charge is often applied the name of gleet, but the term is very indefinite, as it is used with various shades of mean- ing by different authors. Some writers would make it cover all cases of chronic discharge from the urethra, of whatever nature or origin; some make it synonymous with chronic gonorrhoea ; others would restrict it to a col- orless discharge, appearing usually in the morning, and gluing together the lips of the meatus. The adjective gleety conveys the idea of a thin, sticky substance, but so good an authority as the " Index Catalogue of the Sur- geon-General's Office " includes articles on chronic gon- orrhoea under the head of gleet. The word has a certain indefinite terror for the non-medical public, who look upon it as a separate disease very much to be dreaded. Happily, it is not necessary to settle the exact shade of meaning to be attached to the word, in order to consider chronic urethral discharges resulting from gonorrhoea. Discharges are maintained by either general or local causes. Persons in feeble health, or below par from any cause, whether temporary or constitutional, are very prone to continue the discharge indefinitely. Among those suffering from a temporary cause may be classed those persons whose digestive powers have been ruined by improper and excessive use of anti-blenorrhagics, as also those who have persistently starved themselves under the impression that such a course was beneficial to the dis- ease. Patients who are the victims of the tuberculous or rheumatic diathesis, as well as those lymphatic individu uals in whom suppuration in any part of the body is apt to continue indefinitely, are exceedingly prone to con- tinue their gonorrhoeal discharge long past the acute 367 Gonorrhoea. Gonorrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stage. The diagnosis of such a condition is made often by exclusion rather than by positive evidence. Closely allied to these cases are those in which there seems to be a want of vitality or recuperative power in the urethral mucous membrane. Dr. Otis considers that the very fact that the mucous membrane is kept constantly bathed in its own fluid secretions retards the return to a normal condition, the disease thus continuing to perpetuate it- self. Too energetic treatment may be damaging locally as well as generally. Patients show themselves occasion- ally, who have been so energetically bougied and injected with irritating fluids and solids in suspension that recov- ery has been impossible. These cases occur in the prac- tice of very energetic and over-sanguine, but not very ex- perienced, individuals ; but most commonly the patients have, for the most part, directed their own treatment. There is also a class of patients that contract a habit of constantly searching their urethra in the most teasing and persistent manner ; they seem to be forever squeezing the urethra to see if tlie last drop is still there. Such med- dlesomeness is a source of aggravation in other diseases than gonorrhoea, and there can be little doubt that some patients might escape part, at least, of their ills if they were content to examine themselves less curiously. Gleet is most often maintained by some more definite local cause than those just mentioned, to determine which is often a matter of the utmost delicacy. The disease may linger in some of the many crypts and follicles con- nected with the urethra. Dr. Charles Phillips22 describes its persistence in the lacuna magna. The lacuna varies very greatly in its development. Ordinarily it is the merest little cul-de-sac, but it may be extended to the me- atus and appear to divide it into two openings. The per- sistence of the disease in this spot alone must be highly exceptional. Phillips saw four cases, Otis has met with two similar ones. When there is reason to suspect that the disease is seated in the lacuna magna, and a director can be run into it, the walls should be divided. Little fistulous canals opening upon the surface of the glans, near the meatus, are sometimes seen. These follic- ular openings can occasionally be demonstrated to open into the urethra, and in them the discharge is continued. When they are found, they may have opened during the acute disease by a little follicular abscess. These fistulas cannot be very infrequent, but as a cause of the persist- ence of the discharge they are certainly rare. Dr. Ricordi,23 of Milan, records some cases in which the discharge persisted in Cowper's glands. The disease may also persist in other smaller and nameless crypts. Another cause of discharge is a chronic catarrhal in- flammation of the prostate. The discharge is a transpa- rent, viscous fluid, which shows itself from time to time, especially after straining at stool, though there is often an extra amount of moisture at the meatus. See Prostate. But gleet most commonly results from local changes in the mucous membrane of the urethra itself. As a result of long-continued suppurative inflammation, the mucous membrane, at a certain spot, loses its normal epithelial layer, and in its place presents an injected, granulating, pus-secreting surface. An olivary instrument will be pretty sure to show a little hitch in passing that point, and will bring up a drop of blood or blood-stained mucus, while a drop or two more may follow. The result of this granular condition in the urethra is, as elsewhere, the production of cicatricial tissue, which possesses its well- known property of contraction, and contraction may ex- tend far enough to very sensibly diminish the calibre of the urethra, while granulations still exist and cicatrization is incomplete. Even the smallest obstruction causes the urine to impinge somewhat roughly on the mucous mem- brane just behind it, and where there is a sensible con- traction that portion of the urethra behind it is ulcerated, or at least in an unhealthy condition. In such cases it is from this spot that the discharge comes. An abnormally narrow meatus is but another form of stricture, which tends at times to continue a discharge. The time necessary to form a sensible contraction va- ries very greatly in different individuals, and the evidence of a commencing contraction, convincing to one examiner, is not satisfactory to another. Guyon believes that strict- ure is only a late result of gonorrhoea, and that the chronic discharge is the result of a chronic inflammation in the bulbous urethra ; less often the disease persists in the membrano-prostatic portion behind the compressor urethrae, but even then inflammation of the anterior ure- thra is usually conjoined. When the disease is in the anterior urethra the dis- charge is constant, or, rather, what slight discharge there may be finds exit at the meatus. It may be so slight that only the night allows sufficient time for a drop to collect. The frequent washing of the urethra by the urine, when the discharge is very slight, is sufficient to prevent its be- ing seen during the day. To locate the situation of the localized disease, it is necessary to examine the urethra with the bulbous sound. Guyon uses only a No. 15 to 17, as too large a bulb sweeps the urethra clean before it. Passing this bulbous sound down, part way through the pendulous urethra, it brings up on the ridge behind the bulb a small amount of muco-pus ; passed further down to, but not through, the middle sphincter, it returns with a larger amount of pus, showing that in that spot is situ- ated the disease. In the " Atlas des Maladies des Voies urinaires," pub- lished by Guyon and Bazy, are given two plates illustrat- ing chronic urethritis confined to the anterior urethra. The first represents a man who had had his discharge for seven years, and died of intercurrent disease. In him the only inflamed spot was in the perineo-bulbar region, lim- ited abruptly behind by the compressor urethrae, shading off gradually at the anterior portion, and covering a sur- face of four or five centimetres in length. This spot was injected and very superficially ulcerated, showing little rosy granulations rising slightly above the surface, but no appearance of stricture. The second plate shows lesions similarly limited on a patient with epispadias. When the disease is situated in the posterior urethra, the discharge cannot flow out freely at the meatus; it may not appear there at all; when it does, its appearance is spontaneous but intermittent, at different intervals and in a certain abundance. The inter-urethral sphincter gives exit to it only when a certain amount has formed, and with an impulse resembling that of the urine or the spermatic fluid. The patient is conscious of the dis- charge, he feels himself moist, and his clothing is spot- ted. The discharge of the posterior urethra also appears during defecation. Frequency of micturition is almost constant in urethri- tis of the posterior urethra. It is the important symptom, and does not necessarily show that the bladder itself is involved beyond the neck. Though the posterior urethra may be chronically inflamed without involving the blad- der, the bladder is seldom or never inflamed unless the posterior urethra is included by the disease. Patients whose disease is limited to the anterior urethra have no functional symptoms, or at best only a few sensations, as of weight in the perineum ; they are apparently well ex- cept for the discharge. When the examination of the urethra has shown the discharge to be found at the bulb, it is not necessary to extend the examination further. It is only when the in- strument enters the membranous and prostatic urethra that one runs any appreciable danger of inflaming pros- tate, bladder, or epididymis. And though the danger in a chronic urethritis is small, it is best not to enter the posterior urethra except with a definite idea of what one expects to gain by it. When the instrument presses up- on the sphincter there is a sensible resistance, and the patient complains of pain. When, by a slight pressure, the instrument is passed through the membranous por- tion, a much more marked pain is excited, which is con- sidered as of little diagnostic value by Guyon, though be- lieved to be due to the chronic inflammation by Ultzman and others. To be precise in the search for the seat of the discharge, the bulb should not enter the bladder proper, but pass through the prostatic urethra. The dis- charge sought should be brought out by the bulb, or fol- low closely its point as it is removed. 368 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea. Gonorrhoea. The discharge and the spots which it leaves upon the linen have been carefully studied, and are the objects of close observation on the part of the patients themselves. The characters are too changeable to be of great diagnos- tic value. The glandules of the urethra may furnish a discharge which starches and gums up the clothing, so that that characteristic, sometimes ascribed to the pros- tate only, is not of great value. The microscope shows the discharge to be made up of leucocytes and epithelial cells, more or less deformed, which it is not easy to refer to the mucous membrane it- self, the urethral glandules, the prostate, or the bladder. The little bodies peculiar to prostatic discharge are some- times found, as well as spermatozoa. The filaments, which are more or less abundant in the first jet of urine in patients with chronic discharges, show simply that some portion of the mucous membrane is chronically inflamed. According to Ultzman, the fine threads come from the anterior urethra, and the broad, lumpy, and ragged affairs from the posterior urethra. Spermatozoa in these fibres would show a probable ori- gin in the posterior portion of the canal. Rectal examination is necessary to complete the diag- nosis. The frequency with which chronic disease of the prostate is found is very uncertain. Its examination should not be neglected when there is ground to suspect posterior urethritis. To recognize and treat these different conditions is by no means easy. The general and local conditions of atony just mentioned must be recognized by the history. Patients whose constitutional condition seems at fault should be put upon such a regimen as their individual case seems to require. Iron, in some form, is often use- ful, but neither iron nor other tonic should be administered without inquiring into and regulating the patient's whole method of living. Iron with cantharides, in the prescrip- tion recommended by Bumstead, seems to be occasionally of use. R. Tincturae cantharidis 3 ij. - 8. Tincturae ferri chloridi 3 vj. = 24. Ten (10) drops in water three times a day. Some of these patients recover after a sea-voyage, or a summer in the country, but it is best to avoid the error of sending a patient on a long journey to cure a clap without making sure that there is no local lesion present to explain the persistent discharge. When the lesion exists in the anterior urethra it is sometimes possible to cure it by the use of injections with an ordinary urethral syringe. The injection should not, in this case, be allowed to penetrate beyond the com- pressor, but it is necessary that it should reach it. Any attempt to limit the injection by pressure on the ure- thra will prevent it from reaching the extreme point where it is needed. It is better to inject a moderate quantity, not enough to overflow the urethra, and work it carefully backward with the fingers. Solutions of moderate strength only should be used. It is often necessary to make stronger applications to the diseased spots ; this should be done by one of the several instru- ments designed for such a purpose, which deposit a few drops at the bulb. One of the most useful applications is a solution of nitrate of silver, which need not ordinarily surpass five grains to the ounce. Before resorting to nitrate of silver one may use other solutions, washing out the bulbous portion of the canal by a stream from an irrigator introduced through a cath- eter, which is passed to the bulbous portion and not beyond it; the medicated fluid being afterward intro- duced through the same catheter, or by a special syringe. Applications to the posterior urethra are made in the same way, the syringe being introduced through the com- pressor urethrae, but not into the bladder. It is a matter of a little nicety to adjust the syringe at first, but is soon learned. It is possible to introduce the injector until the urine flows through it, and then withdraw it till the flow stops, wffien the point ought to be in the prostatic urethra, or the finger in the rectum will allow a pretty careful ad- justment of the point. When the patient is in a horizon- tai posture, if an instrument with the curve of an ordinary- steel sound be carried about thirty degrees past the per- pendicular, the point ought to be in the membranous urethra. Acute exacerbations occasionally follow these applications. No account of the treatment of chronic urethritis is complete without reference to the use of steel sounds. Worse than useless in an acute urethritis, in chronic dis- charges they are often useful. Begin with a number sufficiently small to be easily admitted, pass the well- oiled sound gently, and allow it to remain for a minute or two if its presence is not painful. Once in two days is often enough for their use, and the size should be slowly increased. An increase of a single number, French scale, is sufficient each time. No irritation or increase in dis- charge should follow their use. The frequency with which they are used should be governed by their effect. Some cases improve when they are passed once in three or four days, and do ill with a more frequent use. It is often necessary to enlarge the meatus to gain the full size requisite. Their use may be combined with the deep in- jections, in which case the sound, as advised by Ultzman, may properly be lubricated with glycerine, that the use of the injection afterward may not be rendered useless by coating the urethra with oil. These methods are the most promising, though many others exist. With no method of treatment will one meet with un- varying success. It is occasionally necessary to advise a patient to endure his trouble with the best grace possible. The treatment of strictures of large calibre will be re- ferred to under the head of Stricture. Gonorrhcea in Women.-Gonorrhoea in the female is chiefly an inflammation of the vagina, which commences often, but not necessarily, at the vulva. In severe cases it includes all the mucous membranes of the vicinity. It is not always possible to say whether the vaginitis is or is not the result of contagion. Mere mechanical violence often causes a very decided inflammation. The presence of urethritis is by some looked upon as pathognomonic of gonorrhoea, but it is exceedingly doubtful. Scalding of the urine is often complained of as a promi- nent symptom, even when the urethra is perfectly free from inflammation, and is due to the irritation by the urine of the mucous membrane of the vulva. An abun- dant discharge of thick, yello-wish pus occurs. When this discharge is not properly cared for it dries upon the neighboring parts, and glues together the hairs, and emits a most disgusting odor. In an acute case the labia become excoriated and oede- matous to such a degree as to render walking and sitting very uncomfortable, and the patient is confined to bed. Acute symptoms are usually on the decline within a fort- night or three weeks. The disease is very apt to locate itself in the posterior cul-de-sac, and there continue without limit of time. It is this tendency to become chronic and to hide itself, as it were, that makes it often impossible to pronounce a woman perfectly free from disease, or to say that it is im- possible for her to have conveyed disease. The complications possible for the two sexes to have in common differ little, if at all, in women from their course in men. Women have also an equal liability to compli- cations of their own proper organs. Suppuration of the vulvo-vaginal gland is exceedingly common, -and its chronic inflammation is probably a common source of contagion. Intra-uterine inflammation, abscess of the Fallopian tubes, ovaritis, and pelvic peritonitis, are the occasional results of the extension of the disease ; occur- ring after gonorrhcea they differ in nothing from cases due to other causes, and are more properly treated of in articles on Women's Diseases. Rest and absolute cleanliness are the two essentials in the treatment of the acute disease. There is here no question of internal treatment, the anti-blenorrhagics are useless except in the urethritis, which is generally but an insignificant part of the disease. An alkali may possibly render the urine less irritating to the inflamed vulva. The higher the inflammation, the more absolute the repose necessary. The parts should be repeatedly washed with 369 Gonorrhrea. Gout. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mild solutions of carbolic acid, chlorinated soda, borax, or plain soap and water. Sitz-baths are not only comfort- ing but useful. Washing the vagina should be accomplished by some one of the methods advised by the gynaecologists, and not by the use of the insignificant vaginal syringes. The water should be as hot as can be borne, and all manipula- tions in the acute stage should be conducted with great gentleness. Astringent substances may very soon be added to the vaginal injection, or better yet, injected after the douche. The same substances may be employed as for males, commencing with a mild solution and gradu- ally increasing the strength. Sulphate of zinc, from one to four grains to the ounce of water, is a good solution to begin with. As the disease becomes chronic and the in- flamed portion smaller, the disease may be pursued, if necessary, with the assistance of a speculum ; by direct applications and the insertion of tampons of absorbent cotton soaked in astringent solutions, according to direc- tions given for dealing with diseases of women. Abner Post. 1 Ziemssen's Cyclopaedia. 2 International Encyclopaedia of Surgery. Vol. II. 3 Maladies des Voies Urinaires, p. 22. 4 France Medicale, 1884, ii., p. 1095. 5 Bumstead and Taylor: Fifth Edition, p. 64. " Ziemssen's Cyclopaedia, vol. viii., p. 769. 7 Lancet, November 9, 1878. 8 Milton on Gonorrhoea, p. 216. 9 Journal of Cutaneous and Venereal Diseases, March, 1884, p. 79. 10 Dr. Louis Bauer : St. Louis Clinical Record, v., p. 270 ; vi., p. 66. Dr. F. B. Greenough : Boston Medical and Surgical Journal. August 24, 1882. Dr. F. N. Otis : Genito-urinary Diseases and Syphilis. Dr. J. William White: International Encyclopaedia of Surgery, vol. ii., art. Gonorrhoea. 11 Wiener Med. Presse, 1883, p, 957. 12 Medical Times and Gazette, July 2, 1881. 13 Gazette hebdoinadaire de Medecine et de Chirurgie, ler janvier, 1886. 14 M. P. Aubert: Lyon Medical, t. xlvi., p. 197. 16 Edinburgh Medical Journal, July, 1885. 16 Wiener Med. Presse, 1883, s. 1161. 17 Fournier: Annal. d. Dermatol., 1868-69, p. 133. 18 British Medical Journal, July 11, 1885. 19 Reynolds' System of Medicine. 20 Loc. cit. 21 Boston Medical and Surgical Journal, August 24, 1882. 22 Maladies des Voies Urinaires, Paris, 1860, p. 34. 23 Giornale italiano, 1874, vol. ii., p. 129. rina is of a transient character, and this distinguishes it from the closely similar affections known as "keratosis pilaris " and " mild ichthyosis " (see Ichthyosis and Kera- tosis Pilaris), due to epidermic growth, and chronic in character. The usual causes of cutis anserina are sudden changes from heat to cold, and vice versa, or strong moral impressions. The condition is rather a physiological than a pathological one. Arthur Van Harlingen. GOURD SEEDS (Calebasse d'Europe, Gourde ou Cou- gourde, Codex Med.). The seeds of the cultivated gourd, Lagenaria vulgaris Ser. Order Cucurbitacece. These, which were "the great cold seeds" of ancient pharmacy, have not yet been omitted from the French Codex, but are fairly obsolete as a medicine. For the Order and Al- lied Pi.ants see Colocynth. Allied Drugs.-Cucumber, Watermelon, and Pump- kin seeds. The pulp of the gourd is bitter and purgative. W. P. Bolles. GOUT (Lat., Gutta ; Itai., Gotta; Sp., Gota; Fr., Goutte ; Ger., Gidit). Syn.: Lithiasis, Lithsemia, Poda- gra. History.-That gout was known in the very earliest times is shown by the writings of Hippocrates (350 B.C.), which give a good description of it, and indications for treatment. The Greeks, and the Romans who fol- lowed in their footsteps, called the disease according to the part affected : thus podagra, gonagra, cheiragra, etc., or arthritis if the joints generally were involved. Galen (a.d. 130) considered gout to be due to an unnatural col- lection of noxious substances, as " bile," " black bile," " blood," or " phlegm, " either separately or collectively, in the affected part. The tophi he thought were caused by a solidification of these bodies. He attributed gout to luxurious habits, and Seneca, who lived in the same epoch, commented on the fact that in Rome the women, who were formerly free of gout, according to Hippocrates, had, through luxury and licentiousness, in which they fully equalled the men, drawn down upon themselves the same diseases that men were liable to, and among these the gout. The ancients considered bad "humors " to be the cause, and here again ' ' bile " played an important part. They recognized the hereditary nature of the disease, and the influence of over-eating and under-exercising as exciting causes. Their treatment, with a view to getting rid of these supposed noxious humors, consisted in purging, vomiting, bleeding, and other similar depletory measures; but they also recognized the importance of a regulated diet and plenty of exercise. During the Middle Ages, the humoral theory still pre- vailing, " tartar" was considered an important cause of the disease. This * ' tartar " was supposed to come from wine which had been drunk, and to form incrustations on the joints similar to those found on the inside of wine-casks. It was not till Scheele, in 1776, and Wollaston, in 1797, showed that gouty concretions were composed of uric acid, that the " tartar" theory was exploded. lu the last century, gout was thought by some to be contagious, and even the great Boerhaave (1668-1738) himself adhered to this view. Toward the close of the century, Cullen advocated the nervous origin of gout, a view which, after having been laid aside for a long while, is now, as we shall see, being revived. Even after the discovery of uric acid in tophi, it was a long time before the connection between this acid and gout was established. To Garrod the palm must be awarded for showing the relationship between the two. In 1848, in a paper entitled " The Blood and Urine in Gout, Rheu- matism, and Bright's Disease," read before the Medico- Chirurgical Society of London, he demonstrated that in the blood of gouty patients urate of soda exists iu abnor- mally large quantities. The most important recent work on gout is by Ebstein, of Gottingen (" Ueber die Natur mid Behandlung der Gicht," 1882), in which Garrod's observations are confirmed by experiments, and new light is thrown upon the nature of the pathological lesions. GONTENBAD. An old bathing establishment at Ap- penzell, a village on the Sitter, six miles south t»f St. Gall, Switzerland. The baths are situated in an isolated spot, in an open valley, at an altitude of two thousand nine hundred feet above the sea-level. They are supplied with water from a very feebly chalybeate spring, con- taining 40 grains of solids in a pint, 3| grains of which are of ferrous carbonate. Administered internally the water has a slight cathartic action. The institution is frequented for the most part by plethoric female invalids and con- valescents. The Jacobs bath and spring, about three miles from Gontenbad, have about the same properties, but in connection with them the milk cure is also prac- tised. J. AL. F. GORADSCHEWODSK, formerly known as the Katha- rine Spring, is the warmest mineral spring of the Cau- casus. It is situated about ten geographical miles south of Terek. At its source the spring has a temperature of 91° C. (195.8° F.), and it contains only 78.4 grains of salts in a pint, chiefly sodium carbonate, chloride, sulphate, with some sodium sulphite. A distinctly naphthous vapor arises from the surface of the spring, containing a small amount of sulphuretted hydrogen and carbonic acid gas. A military station with gas-baths is now located here. J. M. F. GOOSE-SKIN. Under the names Cutis Anserina, Horrida Cutis, Dermatospasmus, Chair de poule, Gdnse- haut, Goose-flesh, etc., is variously designated a well- known condition of the skin, marked by a prominence about the individual hair-follicles in acuminate papular form, sometimes covered with scanty epidermic scales, and usually penetrated by a hair. The condition is usu- ally observed upon the trunk and the extensor surfaces of the limbs, and is the result of contracture in the cu- taneous muscles surrounding the hair-follicles. Like other forms of muscular contraction, cutis anse- 370 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gonorrhoea. Gout. Geographical Distribution.-Gout is eminently a disease of the colder portion of the temperate zone ; both the arctic regions and the tropics being exempt. In this country the disease, in its typical form, seems not to be so common as it is in many parts of Europe. Here the ir- regular, and less easily recognized, varieties prevail, and from this fact it may be that the disease is really more common than is generally suspected. In Europe, Eng- land and Holland seem to have a pre-eminence-both coun- tries where good living is common and a damp climate prevails. Pathology.-Although it had long been known that some connection existed between gout and uric acid, it was not till Garrod demonstrated this relationship that our knowledge on the subject began to assume a definite form, and while much precise information has accumu- lated since then, it must be admitted that the pathogenesis of the disease has so far eluded an exact demonstration. Before entering into a consideration of the various theories regarding the causal connection between gout and uric acid, it will be profitable to pass in short review the physiology of urea and uric acid, and their relationship to each other. Urea.-In the healthy mammalian economy urea rep- resents the end product of proteid metabolism. It is a freely soluble nitrogenous body, CO(NH2)2, forming 2.5 per cent, to 3 per cent, of the urine, or about one-half the total amount of solids. The daily quantity voided is about thirty-five grams. It is probable that its antecedents are in large part the products of tissue waste, or, it may be, that the end re- sults of intestinal proteid digestion-leucin, tyrosin, gly- cin, and asparaginic acid-are converted at once into urea in their passage through the liver, in those cases where they are present in excess in the portal circulation. While all the tissues, including the blood itself, most likely take part in its elaboration, we may infer that the liver is principally concerned in the process, both because various alterations in this organ produce changes in the amount eliminated, as well as from the circumstance that the liver has the power of directly converting ammonium car- bonate into urea (v. Schroeder). Direct electric stimulation of the liver increases the amount of urea (Stolnikow), while destructive processes, as phosphorus poisoning, acute yellow atrophy, suppura- tive hepatitis, cirrhosis, etc., greatly diminish it (Brouar- del, Frerichs, and others), its place being taken by the un- changed products of pancreatic digestion, which then appear in the urine. The daily quantity of urea voided is subject to wide variations. A diet of albumens increases it, while under a non-nitrogenous regimen it becomes much diminished. Muscular exercise, when in combination with free inges- tion of oxygen, has little effect. In acute fevers the quantity is augmented, owing to the increased destruction of tissue going on in the body. After subsidence of the' pyrexia it may be subnormal. Certain drugs, as arsenic and the alkaloids of opium, increase it. Quinine dimin- ishes it. Uric acid (C5N4H4O3), when uncombined, is a highly insoluble crystalline substance, but it exists in the fluids of the body in the form of soluble neutral salts of sodium and potassium, never occurring under its own form. Its source has been the subject of much investigation, and as it, like urea, represents an end form of proteid metabol- ism, it is probably not elaborated in any one organ alone, but by the tissues generally. Certain organs, however, contain it in greater abundance than do others. In the spleen it is found normally in considerable quantities, and in splenic leucocythaemia this amount, as well as that cir- culating in the blood, is enormously increased, without, however, giving rise to deposits, or gouty symptoms of any kind. Diet influences, within certain narrow limits, the amount produced, when the same class of animals is con- sidered. Lehmann, in experiments upon himself, found that he excreted half as much again under a purely nitro- genous diet as he did under a vegetable regimen. In herbivora no uric acid occurs in the urine, its place being taken by hippuric acid ; nevertheless, uric acid is found in their spleens. In birds and reptiles, however, uric acid takes the place of urea, irrespective of diet; but this, as Foster points out, is due to the fact that their kidneys are adapted to excrete a solid substance, while the mam- malian organ is suited for fluid excrementition. Relations of Urea to Uric Acid.-Urea contains by far the larger part of the total amount of N ingested as food, the smaller moiety being eliminated as uric acid, creati- nine, hippuric acid, and ammonia compounds. While this fact itself is readily demonstrable, it yet remains to be shown, however, what stages the proteids undergo be- fore finally emerging as urea. The circumstance that one molecule of uric acid can, by oxidation, be split into two of urea and one of mesox- alic acid, led Liebig and others to regard uric acid as the less highly oxidized precursor of urea, but, while there are some facts which support this view, nevertheless others exist which militate too strongly against it to al- low it an unqualified acceptance. In support of the defective oxidation theory, the fol- lowing observations may be cited. In febrile diseases the normal proportion of uric acid to urea (1 to 45) remains ordinarily unaltered ; the two rising and falling together. When, however, a disturb- ance of respiration, leading to insufficient oxygenation of the blood, supervenes, the •proportion becomes changed, the uric acid being increased relatively as well as abso- lutely (Bartels), while the urea is diminished (Eichhorst). In leucocythaemia the relative as well as absolute quan- tity of uric acid is greatly increased (Bartels, Salkowski). In a case of coal-gas poisoning, Bartels found the pro- portion of uric acid increased to 1 to 27 and 1 to 38. As against the defective oxidation theory may be in- stanced the numerous observations which show that ab- stinence from non-nitrogenous food never causes total disappearance of uric acid from the urine ; whereas, as Parkes remarks, if uric acid were simply insufficiently oxidized urea, all the uric acid should, under these cir cumstances, disappear. The increase occurring in leuco- cythaemia, alluded to above, has been referred by Virchow and Ranke to the accompanying hypertrophy of the spleen. To the writer it seems that these different views, re. garding the relations of urea and uric acid, do not neces- sarily conflict, but that the conditions regulating their in- terdependence probably are different in disease from what they are in health. It is not unreasonable to assume that in health, of the total amount of uric acid produced, only the smaller part is finally eliminated as urates, the balance being con- verted into urea. This supposition does not, by any means, necessarily imply that all of the urea has been derived from uric acid. It is possible that uric acid, which always appears in the urine-even during fasting, and with oxygen in excess-may result from the metabol- ism of particular organs, as cartilage and white fibrous tissue, and that these tissues, while having the power to convert their waste products as far as uric acid, have no means of carrying the oxidation still further, and so pro- ducing urea. The connective tissues have been mentioned particularly, because there are some good experimental grounds for believing them especially concerned in the production of uric acid, aside from the fact that they are the seat of the gouty deposits. What, now, may be the possible nature of the changes in relation between the two going on in disease ? We have seen that the most striking changes occur where the supply of oxygen is diminished. It is possible that here the absolute, as well- as the relative, increase of the uric acid which occurs is due-not to the production of an abnormally large amount-but to a larger quantity than usual escaping oxidation into urea. Certainly the con- comitant absolute diminution of urea might support this view. Theories Regarding the Causation of Gout.-The principal theories may be ranged under three heads : 1. That which looks to an excess of uric acid, either as the result of increased production or lessened elimina- tion, together with a diminished alkalinity of the blood. 371 Gout. Gout. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 2. That which presupposes a congenital or acquired tendency to a faulty metabolism on the part of certain tissues, leading to primary localized necrosis followed by secondary uratic deposits. 3. That which regards gout as the manifestation of a neurosis in which there is a disturbance of that division of the nervous system supposed to preside over metabol- ism. It will be our task to give a brief consideration to each of these different views. I. Garrod's theory, since it is the representative of the first of the three divisions we have made, may be stated to be briefly as follows : Gout is due, primarily, to an excess of urates in the fluids of the body, and, secondarily, to their deposition in the tissues by precipitation caused by a diminished al- kalinity of the blood. The accumulation of urates may be the result of, firstly, excessive production from the ingestion of much nitro- genous food combined with sluggish metabolism (" rich man's gout "), or, secondly, from diminished elimination owing to renal changes, to want of sufficient oxygen, to the influence of lead on the kidneys, etc. ("poor man's gout"), and in both cases the condition may be, and generally is, intensified by a temporary or permanent loss of the uric- acid-excreting function of the kidneys. Garrod believes that this particular function may be suspended, or even completely lost, without loss of powTer to eliminate other waste products. Thus, the function of excreting urea and uric acid are by him considered to be separate, and capa- ble of being performed independently of each other. In different forms of nephritis the urea-excreting function is lost, giving rise to an excessive accumulation in the blood and a subsequent vicarious discharge of the excess into the serous effusions, while in gout wre have a disturbance of the uric-acid-excreting function, the blood being re- lieved of its excess of uric acid by a similarly vicarious deposition in the joints. This view of the renal epithelium acting selectively, and exercising multiple and independent functions, does not seem improbable, since the experiments of Heidenhain and his pupils have shown the kidney to be no mere me- chanical filter, but an organ endowed in its different parts with various selective actions-thus returning to the ideas of Bowman, advanced some forty years ago. Infiltration of the tissues with urates results, according to Garrod, from the co-operation of two factors. The first of these is an accumulation of urates in the blood; the second, a diminished alkalinity of the plasma, with con- sequent lessened power to hold urates in solution, leading to precipitation. The first of these two factors arises either from a temporary increase in the amount of uric acid produced, or from a sudden loss of the uric-acid- excreting function of the kidneys from mental shock, traumatism, exposure, etc. The second factor may be induced by the use of acids, wine, beer, etc., causing di- minished alkalinity of the blood. Garrod states that he has found, in chronic gout, the alkalinity of the blood so diminished that in some cases it approached neutrality. It is, however, to be regretted that no details are given of the methods employed, nor any figures adduced of the results obtained. Alkalimetry of the blood, owing to the rapid spontaneous change in reaction toward a lessened alkalinity, which occurs nor- mally soon after the blood is drawn, is beset with such peculiar difficulties that simple statements with regard to it, unaccompanied by details, should always be received with due reservation. The phenomenon of the paroxysm he likewise refers to the co-operation of two causes. 1. Accumulation of urates in the blood. This gives rise to the premonitory symptoms, as dyspepsia, irrita- bility of temper, cardiac palpitation, etc. 2. Occurrence of one of the wyell-known exciting causes, leading to deposition with secondary inflammation in some joint, but followed also by purification of the blood by elimination, and consequent restoration of the general health. According to Garrod-and this seems a probable view of the case-there is no deposition previous to the par- oxysm, no gradual accumulation, but a sudden deposit of crystalline urates leading to inflammation. It is true that in a number of cases of cirrhotic kidney, giving no history of gout, deposits will be found in the toe-joints ; but though these patients may not have had any seizures of sudden, violent pain in the affected joints, yet most of them will be found to have been "rheumatic," i.e., to have had painful joints at some time during life. The mere accumulation of uric acid salts in the blood is, as we have already mentioned, in itself incapable of producing gout; lessened alkalinity of the blood must coexist as well. Whether changes in alkalinity, accord- ing to Garrod, occur in other affections in which this in- crease exists, has, as far as we know, not yet been deter- mined, but the importance of such a line of investigation must be evident. Hepatic Theory.-A certain school looks upon derange- ment of the hepatic functions as the cause of the accumu- lation of uric acid in the blood. In considering the sub- ject of urea, we saw that the liver normally converts the products of pancreatic digestion-leucin, tyrosin, etc.- brought to it by the portal vein, into urea, and that in certain diseases, involving destruction of the glandular cells, these products pass the hepatic circulation un- changed, reappearing in the urine under their own form, while at the same time the amount of urea is very greatly diminished, or even absent. Now, it is argued, where the hepatic function is insufficiently performed much of the urea which would thus normally be formed does not get beyond the uric acid stage, and hence accu- mulation results. This idea is chiefly based on the amel- ioration which generally follows when the " torpid liver," from which most gouty patients suffer, is stimulated to action by a cholagogue cathartic. The whole theory, however, is based too largely on supposition to merit much consideration. In the first place, it presupposes all urea to have been uric acid at some stage of its exist- ence-for which no proof exists-and, secondly, if the urea really were to a great extent replaced by uric acid, a corresponding decrease of the urea in the urine should occur. This, however, has been proved by Garrod and others not to be the case. II. Ebstein's theory assumes the existence of a local ex- cessive production of uric acid, the result of a peculiar metabolic anomaly. He regards the muscles and bones as the especial seat of this anomalous process, and the de- position in the joint cartilages as merely resulting from unusually favorable conditions offered by the naturally retarded circulation of those parts. This morbid ten- dency he regards as usually congenital, though it may remain latent for years, as in those patients of Charcot where, after hemiplegia, gout developed only in the par- alyzed limbs. He instances, as showing that analogous metabolic anomalies may exist, the persistent tendency in certain individuals toward the production of pyro-cate- chin and of cystin, giving rise respectively to pyro-cate- chinuria and cystinuria. Ebstein seeks to support his theory on clinical as w'ell as on chemical grounds. Clin- ically, he points to the cramps, pains, and feelings of fatigue in the muscles of the affected part, occurring not only during, but before the regular attack has begun, as proof that there is something foreign present which causes the disturbance. Chemically, he instances the fact that normally kreatin, sarkin, and xauthin are found in muscle-all bodies intimately related to uric acid. No uric acid is found in muscle in health, but Neukomm has demonstrated its presence in typhoid fever. Unfortu- nately for the ready acceptance of Ebstein's theory, he has omitted the most important stone in its foundation, namely, the demonstration of the actual presence of uric acid in the muscles of gouty extremities. His views regarding the cause of deposition in the tis- sues, which are the more important since they are based on experiments, will be found under the heading Path- ological Anatomy, Organic Changes. III. Neurosal Theory .--While no modern pathologist would probably undertake, as Cullen did a century ago, to deny the connection between gout and uric acid, referring all the symptoms merely to a disturbance of the nervous 372 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gout. Gout. system, and regarding the articular deposits as mere unim- portant coincidences, yet it has forced itself upon the minds of many that for the ultimate cause we must look to certain vices of the system, either inherited or acquired, in which, the chemical balance being disturbed, a faulty metabolism results, leading to the formation of uric acid. The chem- ical processes of the body are necessarily assumed to be under the influence of the nervous system, nor will this assumption appear in the least unwarranted when we consider that chemical change is the result of cell action, and that cell action is largely determined by nerve-action. Glandular functions, it is true, continue to be exercised for a time, even after extirpation of the gland ; but on the other hand, we know that for its proper functional activ- ity a gland is dependent on its special nerves as much almost as it is upon its blood-supply. We need only in- stance the influence of the chorda tympani nerve upon the secretion of the submaxillary gland. The existence of an undoubted inborn tendency in cer- tain individuals to gout, quite independent of habits of life, gives a certain support to this theory. As Cohnheim (himself long a sufferer, and finally a victim to gout) re- marks, "individuals who have all their lives been noted for their temperate habits may still become subject to the severest attacks of gout," and, on the other hand, we constantly see indulgences of every kind, favorable to the acquisition of the disease, yet remaining ineffectual to produce it. Those who look upon gout as a neurosis regard the over-production and subsequent deposition of urates as secondary to a primary disturbance of the nervous sys- tem, and it seems not improbable that, as our knowledge of physiological chemistry increases, other pathological conditions will be found to exist which are dependent either on passing or on permanent changes in nerve-action. The points of similarity between the manifestations of gout and those characterizing nervous diseases in general are many and striking, and have long attracted attention. We will enumerate only a few of them : 1, The marked hereditary tendency, often traceable through many gener- ations ; 2, the effects of psychic influences, such as great mental occupation, rage, fear, disappointment, etc., in determining a paroxysm; 3, the not infrequent occur- rence of somnambulism, or insomnia, or of grinding of the teeth during sleep; 4, the tendency to neuralgia, myalgia, and cramps ; 5, the influence of barometric change ; 6, the very arthropathies themselves, which we know are of frequent occurrence in certain nervous dis- eases ; 7, that parallelism often seen between different manifestations of the neurotic tendency in different mem- bers of the same family, or in the same individual at dif- ferent periods of life, we find to exist between gout and diabetes. The neurosal origin of gout has been, and is, upheld by many English writers of eminence, such as Paget, Liveing, Ord, Meldon, Duckworth, and others; and Eb- stein's views, though not explicitly so stated, may be held to support this theory. In the present imperfect state of our knowledge it may be yet too early to declare in favor of any one particular theory, still it seems to the writer that a combination of the principal views now prevalent is easily possible. We may begin by supposing an altered manifestation of nerve-force ; this results either (1) in a disturbance of the uric-acid-excreting function of the renal epithelium (Garrod), or (2) in an increased production of uric acid in the muscles and bones (Ebstein), and that deposition oc- curs either from (a) diminished alkalinity of the blood (Garrod), or (i) from the acid reaction of necrotic tissue (Ebstein). But we must in the meanwhile keep our minds open to the fact that satisfactory experimental proofs are still entirely lacking to move us to the acceptance of the existence of any of these conditions. We must remember that Garrod's statements regarding the reaction of the blood still lack exact confirmation, and that Ebstein's supposed uric-acid-forming power of the muscles and bones is as yet entirely unproved. Pathological Anatomy.-I. Changes in the Blood.- Garrod was the first to prove experimentally that in gout there is an actual increase of the amount of uric acid present in the blood. Before an acute attack its pres- ence can, with a little care, be readily demonstrated by the method mentioned below, while, as the paroxysm subsides, the amount is found to diminish, probably as the result of its deposition at the site of the inflamma- tion. In old cases of chronic gout, with tophaceous de- posits, an abnormal quantity of uric acid can be shown to be constantly present. Garrod found from 0.05 to 0.11 grain in 1,000 grains of serum. His method, known as the "uric-acid-thread experiment," he describes as fol- lows : " Take from one to two fluid drachms of the serum of blood and put it in a flattened dish or capsule ; those I prefer are about three inches in diameter, and one-third of an inch in depth, which can be readily procured at any glass-house ; to this add ordinary strong acetic acid, in the proportion of six minims to each fluid drachm of serum, which causes the evolution of a few bubbles of gas. When the fluids are well mixed introduce one or two ultimate fibres about an inch in length, from a piece of unwashed huckaback or other linen fabric, which should be depressed by means of a small rod, as a probe or point of a pencil. The glass should then be put aside in a cool place until the serum is quite set and almost dry ; the mantel-piece in a room of the ordinary tempera- ture, or a book-case, answers very well, the time varying from thirty-six to sixty hours, depending on the warmth and dryness of the atmosphere. " Should uric acid be present in the serum in quantities above a certain small amount noticed below" (i.e., less than 0.02 grain in 1,000 grains of serum), " it will crystal- lize, and during its crystallization will be attracted to the thread and assume forms not unlike that presented by sugar-candy upon a string. . . . The uric acid is found in the form of rhombs, the size of the crystals, varying with the rapidity with which the drying of the serum has been effected, and the quantity of uric acid in the blood. To insure perfect success several precautions are neces- sary. "1. The glasses should be broad and flat; watch- glasses of the ordinary kind are not suitable, being too small, allowing the fluid to be frequently spilled, and also too much curved, causing the film of partially dried serum to curl up and split. " 2. The acetic acid should be neither very strong nor too weak. The glacial acid forms a gelatinous compound with the albumen of the serum, producing flakes ; and very weak acid adds unnecessarily to the bulk of the fluid. ' ' 3. The character and quality of the thread are of some moment. Very smooth substances, as hairs or fine wire, but imperfectly attract the crystals; if the number or length of the fibres be too great, and the amount of uric acid small, the crystals become much scattered, and, there- fore, but few appear in the field of the microscope. The glass should not be disturbed during the drying of the serum, or the crystals may become detached from the thread. ' ' 4. Some attention to temperature is necessary ; if the serum be evaporated at a high temperature-above 75° F., for example-the process of drying may take place too rapidly to allow crystallization ; the temperature of an ordinary sitting-room answers well for the purpose ; the glasses should be protected from dust. "5. If the serum be allowed to dry too much before the examination takes place, the surface becomes covered with a white efflorescence, consisting of feathery phos- phates which may obscure the thread ; they can be re- moved by the addition of a few drops of water before placing the glass under the microscope ; sometimes over- drying causes the film to become cracked and fissured throughout, as well as covered with the phosphatic efflo- rescence. "6. It is well, when practicable, to put up two or more glasses with the serum. "7. The blood should be recently drawn, or at least no change should be allowed to take place in it before the experiment is made, as uric acid, when in contact with 373 Gout. Gout. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. albuminous principles, is liable rapidly to undergo de- composition." Instead of the serum obtained from the blood by venesec- tion, it is now-a-days more practicable to use that produced by a blister, as it answers the purpose equally well for demonstrative purposes. Garrod calls attention to the fact, however, that the serum obtained from a blister, ap- plied directly over the seat of inflammation, will be found free from uric acid ; while that gotten from another blister, applied at the same time, but to some remote part of the body, will be found to contain it. This is cer- tainly a curious fact; but one hardly to be explained on the supposition that the uric acid in the blood, over the seat of inflammation, is destroyed by the inflammatory process ; for, from the fact that in inflammation there is diminished vitality of the part from retarded circula- tion there must be, in consequence, diminished and not increased oxidation going on at the seat of any inflamma- tion. Urea, and oxalic acid in the form of calcium oxalate, have also been found by Garrod in a few cases of gout. Though it has been frequently affirmed that uric acid is excreted in the perspiration of the gouty, Garrod was never able to verify the statement, in spite of numerous experiments made to that end. II. Changes in the Urine.-Normally, about 0.5 gramme (eight grains) of uric acid is excreted in the urine during twenty-four hours, though this amount is liable to variation from the character of the food, individual difference, and also from day to day. It occurs in the urine in the form of salts of soda, potash, and magnesium, the first of these largely predominating. These salts, known as "amorphous urates," form the heavy pink or reddish deposits called " lateritious" or " brick dust," so often seen in urine that has stood in the cold ; they are the acid urates of the bases. We cannot here refrain from alluding to the almost general, but entirely erroneous, practice of inferring, first, an increased formation in the system, and then a corresponding elimination, from the abundance, or even presence, of this deposit. (See Urine.) The precipitation depends not on the amount originally present in solution, but upon the temperature and acidity of the urine. The acid urates are, comparatively, insoluble in cold, acid urine, while they are freely soluble in warm and neutral, or alkaline urine. Hence, urine which has been stand- ing in a cool room, or to which an acid has been added, soon deposits a copious sediment. In the " acid fermen- tation," which sets in after urine has stood a while, the acid urates are decomposed by being deprived of their bases, and, in consequence, crystals of uric acid will be found to have taken the place of the formerly copious sediment. Nor can the presence of these crystals of free uric acid in the urine be taken as an indication of either increased production or excretion, but rather as an index pointing to the amount of free acid present. Bence Jones has shown that this deposition of uric acid crystals is by far the most delicate test regarding the absolute free acidity of the urine ; for a urine very acid to test-paper may contain but little free acid, the acidity being in this case due to the acid sodium phosphate (a salt which has not the property of reducing uric acid salts); while, on the other hand, a urine but feebly acid to test-paper may contain relatively a considerable amount of free acid. The only way to determine, therefore, an absolute change in the daily quantity of uric acid excreted, is to make a quantitative analysis, by precipitating the uric acid from a measured quantity of urine with dilute hydrochloric acid, and weighing the precipitate. Berthollet found that the natural acidity of the urine was lost a few days before a gouty paroxysm, but re- turned before the attack had passed away. Garrod has shown that during the beginning of an acute attack the uric acid, which may have previously been quite abundant, is suddenly diminished, only to be- come more abundant again as the paroxysm progresses. It then decreases in quantity again as the acute symp- toms subside. The stage of diminution in the urine coin- cides with that of increase in the blood, which he inter- prets as showing that the smaller quantity in the urine is due, not to lessened production, but to insufficient renal excretion. In chronic gout there is a persistent diminution in the amount of uric acid excreted, frequently accompanied by intermittent discharges of large quantities, known as "uric acid showers." The amount of urea eliminated is not affected in either the acute or chronic forms, excepting when in the ad- vanced stages of the latter there are extensive renal changes. In acute attacks the amount of urine passed is small, and its color generally deep amber, as in all febrile condi- tions, while the density is increased. In chronic gout the quantity is often beyond the normal, the specific gravity low, and the color light yellow-these changes being generally due to atrophic lesions of the kidneys. Albumen may be present in acute attacks, disappearing with convalescence. In the chronic form it can be shown to exist in about one-half the cases (Garrod), though often in such exceedingly minute quantities that it is quite frequently overlooked unless especial care and delicate tests are used. III. Organic Changes.-These are for the most part structural lesions of the connective tissues, and are either directly connected with, or secondary to, the deposition of uric acid salts. Most prominent are the lesions of the joints. In them the uratic deposit involves particularly the articular car- tilages ; but in old cases every structure entering into the formation of the joint, with the exception, perhaps, of the bones-and even here Cruveilhier and Garrod have re- ported rare instances of deposits being found-may be af- fected. The deposit in the articular cartilages is some- times so general as to give them the appearance of being covered with a smooth layer resembling plaster-of-Paris, or it may occur in minute specks only. It is never di- rectly on the surface of the cartilage, but is invariably covered, except in those cases where inflammatory de- struction of the joint has occurred, with a smooth layer of the most external laminae ; in other words, the deposit is interstitial, not superficial. It is most abundant just beneath this layer, diminishing in quantity as it ap- proaches the bone. Budd (Medico-Chirurgical Trans., 1855) calls attention to the interesting fact that at the borders of the cartilage, where they are covered with a capillary net-work extending inward from the synovial membrane at its point of attachment, the uratic deposit is absent, owing probably to the vascularity of the part, the blood in this capillary net-work causing in some way the absorption and removal of the urates; or, what is also likely, not permitting their precipitation. The greatest accumulation occurs in those parts most removed from the influence of the circulation. With regard to the form of the deposit, it was formerly asserted that it may be amorphous in character, but more recent researches have shown it to be invariably crystalline. Ebstein claims that the true gouty deposit always oc- curs within an area of necrotic tissue surrounded by a zone of secondary inflammation. He discovered this con- dition in all the organs containing deposits which he ex- amined, and they embraced kidney, hyaline and fibro- cartilage, tendon, and subcutaneous cellular tissue. This area, of what seems to be coagulation necrosis (of Weigert), may be demonstrated by staining with Bismarck-brown after previously dissolving out the urates with hot water. Then the sites of the deposits, while retaining their struct- ural details to a certain extent, will be found less deeply stained than the surrounding tissue. He considers this an important discovery, since it throws much light upon the cause of the precipitation of the urates within the tissues. According to him, the pathogenesis of these lesions is as follows : The neutral urates, in excess in the blood and lymph, when brought to organs where, from slight vas- cularity, the current is slow, exert upon the tissues with which they are thus brought in prolonged contact a de- structive influence, finally resulting in localized necroses. 374 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gout. Gout, Now, according to his experiments, necrosis of any tissue is accompanied by an acid reaction of the part involved. This acidity of the necrotic area leads to a precipitation within it of the insoluble crystalline acid urates by the decomposition of the soluble neutral urates in the blood. Ebstein's experiments on fowls (see Gout in Animals, at the end of this article) would seem to confirm the views he has enunciated. More experimentation is, however, necessary. When we consider the location of the gouty deposits, occurring as they do in those parts of the body where both from anatomical structure and peripheral location the circulation is less vigorous than in the more central parts, it would seem as though the diminished rapidity of the blood-current had much to do with the deposition of the uric acid salts. Confirmatory of this view are the ob- servations of Charcot, who found uratic deposits occur- ring on the paralyzed side only of hemiplegics, who, be- fore being paralyzed, were free from gout. The joint involved in ninety-five per cent, of all cases is the metacarpo-phalangeal of the great toe, and even where other joints are affected this joint will almost invariably participate. Next in order come the ankle and tarso- metatarsal joints, then the knee, later the small joints of the hand and wrist, and the elbow. The hip and shoul- der-joints are rarely attacked. The reason why the toes, and especially the big toe, usually suffer most has been sought in the fact that of all joints these are most liable to traumatism, since they bear the whole weight of the body, and from their prominence are most likely to first encounter any obstacle to locomo- tion. It has frequently been noticed that an injury to the toe-some jar, shock, or strain-is sufficient to excite a paroxysm when the predisposition to gout exists. Again, the foot being placed farthest from the motive power of the heart, and constantly sustaining in its dependent po- sition a column of venous blood which no other organ is called upon to bear, has probably a less active circulation than any other part. (This is shown by insufficiencies in the circulation generally manifesting themselves first in the feet and lower extremities.) All these factors, as we have seen, tend to promote deposition. That position, whether taken in regard to its relation to the heart or to external objects, has much to do with the site in which tliQ gouty seizure shows itself is manifested, as we have just seen, by the various small joints of the foot being most frequently involved ; following them comes the knee, and finally the joints of the hands and wrists. The ligaments and periarticular fibrous tissues are very commonly the sites of uratic deposits, known as tophi or "chalk-stones," which, though usually remaining cov- ered by skin, do in some cases cause perforation by pres- sure, when an ulcer ensues, from which the tophus is dis- charged, either as a creamy mass of urates, or in the shape of larger or smaller chalk-like masses. These ulcers heal with difficulty when once formed. They do not contain pus when first opened, though later they may ulcerate and become purulent. The synovial fluid is generally unaffected, but occasion- ally it is found turbid from suspended urates. In old cases, involving all the components of the joint, the syno- vial cavity may be entirely obliterated, complete anchy- losis resulting. The cartilage of the ear often contains tophi, generally in the helix, in the shape of small, yellowish, elevated nodules, covered by translucent skin. As the ear may contain these deposits when none are discoverable else- where, they should always be looked for where gout is suspected. The cartilages of the larynx in rare instances have been found similarly affected. Of the internal organs, with the exception, perhaps, of those changes in the stomach accompanying chronic dys- pepsia, the kidneys, in gout, are the seat of pathological alterations of structure which of all others most seriously react upon the organism at large. The renal disease which occurs is so commonly present and so character- istic that the term "gouty kidney" has come to be ap- plied to it. The lesion of the kidney is one which results in the condition known as chronic interstitial nephritis ("granular," "cirrhotic," "small contracted," "atro- phic" kidney), a form characterized by the existence of an increased amount of interstitial connective tissue, to- gether with a corresponding absence of the secreting ele- ments of the organ. At the same time alterations occur in the blood-vessels. (For the detailed pathological anat- omy, see special article on the subject under Renal Dis- eases.) Chronic interstitial nephritis occurs, no doubt, from causes other than gout, yet it is a significant fact, already alluded to, that in many cases where during life no his- tory of gout was obtainable, an autopsy will show not only "gouty" kidneys, but often extensive deposits in the toe-joints as well. Uratic deposits in the kidneys themselves are frequent, but not invariable. Most au- thorities state that they are situated in the intertubular connective tissue-and this would agree with what we know of their occurrence in connective tissues elsewhere- but Virchow' says that they occur within the tubules themselves. Macroscopically the kidneys vary in appearance, ac- cording to the degree of anatomical change. They may, in the early stages, be almost normal in size and color, but generally they are much reduced in dimensions, while the color is a pinkish-yellow, and the surface uneven and nodular. The two kidneys often vary considerably in the degree of change which they have undergone. Among the minor pathological changes occurring in gout, which, how'ever, from their ready perceptibility often aid in leading the observer to a correct diagnosis, are various affections in the tegumentary system. Chief among these are certain skin lesions, especially eczema, and the various forms of acne, psoriasis and urticaria. Early grayness of the hair, or scattered gray hairs amid black, especially when the hair is crisp and coarse ; brit- tleness, roughness, and corrugation of the nails ; massive, well-enamelled, regular teeth, often worn down on the edges, but undecayed even in advanced life, are all, ac- cording to Laycock, who was the first to note these pecu- liarities, signs of an inherited tendency to the disease. Causes : may be divided into-1, Predisposing ; 2, Ex- citing. Of the Predisposing Causes, heredity plays the most im- portant part, seventy-five per cent. (Garrod) of all cases being traceable to hereditary influence. It should not be forgotten, however, that a tendency to habits which are known to induce gout in individuals perhaps already pre disposed to it, is as well hereditary as the disease itself, and it has been noted that hereditary gout, appearing in many generations of a family with great regularity, did not show itself until its members had succeeded to the family fortune, and were thus enabled to live idly and luxuriously (Garrod). On the other hand, we see gouty manifestations, in the young children of gouty parents, before the other predisposing causes could have had time to become operative. The age, according to Scudamore, at which gout most frequently appears for the first time lies between the thirtieth and fortieth years, it being rare before twenty, or after sixty-six. Cases are on record, however, of its making its appearance in young children (Gairdner states he has seen it in children at the breast !), and again in the very aged. As far as sex is concerned, the male presents a preponderating number of cases, from reasons which have already been considered. When it does occur in women it is apt to be of the irregular type. Alcohol: " The use of fermented liquors," says Garrod, "is the most powerful of all the predisposing causes," and this is shown by gout being of greatest frequence in those countries where much beer, ale, etc., is consumed, as in England and Germany, and its comparative rarity in countries like Scotland, Sweden and Norway, Den- mark, etc., where spirits are drunk instead. Again, the consumption of the heavy wines of Spain, Greece, Hun- gary, and California, which still contain, in addition to large quantities of sugar and more or less free acid, a considerable amount of partly or entirely unfermented matter, has a most marked influence in predisposing to gout; while the light natural wines of France, Germany, 375 Gout. Gout. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and the United States produce no such effect. It is by no means clear wherein this difference lies. It cannot be the amount of alcohol, for, as we have seen, spirit-drink- ers are not, as a rule, gouty. Nor can it be the amount of sugar or of free acid or of salts present-all of which have been blamed as the hurtful agents-for in most in- stances the hocks and clarets contain far more free acid and salts than do the heavy sweet wines. It is most probably due to the partly fermented matters in the latter causing fermentation of the contents of the stomach, and thus giving rise to an acid dyspepsia. It is to this fer- mentation that the acid and gaseous eructations are due, with which the gouty are so often troubled, and, as we shall see, this and every form of dyspepsia is a potent predisposing cause of the malady. Food: solid and liquid. Since time immemorial the over-indulgence in food, especially in animal food, has been with right regarded as a potent factor in the causa- tion of gout. The indigestion produced by over-eating acts (Garrod, Cohnheim, Senator) by causing in the stomach an elabo- ration, through fermentation, of various acids, especially lactic and the volatile fatty acids. These, on absorption, cause decreased alkalinity of the blood, and consequent diminished power for holding urates in solution, leading to secondary deposits ; thus producing that variety of gout resulting from diminished elimination. Proof, however, is wanting to show that the absorption of these acids-since they must be converted into carbonic acid in the blood-does in reality cause diminished al- kalinity. They might do so perhaps by the union of the CO2 with the basic sodium phosphate (thus Na2HPO4 -t-COa + H2O=NaH2PO4+NaHCO1) forming acid sodi- um phosphate and acid sodium carbonate, the former having an acid reaction. It has, on the other hand, been shown (Pfliiger and Zuntz) that the blood still remains alkaline even after complete saturation with CO2. Garrod describes also a form of dyspepsia which is secondary to gout, and which he considers due to func- tional gastric derangement, resulting from the presence of the uric acid in the circulation. This form has for its symptoms a coated tongue, bad taste in the mouth, heaviness and sleepiness after meals, and general languor, together with anorexia and constipation. Active chola- gogue purges generally relieve this condition. In the gouty, indigestion may also be the result of in- ability to take proper exercise, together with the lowered tone of the system generally which frequent attacks pro- duce. Lack of oxygen forms a not unimportant causative fac- tor. In the rich, bodily indolence is often combined with over-feeding, and we have as a result the "rich man's gout." The poor, on the other hand, being, in cities at least, usually huddled together for many hours in the day in factories, and at night in dwellings where there is an insufficient supply of fresh air, acquire the "poor man's gout "-a form by no means as uncommon as is perhaps generally supposed, for post-mortem examina- tion of the toe-joints of hospital patients will often show uratic deposits in cases where, during life, no gout had been suspected. Virchow lays stress on these two appar- ently opposite, but really identical, modes of production of the disease. Psychic influences, as prolonged mental exertion, grief, anxiety, etc., may act not only as predisposing, but also as exciting causes. Lead.-It has been noticed by a number of observers that those employed in manufactures involving the use of lead in its many forms are particularly liable to gout. In his hospital cases Garrod found that as many as one in four of the patients had been lead-workers ; and in many lead-workers who gave no apparent signs of actual gout, an excess of urates was found in the blood. In two cases Garrod administered lead internally with the effect of notably diminishing the amount of urates eliminated. Lead-workers very commonly have nephritis, and hence it is easy to see that through defective renal action an accumulation of urates in the blood might occur. But whether the lead causes first a functional renal disturb- ance which leads to a uratic accumulation, and hence to gout, and this in its turn produces the atrophic changes in the kidney, or whether the lead produces the nephritis first, and this a secondary gout, has not as yet been deter- mined. Exciting Causes.-Many of the predisposing act also as exciting causes when the gouty vice is once established. Thus an over-indulgence in wine, an attack of dyspepsia, the use of certain articles of diet, or sudden fear, grief, or mental excitement of any kind, are often sufficient causes. Anything that lowers either the local powers of resistance, as traumatism, cold and wet, or the powers in general, as extreme bodily or mental labor or haemor- rhage, may also suffice to precipitate a gouty paroxysm. Symptomatology of Acute, Chronic, and Irregu- lar (Masked) Gout.-I. Acute Gout.-Generally after a varying period of general depression, the patient is awak- ened in the early hours of the morning by a pain in the metatarso-phalangeal joint of the great toe-generally the left-of more or less intensity. The pain is usually de- scribed as though the joint were being squeezed in a vice, while there is an accompanying sensation of throb- bing, stiffness, and tension, caused by the local over-filling of the blood-vessels, and the oedema that soon sets in. The attack may begin with a chill, and there is almost always a rise of temperature, accompanied by the ordinary fe- brile symptoms. The toe presents a tense, swollen, shining, often livid appearance, and is exceedingly painful to pas- sive motion, or even to the slightest touch of even the bed- clothes. In a few hours the attack passes off, leaving the patient nearly, or entirely, free of pain, though the joint will still be found sensitive to handling. Toward night the pain and febrile symptoms recur, and often a succes- sion of attacks may occur for several nights, lasting some- times even for weeks, much depending on the original se- verity of the attack and the treatment employed. As the seizure disappears the redness, oedema, and injection of the part gradually vanish also, leaving the toe of its natu- ral size. The skin then desquamates, and for some time after itches a good deal. A period of slight general de- pression follows each attack, succeeded, however, by an improved state of health which usually lasts some time. Premonitory symptoms, when they do exist, are usually referred to some organ from which the patient is accus- tomed to suffer an occasional disturbance of function, gs dyspepsia, constipation, or neuralgia, or there may be psychic changes, commonest of which are depression of spirits or irritability. The feeling of well-being which is generally experienced after an attack of gout is no doubt due, in part at least, to the elimination from the circula- tion of the excess of urates in the blood by their deposition in the joints, but partly also to the regular life the patient is apt to lead for the subsequent first few months. A gouty paroxysm, however, is never to be looked upon as beneficial, though it is sometimes so considered, for each deposit which occurs in a joint renders it so much the more liable to subsequent attacks, besides interfering with its function. Gouty attacks are prone to occur in the late winter and early spring. As a general thing acute gout is not of very common occurrence in the United States. The dis- ease here assumes more often the irregular type, and it may be remarked in passing that it is a disease of far greater frequence than is usually appreciated. After a patient has had several acute attacks it will be noticed that the intervals become shorter and shorter, and that the general health is not so good. Occasionally but a single acute attack occurs in a lifetime, or attacks may recur only at intervals of years, but this is not the rule. Generally, unless consistent treatment is pursued, and not always then, the frequency of the acute attacks increases. II. Chronic Gout.-After the recurrence of a certain number of attacks the joints affected will be noticed to have become more or less deformed by the deposition in and around them of uratic salts, which, in the form of tophi or " chalk-stones," seriously interfere with the func- tion of the extremities. As the feet are the parts most frequently affected, the patient experiences difficulty in walking, and the consequent withdrawal of the necessary 376 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gout. Gout. amount of exercise and fresh air is often a strong pre- disposing cause to the occurrence of various functional derangements, chiefly involving the alimentary canal. There is apt to be acid or flatulent dyspepsia or con- stipation, with all the ensuing evils of headache, neu- ralgia, lassitude, depression, and irritability. In many cases eczema or psoriasis makes its appearance. The former is particularly troublesome, and, when on the lower extremities, as frequently happens, adds not only another difficulty to locomotion, but the itching that it causes often deprives the patient of needed sleep. In course of time partial or complete anchylosis of the joints may set in, and, in consequence, deformity of the parts and partial atrophy of their related muscles. Renal lesions are generally, though by no means invariably, associated with the later stages of chronic gout. With them come all those disturbances, both functional and organic, of the circulatory system so characteristic of kidney disease. The above is the picture of a severe instance of the course of chronic gout; but between it and the mildest manifestations all degrees of difference exist. In many instances the signs of the disease limit themselves to more or less pain and stiffness occurring at intervals in various joints-usually of the feet and hands-and alternating, perhaps, with occasional attacks of eczema, and while it is true that gout, generally speaking, tends to shorten life, yet many afflicted with it attain to an even unusually old age. III. Irregular {Masked) Gout has been divided into two kinds : First, the retrocedent variety, in which, during an attack, or while one is pending, the pain and other attend- ing symptoms leave the joint affected and become trans- ferred to some other organ. Second, irregular gout proper. Under this is included various organic or func- tional disturbances of different organs, occurring in pa- tients who are either of pronounced gouty habit and have had arthritic attacks at some period, or in individuals who inherit a tendency to the disease without having ever had a distinct articular manifestation of it. 1. Retrocedent Gout. If, when a gouty paroxysm is imminent, or during its height, some strong local effect be brought to bear upon the joint, as the application of cold compresses or of powerful irritants, or exposure to cold and wet, it has often been observed that, while the joint symptoms suddenly abate in the course of a few hours, other symptoms, usually of an alarming kind, set in. Thus the stomach, intestines, lungs, heart, or brain may all be affected, and relief is not usually obtained un- til the attack is made to return to its original seat. When the stomach is affected the most violent pains are experi- enced in this organ, with vomiting and belching of quan- tities of gas. At the same time the patient experiences the greatest feeling of anxiety and a sensation of impend- ing death. If the intestines be involved there is intense pain and prostration, diarrhoea, tympanites, and all the symptoms of an enteritis, so severe that the patient not infrequently succumbs. When the heart is attacked signs of cardiac failure present themselves, and if the lungs be the seat of trouble, violent dyspnoea results. A gouty retrocession to the brain may be marked by mani- acal symptoms, lasting a longer or shorter time, or by apoplexy-though in the latter case it is often a question whether the gouty attack does not merely act as an ex- citing cause of the hsemorrhage, the cerebral arteries being already diseased. 2. Irregular Gout. Many persons suffer from slight ar- ticular troubles of a gouty nature without ever experi- encing an acute paroxysm. These individuals are often in- clined to various ailments, which, from their yielding to a treatment for gout, have been put down as of gouty origin, and as being manifestations of the gouty diathe- sis. This form of gout is more common in those who, being strongly inclined to the disease hereditarily, live temperately; hence it is the form to which women are commonly subject. The diagnosis of these cases is often obscure, and to gain a clear insight iuto the nature of the trouble pains must be taken to carefully trace the pa- tient's antecedents, especially with reference to heredity and to former habits, and to the occurrence of even slight articular tendernesses. The serum of the blood should be examined in the manner already described. The troubles more commonly connected with the gouty diathesis are gastric and intestinal dyspepsia, both flatu- lent and acid, bronchitis, asthma, cardiac palpitation, cystitis, prostatitis,1 nephritis, conjunctivitis, and various skin diseases already alluded to, as eczema, psoriasis, acne, and prurigo. There are besides various gouty af- fections referable to the nervous system, commonest of which are neuralgias of the trigeminal, sciatic, and inter- costal nerves, and hemicrania. Hypochondria and mel- ancholia of varying degrees, from slight depression of spirits (which is common), to profound psychic disturb- ance, may also occur. In rare cases maniacal attacks as well as epilepsy have been thought to have had a gouty origin. The pathology of retrocedent and irregular gout is even more obscure than that of the regular form, as but few cases afford an opportunity for making pathologico-ana- tomical investigations. The organs affected-as the stom- ach, intestines, kidney, and prostate-may be found in a state of severe inflammation; on the other hand, often nothing abnormal can be observed. This is especially true with regard to the nervous system, in which uratic deposits have never been found. Treatment.-The object to be attained in the treat- ment of gout is twofold. In the first place, -we seek to prevent the excessive formation of uric acid by prophy- lactic measures. In the second, an increased elimination of that already formed, together with the alleviation of the symptoms, both acute and chronic, which its pres- ence provokes, is aimed at. ' The preventive treatment resolves itself almost entirely into the formation of correct habits regarding food and exercise, while it is to drugs that we must look for means to hasten the elimination of the uric acid, or to relieve suffering. Prophylaxis.-Diet. To those of gouty tendencies it may be said that, as a rule, they may eat of nearly all di- gestible food in moderation, the quantity and quality varying with the amount of bodily and mental work per- formed. This moderation, however, few will observe, for in general it may be said that nearly all who have the means constantly take more food than is requisite to repair the daily waste of tissue. This habit becomes very strong when once established, for at every meal the pal- ate is tempted with savory dishes long after mere appe- tite has been appeased. That the extra work thus thrown upon all the organs of assimilation and elimination will in the long run prove injurious to them, we have abun- dant evidence. If organic disease does not eventually occur, functional derangement is almost inevitable. A diet of animal food only, as Lehman has shown in experiments performed upon himself, increases the amount of urea and uric acid, while a non-nitrogenized and vegetable diet diminishes it ; a mixed diet stand- ing about midway between the two. From these ex- periments it becomes evident that for those who are predisposed to the formation of uric acid only so much nitrogenized food-whether as meat, eggs, milk, cheese, etc., or as peas,- beans, lentils, and other legumes-should be used as seems requisite for the proper maintenance of the bodily health ; and far less is needed than is generally supposed. Theoretically a diet composed of the carbo- hydrates-starches and sugars-is indicated, and while in practice it is often found that these articles are not well borne, giving rise to acid and flatulent dyspepsias, yet the writer has often noticed that it is not so much the foods themselves that are at fault as it is their mode of preparation, or the indulgence in them in too large quan- tities, causing an overloading of the stomach, and in con- sequence a suspension or impairment of function. Com- plaints are often heard that oatmeal disagrees, causing heart-burn and belching of gas. As commonly prepared, by ignorant cooks, oatmeal is more or less hard, the grains keeping, in part, their form and consistency. Many people, indeed, prefer eating it in this state. When, after soaking over night, it is boiled to a creamy mass, with plenty of water or milk, so that the grains are 377 Gout. Gout. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. scarcely distinguishable, oatmeal is almost always, except for confirmed dyspeptics, an easily digested food, pro- vided it is taken in moderate quantities. The ' ' partly cooked " preparations, now much used, are excellent. The indulgence in sugar, in its various forms, is often forbidden to the gouty, under the impression that it causes " acidity," and from a similar reason fruit is likewise prohibited; but it will probably be the experience of everyone that sugar in its pure state may be taken with- out inconvenience ; and only when it is combined with the juices of fruits, as in jellies, syrups, and similar prepara- tions, does it give rise to indigestion. Similar observa- tions may be made regarding fruit. The writer has fre- quently noticed that while half a dozen or more ripe peaches could be eaten without the slightest inconve- nience, half the amount, if previously cut up and left stand- ing a short time, sugared, would nearly always give rise to heart-burn and a sensation of gastric fulness. Garrod (Lancet, April 7th and 21st, 1883) has called attention to these important facts. He ascribes the action of sugar, when in combination with fruit juices, in producing acid- ity and heart-burn to a fermentation occurring in the mixture-a fermentation which may either continue in the stomach, or, whose products already elaborated out- side the body, give rise to dyspepsia when taken with the food. Stewed fruits-as dried apples, pears, peaches, and prunes-form a pleasant dessert for the gouty, when eaten soon after preparation; for here, again, I have noticed that when kept a day, even in winter, some, probably fermentative, change occurs, which, though undetected by the taste, renders them indigestible. Fothergill rec- ommends the neutralization of the acid, in order to avoid the use of an excess of sugar, and for this a small amount of sodium bicarbonate may be used. In my experience, however, this destroys, in a great measure, the pleasant taste of the fruit. However, it is worth trying with such sour things as currants, rhubarb, etc. Ripe fruit of nearly all kinds is strongly to be recom- mended. The salts of the vegetable acids therein contained, being converted into corresponding alkaline carbonates, tend only to increase the alkalinity of the blood. -Fruit, besides, keeps the bowels open and increases the urinary secretion, and thus promotes chemical activity in the tis- sues. Certain fruits, containing many small seeds, like huckleberries, raspberries, blackberries, and strawberries, are apt to irritate the intestinal tract, and so cause dys- pepsia, and hence should be avoided. In laying down directions for diet, individual peculiar- ities should ever be borne in mind, for it will be found that an amount of food amply sufficient for one individ- ual will be inadequate for another, though the work done by each may be apparently the same. No hard and fast rules can be made; but it can generally be said that the smallest quantity of food that can be taken without loss of health, strength, and energy, or unnatural emaciation, is the best for the organization. A good breakfast may be made on a dish of crackers, soft oatmeal, hominy, or wheaten grits, with milk or cream, and sugar. Tea or coffee-not too strong-and a piece of broiled bacon or fish, with toast. Fruit at the beginning of the meal is relished by many. For lunch, salads of any kind, with simple dressing of oil, vinegar, pepper, and salt-no mayonnaise-sardines or canned salmon, with bread and butter and fruit, and a cup of chocolate or glass of milk. For dinner, soup, fol- lowed by a single kind of meat-roast, broiled, or boiled- with vegetables; and for dessert, fruit stewed or raw, or a light pudding. At a great variety of dishes at one meal, especially in the way of meats, the stomach usually re- bels, a fact already observed by Sydenham. Food should be prepared as plainly as is compatible with enjoyment, elaborate and highly spiced dishes being avoided. Frying in the American fashion, in a shallow pan with a thin layer of fat, is an especially pernicious mode of cooking. The fat is heated to a temperature at which its acids are set free, and these are most potent dis- turbers of digestion. Frying should be done according to the method in vogue in France and Italy, namely, in a deep pan. containing enough boiling fat to entirely cover the article to be fried-a mode which in this country has not extended beyond doughnuts and crullers. Every kind of fish, except when smoked, may be eaten, giving preference to those of soft fibre ; likewise poultry, beef, and mutton. Veal, ham, and pork should be very sparingly indulged in, as they are the hardest of all meats to digest. Vegetables are a great boon to the gouty. They afford sufficient bulk to allay the appetite, without introducing too much nutriment, besides supplying the system with alkaline soda and potash salts. It should not be forgot- ten, however, that peas, beans, 'and all legumes contain in their casein a large amount of nitrogenous matter. Fat, in the form of butter and cream, or bacon, by soon satisfying the appetite, is a desirable article of food. Ac- cording to Voit, fat' lessens the destruction of the albu- mins of the body, and acting in this way as a preserva- tive of the tissues, diminishes that appetite which is the exponent of their demand for repair. Hence Ebstein rec- ommends fat as one of the principal articles in his dietary for corpulence. Gouty people with an inclination to obesity should be cautioned against such ill-advised procedures as the ' ' star- vation treatment," " Banting cure," violent purging, etc. By these means, it is true, patients often lose greatly in weight, but generally in health and strength as well. Alcohol. From what we have, seen regarding the ef- fects of alcohol in causing gout, it will be safe to advise gouty individuals to abstain, as a rule, from alcohol in any shape. For if spirits be taken the danger of falling into habits of intemperance should most earnestly be considered ; while all wines tend, if habitually indulged in, to cause more or less derangement of the diges- tive functions. The white wines are often exceedingly sour, while the clarets, in addition to being acid, contain more or less tannin, which interferes with digestion, by precipitating the albuminoids of both the food and the digestive ferments. If long habit has rendered the use of wine at meals a real or fancied necessity, a good quality of hock or claret is to be recommended, or if circum- stances seem favorable, a glass of well-diluted whiskey or brandy, to be drunk only during the meal, may be in- dulged in. Heavy ports and sherries, as well as the sy- rupy and fiery wines of Greece, Hungary, and California, are by all means to be avoided by the gouty. So, too, beer and ale under any form. Cider, when thoroughly fer- mented and made of sound apples, may be used in moder- ation. It has for years been a staple drink among the New England farmers, among whom gout is certainly not common, being indeed all but unknown. But in es- timating the influence of this fermented liquor in the pro- duction of the disease in question, the active, out-door lives of those who use it most freely must always be taken into consideration. Exercise. In combination with a restricted animal diet the introduction of a full supply of oxygen into the circu- lation, by means of exercise, is imperatively to be recom- mended when feasible. Gymnastics, Indian clubs, rowing weights, and the like, may be used indoors ; while out of doors riding, rowing, canoeing, walking, shooting, fish- ing, and sailing-in fact, anything involving activity- should be indulged in. It is important to observe that exercise should not be taken merely for its own sake, but a large degree of mental enjoyment ought to go with it, in order to get the full benefit. For this reason billiards are especially to be recommended to elderly men. Several miles may be walked around a table, without fatigue, and the various postures necessarily assumed, together with the mental tension requisite to play well, give a most de- lightful sense of exhilaration to both body and mind. Those who by reason of age or infirmity are inca- pable of active exertion, should resort to driving, a great deal of unconscious muscular exertion being used in the automatic adaptation of the body to the constant move- ments of a carriage. I have seen also much benefit fol- low a systematic course of massage. By massage old and crippled patients obtain an amount of muscular ex- ercise, and a correspondingly increased activity of the cir- 378 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gout, Gout, culation, which they could get in no other way. A dim- inution of the pains and stiffness in the joints, and a feeling of general well-being, follow, which become strik- ing when compared to the patient's previous condition. Mental Influences. As gouty persons are at all times liable to fits of depression, but especially so when con- fined to the house by reason of painful joints, it is im- portant that theii- minds should be pleasantly employed and diverted as much as possible from themselves. Upon the accomplishment of this end much of the success of treatment will often depend. Medicinal Treatment.-1. Acute Gout. The principal indications for the treatment of an acute paroxysm are, first, to relieve pain, and then to restore the patient as rapidly as possible to health. As it is very likely that tlie attack has been preceded by gastric and intestinal dyspepsia, accompanied by portal congestion and a torpid liver, it is a good rule to give at the outset a brisk chola- gogue cathartic, such as Hunyadi water, or Rochelle salts, or a mercurial purge. The bowels should be kept free, but anything like continuous purging should be carefully avoided. A compound cathartic pill (U. S. Ph.) given every second night will generally effect this pur- pose ; or, if the patient be of robust constitution, saline waters may be used instead, either the natural ones, such as Hunyadi, Friedrichshall, Congress, and Hathorn, or those prepared from the artificial salts. A pleasant mode of administration is by means of the effervescing salts. When the pain in the affected joint is so severe as to deprive the patient of sleep and rest, hypodermatic in- jections of small quantities of morphia should be given, or local anodynes may be used, and of these Garrod strongly recommends a solution of two to three grains of atropine in an ounce of alcohol and water. Compresses wet with this are laid upon the joint, and covered with oil silk or rubber tissue, to prevent evaporation. W armth and moisture, in the shape of hot cloths, or a sponge wrung out of hot water, or even wrapping the part in cotton batting, covered with rubber tissue, to cause local sweating, are means which often afford much relief. Regarding the use of cold, as well as local depletion by leeches of the inflamed part, all experience goes to show that they have a very decidedly bad effect upon the course of the disease. Cold is apt to drive the gouty manifestations away from the site originally affected, and cause its retrocession to some internal organ, with dis- astrous results ; while after leeching, Garrod says, he has witnessed, in several instances, permanent stiffness of the joint from anchylosis. Blisters are recommended by him where pain and stiffness persist for some time after the acute symptoms have passed off. The use of colchicum for controlling the gouty parox- ysm has been in vogue now for more than a century, and w'hile there is no doubt regarding its efficacy in the acute stage, there is an almost equal unanimity of opinion as to the harmful effects of its prolonged use. Of the nature of its action in gout, it may be said that nothing certain is known, for no connection can be traced between the al- leviation of the symptoms and its ordinary physiological effects. It has been claimed that colchicum increases the elimination of uric acid, but Garrod's experiments seem rather to prove the contrary, especially after prolonged use. In order to obtain the best therapeutic results colchi- cum should not be given in doses large enough to pro- duce effects upon the alimentary canal-nausea and purg- ing. Garrod advises beginning with a rather large dose, however, such as half a drachm to a drachm of the wine, diminishing the amount later to twenty minims or less, as the paroxysm passes off. Its effect upon the inflam- mation is wonderful, the pain being allayed and the patient put into a state of bodily and mental comfort within a few hours after its first administration. Hence the temptation both for the physician and patient to use the drug is very great, but it is a weapon that must be employed with skill and discretion, else he who wields it may do more harm than the disease would if left un- checked. For it is the opinion of most good authorities that the indiscriminate use of colchicum tends to lessen the, intervals between the attacks, and to lower the health generally of those who use it too freely. Consequently its use should be limited to allaying the severe pains at the outset of an acute attack, or to the exacerbations of the chronic stages. The use of the salicylates has of late found many ad- vocates, and in a certain number of cases they prove very effectual. The salicylate of soda may be used in 15 grain doses, repeated every three to four hours. Should nausea occur, a few doses may be omitted. Some patients bear better the oil of wintergreen (which contains ninety per cent, of methyl salicylate) given in capsules. During the febrile stage, as well as for some time after, the diet may consist of simply prepared, digestible foods, preferably the starches and fresh vegetables. Wine and stimulants of all kinds should be avoided. 2. Chronic Gout. Upon the subsidence of the acute symptoms the patient will often be left for a period in a state of languor and debility, in which the use of iron, strychnia, quinine, and other tonics will be called for. At the same time it is important to facilitate the elimina- tion of the excess of uric acid from the system. To effect this we seek to increase the alkalinity of the blood by the free administration of alkalies, which serve also to pro- mote the secretory powers of the kidneys. At the same time large quantities of water are to be taken to increase their solvent, but especially, also, their diuretic, effects, seeking thus, by free diuresis, to wash the uric acid out of the tissues. Of the alkalies, Rochelle salts-the sodio- potassium tartrate-by being practically tasteless and in- expensive, is preferred by many. A drachm, taken in a full tumbler of hot or cold water between meals-the first dose immediately oh rising in the morning-is generally sufficient to maintain an alkaline reaction of the urine and cause free diuresis. The bicarbonates of sodium and potassium, or Carlsbad salts, a teaspoonful stirred up in half a glass of lemon-juice and water, and drunk while effervescing, is a pleasant mode of administration. Or the prepared effervescing citrates may be used instead. Garrod, basing his course upon the great solubility of the urate of lithia, and the great alkalizing powers of the salts of this metal, was the first to prescribe it for the re- moval of uric acid, and although its high price was for a long time a drawback to its general use, the discoveries of new sources of supply in the shape of natural lithia waters have now led to a pretty extended employment. The citrate, owing to its solubility, is the form mostly used when it is to be given in powder, while the mineral waters are solutions of the carbonate in an excess of car- bonic acid. Five grains to half a drachm of the citrate, in a glass of water, given three times a day, will have a marked effect in rendering the blood more alkaline, as will be shown by the increased alkalinity of the urine. When its use for a considerable period seems indicated, it is advisable to use small doses, as large ones are apt to cause indigestion, and here the artificially carbonated lithia water may be ordered-a wine-glassful between meals. (It may be re- marked that the practice of ordering alkaline mineral waters to be taken during meals, when the natural gastric secretion is acid, seems to be almost as common as it is unphysiological. They should be taken an hour before eating, when the stomach will be free of food, and the natural reaction of its secretion alkaline. In this way the full alkalizing and diuretic effects are obtained.) Gar- rod recommends the external application of solutions of lithia salts for the removal of gouty concretions. Com- presses wet with the solution are secured about the part by means of gutta-percha tissue. He instances the re- moval by this means of a tophus the size of a small egg after a six weeks' application. Where there is considerable articular stiffness the ad- ministration of potassium iodide will be found beneficial, given in small doses for a considerable period of time. In general, the remarks made upon the prophylactic treatment of gout apply to its chronic state. Between the acute attacks everything should be done to elimi- nate, as far as possible, the cause of the trouble, and to place the patient on the best physical and mental foot- 379 Gout. Grape Cure. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing. Every individual has his peculiarities, which must be studied, and it frequently requires much care and pa- tience to find the exact mode of treatment best adapted to each case. portant of which are the sulphate and sulphite of calcium. In large doses it exerts a purgative action. For bathing it is used in the same manner and for the same affections as other sulphurous waters. J. M. F. Bibliography. Bartel's Article on Renal Diseases, Ziemssen's Cyclopaedia. Bence Jones: Applic. of Chem. and Meehan, to Path, and Therap. London, 1867. Budd : Med. Chir. Trans., 1855. Brouardel: Arch, de Phys. Norm, et Path., s-r. ii., 3. Cohnheim: Allgeineine Path. 2d edition. Berlin, 1882. Delafield and Prudden : Pathological Anatomy. New York, 1885. Dickinson : Path, and Treatm. of Albuminuria. 2d edition. London, 1877. Ebstein : Die Natur und Behandlung der Gicht. Wiesbaden, 1882. Foster: Physiology. 3d edition. Fowne's Chemistry. 1873. Gairdner : On Gout, etc. London, 1851. Garrod: On Gout and Rheumatic Gout. 2d edition. London, 1876. Also, Reynolds' Syst. of Med., article Gout, vol. i. 1866. Also, Lancet, April, 1883. Liveing : Megrim, Sick-headache, and some Allied Disorders. London, 1873. Landois : Physiology. Translated by Stirling. 1885. Loebisch : Harnanalyse. Vienna, 1881. Meldon : Lancet, 1872 ; Brit. Med. Jour., 1881. Neubauer and Vogel: Analyse des Harns. 1876. Ord: St. Thomas' Hospi'al Reports. 1872. Parkes : The Composition of the Urine. London, 1860. Ralfe: Morbid Conditions of the Urine. London, 1882. Senator: Article Gout, Ziemssen's Cyclopaedia. Todd: Clin. Lectures on Certain Diseases of the Urin. Organs. London, 1857. Virchow: Berl. klin. Wochenschr., Jan., 1884. Wagner: Der Morbus Brightii. Leipzig, 1882. Ziegler; Pathologische Anatomic. Jena, 1885. Walter Mendelson. 1 Harrison : Lancet, November 24, 1883. GRAFENBERG. A colony belonging to Freiwald, in Austrian Silesia, in a mountainous region, at an altitude of more than 2,100 feet; about six miles from the rail- road station Ziegenhals. Owing to its situation, it is protected from the cold northern and northwestern winds, those from the northeast and southeast being most prevalent. The air, pure and bracing, is said to contain a large proportion of ozone, and is rendered fragrant by the surrounding forests of pine. The average temperature for the year is 7° C. (44.6° F.), but, as would be expected in a high mountainous situation, frequent sudden, and at times very severe, changes of temperature occur. It was at Grafenberg that Priessnitz originated his cold-water treatment, which is still much employed there ; but the place is resorted to for the most part dur- ing the summer, for the sake of its fresh and invigorating atmosphere. J. M. F. GRANA. A thermal spring (104° F.) near Guadix, in the southeastern portion of Spain, containing 18.816 grains in each pint, principally calcium and magnesium sulphates, with a considerable amount of ferrous car- bonate. J. M. F. GRANDRIF, PUY DE DOME. A village in the south- eastern part of France, having a cold mineral spring classed among the bitter waters. Of salts it contains but 3.57 parts in ten thousand, consisting principally of earthy carbonates with a small amount of iron. The water is recommended in the treatment of intermittents (Eulen- burg). J. M. F. GOUT IN ANIMALS. True gout in animals is either really extremely rare, or, perhaps, only apparently so, from the fact that during life its occurrence might not attract attention, and after death the lesions could easily be overlooked unless especially sought for. Among veterinarians, Bruckmuller is the only one who has re- corded the occurrence of what may be regarded as a case of true gout. In an old hound he found chalk-like de- posits of sodium urate in the periosteum of the epiphyses, and in the ligaments of many of the joints, especially those of the ribs and costal cartilages. In birds and rep- tiles, deposits of urates have been observed in many of the tissues. Aldrovandi noticed tophi in the toes of falcons, and Bertini, of Utrecht, found the same in parrots. Meg- nin likewise found in the toe-joints of a parrot numerous crystals of urates, and he thinks the disease may, perhaps, be not uncommon in birds kept in confinement. Pagen- stecher discovered deposits of sodium urate throughout the muscles of an alligator whose kidneys contained a grumous mass in their tubules and excretory duct. The hip-joint contained, besides sodium urate, free uric acid. An extract of the flesh gave, in addition to urea, large amounts of kreatinin and uric acid, and a small quantity of xanthin. Liebig also found uric acid in the flesh of an alligator. Virchow has described the occurrence in the muscles and connective tissues of a pig of a substance which he determined to be probably guanin (see Guanin), a nitrog- enous body of the xanthin series. From these scanty observations we see that the lower animals probably suffer from the same, or an analogous, morbid condition which in man produces gout; but the circumstances under which these affections occur in ani- mals have, as yet, been so little observed, that they are of but small use in throwing light upon the disease as it exists in man. GRANULATION. By granulation we mean a process of new formation of tissue that occurs in connection with wounds, ulcers, and other conditions involving damage to or loss of tissue. The process is one of repair, and may accompany all so-called productive inflammations. When granulation takes place, little vascular tufts of new- formed tissue spring up, and, projecting above the in- flamed surfaces, produce a characteristic papillary ap- pearance, from which the process has derived its name. The structure of these tufts follows the type of the per- manent papillae of the integument. Granulations consist essentially of a loop'of blood-vessels surrounded and cov- ered by embryonal tissue. The little projections have in general a rounded shape, and they may be either flat or somewhat tapering. Their size is quite variable, but does not, as a rule, much exceed that of the head of a pin. We distinguish between simple granulations and com- pound ones. The latter may attain comparatively large dimensions, but are then always studded with smaller secondary granulations. If granulation is to take place, the inflammatory pro- cess must extend over a certain length of time, and must not be too severe. For example, clean-cut wounds unite by so-called primary intention, which leaves no time for granulations to be formed. It is in the so-called union by second intention that these little papillary vegetations appear upon the divided surfaces, which unite more gradually and with the formation of a broader cicatrix than is observed in primary union. It is superfluous to recognize union by third intention as a separate variety of cicatrization, the process being in every respect a heal- ing by granulation. Histologically, granulations are highly vascular, tem- porary formations that, apart from abundant blood-ves- sels, consist of imperfectly organized or embryonal tissue. It is easy to recognize two chief varieties of cel- lular corpuscles that enter, into their formation. The first variety is not distinguishable from ordinary leuco- cytes (a, Fig. 1411). The others are much larger than the former, and from their resemblance to epithelium have been called epithelioid corpuscles (b, Fig. 1411). Several of these cellular elements may coalesce, and thus produce Bibliography. Bruckmuller : Lehrbuch der path. Zootomie. Vienna, 1869. Ebstein : Die Natur u. Behandlung der Gicht. Wiesbaden, 1882. M6gnin : Gaz. hebdom., 1881, No. 13. Pagenstecher : Verhandl. des naturforsch. med. Vereins zu Heidelberg, Bd. III., 1865. Virchow: Virchow's Archiv., Bd. 35 (1866). Walter Mendelson. GRABALOS. A tepid gypsum spring in Logrono, Spain, eleven hundred feet above the sea. It contains salts in the proportion of 8.60 grains to the pint, most im- 380 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gout. Grape Cure. still larger so-called giant-cells (c, Fig. 1411). There is no doubt that the permanent connective tissue of cicatri- zation takes its origin directly from the several corpuscles in question. The writer was able to convince himself of this fact while engaged in experimental researches under the supervision of Ziegler, to whose elaborate studies our knowledge of the subject is so largely due. Ziegler has very properly called these epithelioid cells formative cor- puscles. Protoplasmatic offshoots from their bodies be- scars. At times, owing to continued irritation, deficient nutrition, or reduced vascularity, degeneration occurs. The granulations then appear to melt away, and a de- structive process is set up which may lead to grave re- sults. What is commonly known as " proud flesh " consists of granulation-tissue. When too exuberant, it becomes ne- cessary to remove it by scraping or cauterization, but often it denotes merely healthy reparative action. Edmund C. Wendt. GRAPE CURE (Ger., Traubenkur, or Wein- traubenkur ; Yr., Cure aux raisins; Itai., Cura dell'uva\ The somewhat pedantic term ampelo- therapeutics a vine) has been used synonymously ; but it would seem that botryo- therapeutics ^Arpvs, bunch of grapes), or staphy- linotherapeutics (aTa^uXi), bunch or cluster of grapes), is more in accord with etymology. (See riepl rr)s 8ia <rrpa(pvKd>v Oepairetas. 'H EN A0HNAI2 IATPIKH MEAI22A, 1858-59, pp. 179-188; also, MEAI22A A0HNX1N, 1864, pp. 374, 389.) Notwithstanding certain objections to the im- plied meaning of these terms, they are held to signify the course of regimen that has for its ob- ject the amelioration of sundry chronic ailments by the rational and systematic employment of a diet composed exclusively or chiefly of grapes. The so-called fruit cures are among the most useful of the applications of bromatology to medicine, and the dietetical use of tigs, cherries, greengages, currants, raspberries, and of straw- berries, has long been in repute with some Eu- ropean physicians. Van Swieten is said to have recommended in special cases the eating of twenty pounds of strawberries a day. He also reports a case of phthisis healed by strawberries, and cites cases in which maniacs regained reason by the exclusive use of cherries as an aliment. Hoffmann (Fred.), Richter, and Berger report analogous cases. According to Geoffroy ("Mat. Med.," Paris, 1750, vol. i., p. 52), Forestiushas seen invet- erate diarrhoea, that had resisted all treatment, healed by the sole use of over-ripe medlars. Linnaeus, a great suf- ferer from gout, thought he removed and lessened its attacks by a fruit regimen. It is within the memory of many persons now living that obstinate cases of bowel disease, among soldiers of the late civil war, recovered rapidly on eating peaches. Both dates and raisins have been equally regarded as a comestible and a medicament. But it is to the capital virtue of grapes, which contain nutritive principles necessary to maintain health, that one must look for the attainment of determinate results. In many of the works on viticulture and oenology, the literature of which consists of something over six hundred volumes, mention is made of the therapeutic use of grapes. The landmarks of the subject may be found as far back as the laws of Moses, one of which permits the eating of "grapes, thy fill at thine own pleasure." In the time of Nero, a Greek physician, Dioscorides (Pedanius), mentions in his work on Ma- teria Medica the curative virtues of grapes. In the same connection their use is detailed by Pliny with admirable thoroughness. Celsus, Galen, the later Ara- bian physicians, and the German references, mostly in the tenth century, may also be cited. But few English authors, as Pringle, Cullen, and Sir James Clark, refer to the subject, and that only in the most allusive manner. In fact, English-speaking peoples generally seem to know but little of grapes as a therapeutic means, notwithstand- ing the late rapid advances of viticulture in the vicinity of Cincinnati, in California, in Australia, and at the Cape of Good Hope. There being no special work on the grape cure in English, it is to German works, and especially those of the last twenty years, that one must turn for methodical instruction regarding the chemical study of grapes and the clinical observation of their effects. Perhaps the empirical knowledge of the alimental prop- erties of grapes observed in the fattening of certain mi- gratory birds, and the more palatable flesh of young foxes Fig. 1411.-Granulation Cells of Different Types. X 500. Picrocarmine preparation. (Ziegler.) come the fibres of the permanent connective tissue, while the remaining protoplasm goes to form the fixed corpus- cles of that tissue (d, e, Fig. 1411). The new formation of blood-vessels in granulation is similar to the original vascular development in the em- bryo (see Fig. 1412). Solid processes branch off from capillaries, and, meeting, coalesce. Then a process of tunnelling begins, until the solid offshoot becomes a cap- illary duct. Granulating surfaces receive their epithelial covering from the proliferation and extension of the contiguous epi- thelium. It may happen that little islands of epithelium arise in the central portions of granulating wounds. This is due to the circumstance that the original injury failed to destroy all the epithelial structures of the part. In the skin, for example, the sebaceous glands, or a few hair- Fig. 1412.-Vessels of a Granulating Wound Injected. (Billroth.) follicles, may prove the starting point of this apparently anomalous phenomenon. Healthy granulations have a distinctly bright-red look, and pus is produced at their surface in sparing quanti- ties. They bleed readily, however, on being touched-a fact which is owing to the superficial position of their looped blood-vessels. Flabby granulations generally de- note low vitality, and such unhealthy growths apparently "secrete" an abundance of pus. Granulating surfaces, when maintained in contact with each other, at length unite. Vascularized connective tis- sue, that is to say, cicatricial tissue, forms the perma- nent bond of union between the opposing structures. But granulation need not necessarily lead to the formation of 381 Grape Cure. Gravel. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. after a grape diet, may have had more to do with the employment of grapes as a medicament than any knowl- edge deduced from their chemical study. The nutriment afforded by good grapes is typically representative of all the alimentary principles, although they are poor in pro- tein compared with some other foods, the proportion be- ing one to twenty, according to Fresenius, and it requires oue pound and a quarter of grapes to yield the equivalent of protein found in one egg. Much, however, depends on the variety of grape, the soil in which it is grown, and the meteorological conditions under which it ripens. The juice of grapes is looked upon by many chemists as a sort of vegetable milk, the composition of which closely resembles that of human milk. A very curious resem- blance also has been shown to exist between buttermilk and grape-juice. Besides, grapes contain the mineral salts in variable quantity, the proportion depending on the vari- ety of grape and on mesological conditions. All parts of the grape have been well studied chemically. For the sake of brevity it is only necessary to refer the reader to some of the more comprehensive analyses.1 What was especially observed in regard to grapes in the time of Pliny is the same now as then. Their earli- est physiological effect is the promotion of the secretions and of the excretions, without irritation of the intestinal canal, provided the grapes selected are proper for the treatment and there is no contra-indication. The use of sweet and akaline grapes, by suddenly breaking up all the habits of nutrition, rapidly reconstructing the blood, and exercising a salutary action on the nervous system, favors the formation of fat; but if the- grapes be watery and sour, or not sufficiently ripe, weight is lost rather than gained. The continuous consumption of grapes removes tartar from the teeth and may attack the enamel. If the practice be kept up for a long time it may cause stomati- tis, or weaken the alimentary organs, and grape sugar may be introduced into the blood and decomposed, or be partly excreted unchanged. Jaundice has been observed to oc- cur in children, and dizziness to arise from fulness of the stomach. The dextrin present makes the pancreatic al- bumen more soluble, and further increases the secretion of pepsin. The potash salts, which vary from two to four parts in the thousand, have also been supposed to increase the cardiac activity. The large proportion of phosphoric acid in Malaga and Hungarian wines may be turned to advantage in the treatment of infantile diarrhoea, the wine being dealcoholized by evaporating to one-fourth and sweetened, and of this a tablespoonful may be given. The seeds and skins of grapes, acting mechanically, may oc- casionally cause serious intestinal disturbance by the in- troduction of one of these substances into the vermiform appendage ; but the danger from this cause is, perhaps, no greater than that arising from other articles of food, as apples, etc. Detailed accounts in regard to the urinary excretion are rather conflicting ; some observers saying that its specific gravity is smaller, while others say not; the re- action may be either neutral or acid, the chlorides in- creased, the uric acid lessened or increased, and the same as regards the urea. There is sometimes a phos- phatic deposit and alkalinity of the urine. Aside from physiological speculation, it is known that the laxative effect of grapes is superior to the mere purga- tive mineral waters, for while increasing the excretions they also increase the weight and vigor of the body. Their use in various intestinal diseases dates as far back as the Roman empire, at which time, according to Pliny, grapes were used, both externally and internally, without the skins or seeds, in diarrhoea, dysentery, and even in the chronic dermatoses, gout, etc. In modern times Tissot, Pringle, and Zimmerman speak of their use in dysentery, and, indeed, they seem to have been em- ployed and recommended in the most different diseases. But it is more particularly in constipation and in hypochon- driasis produced by dry catarrh of the intestines that this fruit acts beneficially by moderately relaxing the bowels and by relatively increasing the secretions. The grape cure is of great value to persons of irregular digestion who have deluded themselves into the habit of taking purgatives ; and its virtues as a reparative agent are par- ticularly recommended by its partisans in scrofula, in diseases of the liver or spleen, in hyperaemic congestion, in haemorrhoids, in menstrual derangements, in chlorosis, and in anaemia, particularly that of convalescence. The sequelae of alcoholism, particularly the stomachic and abdominal troubles, are greatly benefited by the grape re- gimen ; and it has been recommended in chronic diseases of the genito-urinary organs. The aphrodisiacal effect of grapes, which Rhazes in the ninth century formulated " erectionem augmentat," may be turned to advantage in the treatment of impotency, if the fruit is taken in large quantity. The writer has succeeded by this method in breaking up the bromide habit in a case of obstinate insom- nia after all other means had failed. (See Medical Record, New York, October 10, 1885, p. 418.) Some German physicians consider the grape cure of doubtful efficacy in the uric acid diathesis. Its use is con- tra-indicated in chronic tuberculosis and in haemoptysis, unless the digestion is sound. Fonssagrieves, however, attaches great utility to the cure in pulmonary lesions. It should also be interdicted during menstruation and hae- morrhoidal bleeding, and is never to be employed in preg- nancy and nursing. The methodical use of grapes in quantities of from three to eight pounds daily, with or without other nour- ishment, according to the therapeutic object and the pa- tient's peculiarities, is much in vogue at the so-called grape- cure stations in Germany and Switzerland ; such places as Duerkheim, Meran, Vevay, Aigle, Celles-les-Bains, and Bingen, being noted for grapes and as climatic places of great repute. Other places of the kind are to be found in the south of France, in Italy, and in Austria. At these stations the grape cure and the milk cure go to- gether, and both are usually combined with the employ- ment of mineral waters. The time of year at which the cure is most practicable is from the middle of August to the last of October. The grapes are eaten preferably in the open air, before breakfast, and on an empty stomach ; but if the stomach is weak a small crust of bread may be taken with the first portion, between seven and eight in the morning. The second portion should be eaten one hour before dinner ;■ the third in the afternoon, between three and five o'clock, two hours after dinner, and a fourth may, sometimes, be eaten just before bedtime. The grapes must be fresh and ripe ; they are to be crushed between the tongue and palate, not the teeth, and the skin and seed should be ejected. This latter precaution is, however, not indis- pensable, being one of those things that may be left to individual preference. Beginning with from one to two pounds the quantity is to be daily increased half a pound until the prescribed quantity is reached, and then slowly decreased. The treatment requires from one to six weeks, during which all heavy and greasy dishes are to be inter- dicted. Food that causes flatulence, potatoes, eggs, milk, cheese, and beer are also to be avoided ; but coffee, choco- late, tea, bread and butter, tender fishes or meat, and, in some instances, cod-liver oil, are permissible. It is also advisable to use an alkaline powder or a wash to protect the teeth, and prevent the gingivitis that may sometimes occur. As a rule, the grapes especially suitable to bring about a therapeutic modification are those that contain a large percentage of grape sugar. Among the richest are the Hungarian, which contain 301 parts in the 1,000. When the stomach will not take the grapes by eating, the freshly expressed juice may be used. The must may also be bot- tled by a special process (procede Appert), and employed at any time of the year. Externally grapes have been used in the form of baths, which are provided at some of the European grape-cure stations for persons who want to be plunged into the mash of the grapes while it is in a state of fermentation. These baths, used principally for rheumatism, were formerly recommended by Tissot in peripheral paralysis. The grape regimen, as an after-cure, is regarded in Ger- many as necessary and indispensable to the completion of a thermo-mineral treatment. Whether used as a princi- 382 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Grape Cure. Gravel. pal or as an accessory resource of treatment, in order to be well tolerated and successful it requires the concourse of adjuvant hygienic influences, which may lead to the supposition that success has been obtained rather by such influences than by the grapes themselves. The writer has, however, obtained the happiest results, aside from climatological influence, in patients who lived in town and used the grapes methodically at home. Irving C. Rosse. 1 See Knauthe (T. H.) : Uber Traubenkuren ; Schmidt's Jahrbiicher, 1873, clviii., 107. Also. Konig (Dr. J.): Die menschlichen Nahrungs- und Genussmittel, Berlin, 1880, and a similar work in 1882. Composition.-The young leaves, tendrils, and green fruit of the vine are sour and astringent, containing tar- taric, malic, and other fruit acids or their salts ; tannic acid, quercetin, quercitrin, etc., sugar, gum, and several earthy and alkaline bases. They are more or less em- ployed in Europe in the form of " teas " or syrups as do- mestic remedies. The juice of one particularly sour va- riety expressed from the green fruit, and known as verjus, is used to make a flavoring and refreshing syrup. The sap of the stems has been also employed. Ripe grapes, and especially raisins, are much sweeter, containing from ten to forty per cent, of sugars (dextrose, levulose, inosite) besides the acids, salts, etc., above mentioned. Use.-As stated above, grapes and raisins have no me- dicinal properties, but as an article of diet are refrigerant, antiscorbutic, and refreshing. Allied Plants.-The genus has a number of species which bear more or less eatable fruits, but none of which have any particular active properties. The Virginia Creeper (Ampelopsis), so extensively planted for ornament, belongs to a neighboring genus. Allied Substances.-Nearly all fruits. See Figs, Tamarinds, etc. W. P. Bolles. GRAPES (Raisins verts et secs, Codex Med.; Uva, Ph. Br.; Raisins, "Currants," etc.). The entire unimpor- tance of grapes in medicine and pharmacy-excepting in the regimen known as the " Grape Cure," and in the manufacture of wines, both of which have separate arti- cles in this work to which the reader is referred-renders an extended notice of them here inappropriate. They were omitted from our Pharmacopoeia at its last revi- sion ; in earlier editions of it they (raisins) appeared as a minor ingredient of the tincture of rhubarb and senna, to which they were added as a sweetening and flavor. In the British official list they fill only the same subordinate position in the compound tincture of cardamom and the tincture of senna. Of the numerous species of vine' in different parts of the earth, the only one officially recognized is the Euro- pean, Vitis vinifera Linn.; order Vitacea, of which a de- scription would be superfluous. It is undoubtedly a na- tive of the southern parts of Europe (Italy, Greece, etc.), of Asia Minor, and Western and Central Asia, etc., in all of which countries it still grows wild. It has been culti- vated also since the earliest known times, and regarded as the most valued and precious of fruits. It is a variable plant, and in the long course of its improvement has de- veloped, like other garden treasures, a great number of more or less well-defined varieties and hybrids, distin- guished by the color, size, shape, and flavor of their fruits, the number, presence, or absence of seeds, and the thick- ness of skin and bloom. About a hundred are recognized and named by the gardeners. The European vine has been introduced into most temperate countries, in the warmer of which, like California, it grows in the open air ; but in the cooler, as in the New England and Middle States, it requires the protection of glass. The varieties raised as luxuries in our cold graperies are generally of this plant. In addition to this imported species, most suit- able countries have their own native vines, which have already begun to appear as improvements and variations from their wild stock. These have in general the advan- tage over the European ones that they are hardier and better adapted to the climate they grow in. Thus in the United States (north of the middle), all the out-door grapes are developed from one or another of the dozen or so' indigenous species-the Isabella, Catawba, Concord, etc., from V. Labrusca Linn.; the Scuppernong from V. vul- pina, Linn. etc. The principal grape-producing countries of Europe are Spain, France, and Germany, where enor- mous quantities are consumed or made into wines, liquors, or raisins. Besides these, Asia Minor and many Medi- terranean islands are very productive. In our own coun- try the Middle States and California are developing an ex- tensive grape culture. Raisins are dried grapes. They are prepared either by simply allowing the fruit to hang on the vine until it dries, in five or six weeks, or hastening that process by snip- ping or breaking the stem partly in two, or plucking the bunches entirely and laying them upon a board floor or loft in the sun. In other places, where the climate is less fa- vorable, they are dipped in scalding water, or in lye, and exposed to artificial heat until dry. The former, " sun- dried raisins," are preferred. Sometimes raisins are packed in the bunches, at others separated from the stem, or " loose." The principal varieties are " Malaga," " Valen- cia," " Sultana" (Smyrna, seedless), and the little "Co- rinthian," commonly called "dried currants," from the Greek islands. GRAVEL. The term gravel, as signifying a disease, is usually applied to the condition caused by the passage of a calculus from the kidney along the ureter into the bladder. Using the word in a broader sense, it may refer to all renal concretions, whether deposited in the tubules of the kidney, or found imbedded in the substance, or in the pelvis of the organ. Other impediments, such as a clot of fibrin, may perhaps, in rare instances, give rise to the same symptoms as those caused by a true concretion, and there is some reason for thinking that certain irritative conditions of the urine, as when it is unduly acid, may cause spasmodic pain in the region of the kidney and ureter independently of any mechanical obstruction. The term renal colic may be applied to all of these sev- eral conditions, but the most common cause, by far, of the symptoms belonging to them, and that to which the word gravel should properly be restricted, is a concretion caus- ing mechanical obstruction. Symptoms.-A calculus may remain in the pelvis of the kidney for an indefinite time without giving any sign of its presence ; but as soon as it engages in the ureter, unless so small as to pass readily through that tube, it pro- duces symptoms of greater or less severity, in conse- quence of the tension to which it gives rise. Pain vary- ing in degree, and often of great severity and of a tear- ing character, is felt in the region of the kidney, ex- tending toward the pubes, and sometimes down the thigh and along the urethra. This is frequently accom- panied with nausea and vomiting, reflex in character, and with retraction of the testicle on the affected side. A tendency to frequent micturition is common, from irrita- tion reflected to the neck of the bladder. The symptoms described sometimes cease suddenly, soon after their first appearance, and being subsequently renewed, continue more persistently. This is probably due to the calculus becoming partially engaged in the upper part of the ure- ter, and then falling back into the pelvis of the kidney, whence it again starts on its journey and passes further on. In some cases the abrasion caused by the rough edges of the calculus gives rise to hsematuria. So in- tense is the agony caused by the passage of a large calculus that the sufferer, until relieved by remedies or by the es- cape of the offending cause, will writhe in contortions. Few, if any, exhibitions of human suffering are more urgent in their demand for relief than those occasioned by gravel. Happily, the resources of modern art are al- most always sufficient to give prompt and perfect relief, and also in many cases to prevent the return of the mal- ady. Without the occurrence of an actual attack of gravel there is sometimes an ill-defined uneasiness in the lumbar region, with a disposition to pass water frequent- ly. And in some cases the calculus may be so small as to make its escape from the kidney to the bladder, and through Ihe urethra, and yet its presence may never have been suspected. 383 Greenbrier Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Etiology and Varieties.-The origin of renal cal- culi is somewhat obscure, and has been the subject of much speculation. It is impossible, within the limits of this article, to consider the chemical details of the many theories which have been advanced in explanation of their cause. It must su._ 3 to say that the nuclei of the calculi consist, in a large proportion of cases, of de- posits of uric acid, phosphate of lime, or oxalate of lime, in the cells of the uriniferous tubules, where they are retained from some deficient eliminative action. In some comparatively rare cases the nuclei are derived from the blood, and consist of minute clots of fibrin or of blood. Nuclei thus formed grow by successive layers being de- posited upon them from the urine, or from the mucus of the urinary passages. These layers vary with the chemi- cal character of the urine; when this is persistently acid, the deposits around the nucleus may consist of uric acid or urates, or sometimes of oxalate of lime, or of all of these substances together. When the urine is alkaline, phosphatic deposits occur. Not uncommonly these dif- ferent substances are found in alternating layers, in con- sequence of the varying chemical condition of the urine at different times. The chief constituents of renal calculi are: first, uric acid or urates ; second, phosphates ; and third, oxalate of lime. Uric acid, either in a free state or combined with bases in the form of urates, may be deposited from the urine whenever it contains an absolute or relative increase of acid. An absolute excess of acid would seem sometimes to be caused by cold checking the action of the skin and thus increasing the elimination of acids through the kid- neys. On the other hand, profuse action of the skin in warm weather may lessen the watery element of the urine and thus cause a relative increase of its acid. In either case, if nuclei have already been formed in the tubules of the kidney, they may grow by deposit upon them from the excess of uric acid or urates in the urine. Calculi consisting chiefly of uric acid are the most frequent of all forms of renal concretions, constituting about eighty per cent, of all that are met with. They may be passed in the form of a red sandy substance, or in larger particles, varying in size from that of a pin's head to that of a large pea. In the bladder they may gradually attain a far larger size, even that of a hen's egg; but in this form their consideration, like that of other large stones, belongs to the province of surgery. The urates of ammonia, soda, and lime are frequently combined with a considerable amount of uric acid, or of oxalate of lime, but are seldom met with by themselves. The phosphate of lime, the phosphate of magnesia, and the phosphate of magnesia and ammonia, or triple phos- phate, are insoluble in alkaline liquids, and are therefore deposited when from any cause the urine becomes alka- line. Alkalinity of the urine may be due to imperfect elimination of carbonic dioxide from the system, such as occurs in conditions of general debility with feebleness of respiration, the excess of carbonic dioxide uniting with bases to form the alkaline carbonates, and thus rendering the urine alkaline. Another cause is the fermentation pro- duced by an excess of mucus in the urinary passages, and the consequent breaking up of urea into water and car- bonate of ammonia, the ammonia combining with the phosphate of magnesia to form the triple phosphate. There is reason to believe that this fermentation is due to a micrococcus which may be introduced into the bladder. In other cases it is formed only after the urine is passed into a vessel to which the fermentation-germ has access, and then, of course, it has nothing to do with the produc- tion of a calculus. A nucleus of any kind having been formed in the kidney, it may grow whenever the urine becomes alkaline by accretions of the phosphate of lime or mixed phosphates. The most common phosphatic calculi consist of a mixt- ure of phosphate of lime and triple phosphates. These are often of considerable size, and are soft and friable in consistence. When composed of phosphate of lime alone, which is rare, they are brittle and compact in structure. Oxalate of lime is present as a deposit in the urine from various causes. Sometimes it is directly supplied from articles of food containing it, such as rhubarb, goose- berries, or tomatoes. In other cases it is apparently de- rived from saccharine, starchy, or fatty matters in the food, or from lactic or butyric acids ; all of which, when imperfectly oxidized, yield oxalic acid, and this combines with lime to form the oxalate. In other cases still, it seems to be directly formed from the mucus of the urin- ary passages when they are in a catarrhal state. How- ever formed, oxalate-of-lime calculi are hard, compact, and of a rough surface, which gives rise to the term "mulberry calculus" that is used to designate them; this roughness may cause a great deal of irritation, and even haematuria. Frequently the lime-salt is combined with alternate layers of uric acid, which, as already stated, may arise from an acrid state of the urine ; and this may exist along with the conditions which produce the oxa- late. In addition to the varieties of calculi just described, some rarer forms are occasionally met with, such as those consisting of cystin, xanthin, fibrin, and blood-clots. Diagnosis.-In general the diagnosis of renal calculus, when an attack of gravel actually occurs, may be made without difficulty, by attention to the symptoms already described, especially the situation and direction of the pain, the suddenness of its occurrence, and the retraction of the testicle. A careful examination, however, of the urine, or of any fragment of gravel that may be passed, is necessary for the differential diagnosis between the various forms of calculi, with a view to the preventive treatment adapted to them respectively. For this purpose, any calculus passed may be tested chemically in the following manner : First, to test for uric acid: let the calculus, placed upon a piece of glass or a plate, be touched with a drop of liquor potassae ; if it dissolves perfectly, and this solu- tion, on being treated with a drop of hydrochloric acid, gives a white precipitate, it consists most probably of uric acid or urates. The application of the murexide test to this precipitate, which is made by touching it with nitric acid and then with ammonia, and finding a purple discol- oration if it consists of uric acid or urates, makes this a certainty. Cystin and xanthin also, like uric acid, dis- solve in the alkali, but they do not give the murexide re- action. Secondly, to test for phosphates: let the calculus be touched first with hydrochloric acid ; if it dissolves, and the solution gives a white precipitate when touched with a drop of liquor ammoniac, it is shown to consist of phos- phates. If in applying the first test only a part of the calculus is soluble in liquor potassae, the remainder being soluble in the hydrochloric acid ; or in applying the second test only part is soluble in the acid, the remainder dissolving in the alkali, the calculus is then shown to consist partly of uric acid or urates, and partly of phosphates. Thirdly, to test for oxalate of lime: this substance is also soluble in the mineral acids like the phosphates, but it may be distinguished from them by becoming charred and blackened under the blow-pipe, and by leaving an ash which dissolves with effervescence in hydrochloric acid. These tests will almost always suffice to determine the nature of a calculus. Prognosis.-The prognosis of an attack of gravel is in general favorable ; for in most cases, even when rem- edies are not used, the calculus will gradually pass down, and, after more or less suffering, relief will be gotten when it falls into the bladder. The duration may, how- ever, be materially lessened or cut short by appropriate remedies. One attack of gravel is likely to be followed by another, because the condition which has caused the first may continue or recur ; but here again the tendency to recurrence may be diminished or made to disappear by treatment. There is, however, a possibility of a serious or even fatal result in any case of gravel, so that an at- tack is not to be made light of in view of the general ten- dency to recovery. Thus a permanent obstruction of the ureter may result, with accumulation of urine, causing 384 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Greenbrier Springs. distention of the ureter and pelvis, with hydronephrosis and atrophy of the kidney. Or a calculus failing to en- gage in the ureter may remain in the pelvis of the kid- ney, and there increase in size and set up inflammation and suppuration, the condition termed calculous pyelitis. Or again, the stone becoming impassably lodged in the ureter may cause ulceration through that tube, and con sequent peritonitis and death. These serious results are, however, rare. Treatment.-The treatment of gravel has three ob- jects in view : the relief of the paroxysm, the expulsion of the calculus from the bladder, and the prevention of subsequent attacks. When the paroxysm is accompanied with severe pain, a hypodermatic injection of morphia, or of morphia and atropia, should be administered at once, not only for the speedy relief to the pain that it gives, but because it tends to relax the spasmodic contraction of the transverse mus- cular fibres of the ureter, and thus facilitates the passage onward of the calculus. It is generally not necessary to administer more than five or six minims of Magendie's solution of morphia, or of this solution with one-third of a grain of sulphate of atropia to each fluid ounce ; and a larger dose might be objectionable in a condition in which the pain is liable to stop suddenly from the escape of the calculus, and thus leave the action of the morphia unbalanced by the antagonism existing between pain and opium. In mild cases the administration of opium by the mouth may be sufficient; and in very severe ones the writer has sometimes found it necessary, in addition to the hypodermatic use of morphia, to give a few whiffs of chloroform by inhalation, so as for a moment to lull the intense agony and allow the morphia to begin its own more permanent anaesthetic action. Hot baths or hot fo- mentations to the lumbar region may aid in relieving pain and relaxing spasm. If constipation exists it is ad- visable to give an enema, as the distended bowels may impede the downward passage of the calculus, and also, by pressing on the kidney and ureter, may increase or prolong the pain. The second indication is to promote the discharge of the calculus after it has passed into the bladder. In a large number of cases this occurs spontaneously, and even unnoticed if the calculus is small, because, having passed through the ureter it can easily traverse the wider chan- nel of the urethra if it once engages in it. It is recom- mended by some writers that the patient should retain the urine until the bladder is quite full, and then, while compressing the urethra, should make an expulsive ef- fort, removing the pressure at the same moment, so that the outward current may sweep the calculus away. This manoeuvre may be repeated several times, but it is in most cases unnecessary, and may be resorted to only when the patient has felt the calculus engage at the ori- fice of the bladder and then fall back again. The third indication is to be accomplished by the use of agents which may modify the chemical character of the urine so as to prevent the formation of deposits, and thus protect against subsequent attacks. When the cal- culus consists of uric acid and urates, or even if this is not demonstrated, whenever the urine is very acid, the patient having had previous attacks of gravel, one of the alkalies, such as bicarbonate of potash, or one of the salts of lithia, should be administered for a few days until the urine becomes only moderately acid, or even neutral, when it may be withdrawn, and resumed if occasion should arise. In this way the further deposition of uric acid may be prevented, and it is even possible that small calculi of this substance may be dissolved in the bladder by keeping the urine slightly alkaline. The free use of water as a diluent is very serviceable, by preventing concentration of the urine. If the calculus is phosphatic in composition, and the urine is alkaline when first passed, it may be assumed that the deposit is due to this alkalinity, and the effort must be made to restore the urine to its normal acidity. This is not always as readily accomplished as is the con- verse task of rendering acid urine alkaline, yet by proper means good may often be effected. Benzoic acid in the form of benzoate of ammonia, dose gr x.-xv., three times a day, is probably the best agent for this purpose, as it is eliminated in the form of hippuric acid, and thus restores the acid reaction of the urine. Boracic acid has also an acidifying action, and may be given in the1 same dose : and as it has antiseptic properties it tends to lessen the suppuration in the urinary tract, which is frequently found associated with phosphaturia. If the alkalinity of the urine is persistent, the bladder may be washed out with a solution of boracic acid, five grains' to an ounce of water, or of sulphate of quinia, two grains to an ounce. When the urine contains much mucus, benefit may result from turpentine in doses of ten or fifteen drops three or four times a day. When the calculus proves to be oxalate of lime, or when crystals of that salt are found in the urine under the microscope, gentle saline aperients are advisable, to promote removal of mucus from the alimentary canal, and thus check the development of lactic and butyric acids ; for this purpose the Carlsbad salt, in the dose of a teaspoonful before breakfast, is effective. Dilute nitro-muriatic acid, in the dose of fifteen or twenty drops, three times a day, is believed to be useful in preventing the formation of the oxalic acid. As oxa- luria is generally connected with disturbance in primary or secondary digestion, the diet should be carefully regu- lated, and the digestion invigorated by mild bitter tonics, while at the same time oxidation should be promoted by exercise and change of air. Samuel C. Chew. GRAYSON SPRINGS. Location and Post-office, Gray- son Springs, Grayson County, Ky. Access.-From Louisville via Chesapeake, Ohio & Southwestern Railroad to Grayson Springs Station, sixty- seven miles; thence by stage to springs, two and a half miles. Analysis.-According to Dr. Peters, these waters con- tain chloride of sodium, sulphate of magnesia, phosphate of soda, sulphuretted hydrogen gas, and carbonic acid gas (Walton). Therapeutical Properties.-This is a popular sul- phur water among the inhabitants of the surrounding country. Hotel, Grayson Spring. G. B. F. GREENBRIER WHITE SULPHUR SPRINGS. Loca- tion and Post-office, White Sulphur Springs, Greenbrier County, West Virginia. Access.-By Chesapeake & Ohio Railway to White Sulphur Station. Analysis (Professor Hayes).-Fifty thousand grains of water contain ; Grains. Sulphate of lime 67.168 Sulphate of magnesia 30.364 Chloride of magnesium 0.859 Carbonate of lime 6.060 Organic matter (dried at 212°) 3.740 Carbonic acid 4.584 Silicates (silica 1.34, potash 18, soda 66, magnesia, and a trace of oxide of iron) 2.960 Total 115.735 One gallon (237 cubic inches) contains: Gas. Cubic in. Nitrogen gas 4.680 Oxygen gas 0.498 Carbonic acid 11.290 Hydro-sulph. acid 0.271 Therapeutic Properties.-This water has a high reputation for its beneficial effect in chronic diseases due to retarded or crippled action of the bowels, liver, kid- neys, or skin. Provision is made for hot and cold baths, and skilled medical attendance. This spring is situated on the western slope of the Apa- lachian chain, latitude 37|° North, longitude 3|° West from Washington, at an elevation above tide-water of 2,000 feet, and surrounded by mountains which tower 3,500 feet above the sea. The flow of water is thirty gallons a minute, not per ceptibly varying during periods of wet or dry weather. It has a constant temperature of 62° F. The climate is 385 Spri,,S8• REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. delightful and invigorating, cool mornings and evenings, and seldom oppressively warm. The thermometer ranges in summer between 60° and 75° F. Hotel accommoda- tions are ample and of the best. The Springs Hotel has a capacity for 2,000 guests, and there are several board- ing-houses in addition. The grounds are artistically cultivated, and the scenery of the surrounding region, commanding extensive views of the mountains of the Alleghany and Greenbrier ranges, is grand. History.-The curative properties of this spring were known to the Indians. As early as 1780 it began to be a health-resort, the visitors living in tents and log cabins. In 1857 the hotel was erected, and the grounds improved. It rapidly grew in favor, and soon became the favorite resort of the wealth and fashion of the South. Numbers of private cottages were built, and the springs increased in popularity till interrupted by the war. In 1880 the property changed hands. The new owners made exten- sive alterations and improvements, and the White Sul- phur bids fair now to surpass its past popularity. On the property is a chalybeate spring containing iron in the form of a carbonate. There are two churches within the grounds, and good schools are at convenient distance. Geo. B. Fowler. potash, lime, chlorine, alumina, silica, and traces of several other articles. These ingredients combined in the water form sulphate of lime, sulphate of magnesia, sul- phate of iron, protoxide of iron, carbonate of magnesia, carbonate of soda, bromide of potassium, chloride of po- tassium, chloride of soda, etc. One gallon of the water evaporated to dryness contains 216.48 grains of solid matter. The temperature of the water, 50° F., remains stationary summer and winter. Therapeutic Properties.-This is a mild sulphur water of established efficacy. Its use, in connection with the well-equipped and excellently managed sanitarium, has made this a deservedly popular resort. The spring flows from the foot of a large hill, at the rate of one hun- dred and thirty barrels per minute, forming a stream large enough to furnish power to a grist-mill. The water is of an emerald hue, but so translucent that small objects are visible at a depth of twenty feet. It is located in a natural park of about ten acres, which is diversified with glens and ravines, and is well shaded and laid out with walks. The average temperature of the locality is about 50.2° F., with an annual rainfall of forty-four inches. Churches and schools are easily accessible. The hotel is a four-story brick building, containing seventy sleeping- rooms. G. B. F. GREENCASTLE SPRINGS. Location, Putnam County, Ind.; Post-office, Limedale, Putnam County, Ind. Access.-By the St. Louis, Vandalia, Terre Haute & Indianapolis Railroad (Vandalia line), the Louisville, New Albany & Chicago Railroad (Marion route), and In- dianapolis & St. Louis Railroad (Bee line) to Greencastle. The first two lines cross at Greencastle Junction (P. O., Limedale). The springs are one mile south of Greencastle, and one-half mile north of Greencastle Junction. Analysis.-(E. T. Cox, State Geologist.) GREIFENBERG. An alkaline chalybeate spring in Upper Bavaria, on the shore of Lake Amm. The water is used chiefly for bathing, at the baths of Theresia, where peat-baths are also administered (Eulenburg). J. AL F. GREIFSWALD. Salt and peat baths in Pomerania, about a mile from the city of Greifswald, or Greifswalde, on a gulf projecting from the Baltic Sea. The city has about twenty thousand inhabitants, and is noted for its university, founded in 1456. There are in the immediate vicinity of the city numerous salt-springs, and strong peat- beds rich in iron. An analysis of the salt-water from the springs, made by Professor Schwanert, in 1878, reveals the following as the solid constituents of one pint: North or Daggy Spring, 56° F. Grains per gallon. Middle or Dewdrop Spring, 52° F. Grains per gallon. Carbonate of potassa .. 0.105 0.089 Carbonate of soda 0.119 0.085 Carbonate of magnesia. 5.642 6.405 Carbonate of protoxide of iron. 0.490 2.857 Carbonate of lime 17.465 14.267 Chloride of sodium .... 0.952 0.835 Sulphate of soda 0.161 0.119 Sulphate of magnesia.. 1.260 1.244 Alumina 0.189 0.090 Silicic acid 0.11'5 0.005 Loss and undetermined 0.112 0.274 26.600 26.270 Grains. Sodium chloride 230.762 Potassium chloride 0.752 Calcium chloride 10.276 Magnesium chloride 8.362 Magnesium bromide 0.195 Calcium sulphite 1.360 Calcium carbonate 1.641 Ferrous protoxide 0.408 Silicic acid 0.109 Partly combined carbonic acid 2.711 Small amounts of magnesium iodide and lithium chlo- ride. with traces of phosphoric and nitric acids. Total 256.576 In addition to these two there is another spring called the " South" or " Diamond" Spring, the water of which is similar to the above. The temperature is 51° F. Therapeutic Properties.-The water is a carbo- nated-alkaline chalybeate. It is alterative, tonic, slightly aperient, and diuretic. The following is from the report of the State Geolo- gist : " The geological formation of the place is subcar- boniferous and millstone grit, with outcrops of coal measures in the vicinity. There are excellent limestone quarries in the neighborhood, one being on the grounds with the springs. The ordinary drinking-water is satu- rated with carbonate of lime." The springs are in a beautiful valley in the blue grass and corn region of Indiana. Greencastle is the seat of De Pauw University. There are also public schools and churches of nearly all denominations. Hotels.-There are no accommodations at the Springs, but at Greencastle there are several excellent houses. G. B. F. New and well-equipped salt and peat bathing establish- ments have been erected, with drinking-halls and all con- veniences. A steamer also conveys visitors in twenty minutes to the pleasant strand bathing-places at Eldena and Wiek. The indications for the baths of Greifswald are the same as those of other salt and peat baths. J. M. F. GRENZACH. An alkaline mineral spring, about two miles from Lorrach, on the Rhine, worthy of notice, but little resorted to. In composition it resembles the water of Carlsbad, one pint containing : Grains. Calcium carbonate 4.759 Magnesium carbonate 0.015 Ferrous carbonate 0.783 Calcium sulphate 8.701 Sodium sulphate 24.952 Potassium sulphate 0.144 Magnesium chloride 2.150 Sodium chloride 14.558 Carbonic acid 1.635 GREEN SPRING. Location and Post-office, Green Spring, Sandusky County, O. Access.-By the New York, Chicago & St. Louis Rail- way, and Indiana, Bloomington & Western Railroad to Green Spring. Analysis.-According to the analysis made by Profes- sor O. N. Stoddard, of Miami University, Oxford, O., this water contains carbonic, hydro-sulphuric, and sul- phuric acids, sulphur, magnesia, soda, iron, bromine, Total 57.697 The waters are indicated in about the same classes of cases as are those of Carlsbad. J- M. F. GREOULX, or Greoux. A village in the Department of Basses Alpes, France, thirty miles southwest of Digne. 386 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Soin^1^ SprI"S8' Two springs are mentioned, the Old, or Gravier, and the New7. Both are warm (78° to 100° F.), and contain lime and sulphur, With a small amount of iodine and bromine, and a very large amount of sodium chloride ; total solid constituents, 19.28 grains in a pint; also some sulphuret- ted hydrogen gas. Indications.-The waters of Greoulx have been rec- ommended for the most part in the treatment of chronic skin diseases, syphilitic and rheumatic affections. Good accommodations are in readiness for visitors, and the re- sort is well patronized. The bathing facilities are excel- ent; inhalation rooms and swimming schools have also been added. J. M. F. etc., it is of very much less value. A fluid extract (Ertrac- tum Grindelia Fluidum, U. S. Ph.) is prepared, of which from two to four grammes may be given several times a day. Allied Plants.-Sunflowers, Thistles, etc. ; for the order, see Chamomile. Allied Drugs.-Turpentine, Cubebs, and various other oleo-resins. An artificial derivative from oil of turpentine, Terebene, has during the present year had a little reputation in " winter cough." IE P. Bolles. GROIN, MEDICAL AND SURGICAL APPLIED AN- ATOMY OF. The groin is the depressed part of the body between the belly above and the thigh below. Its limits are wholly artificial. A line drawn horizontally, the subject being erect, from the anterior superior spi- nous process of the ilium to the linea alba forms the su- perior limit of this region, while below, it may be defined by a line parallel to the former one, and extending from the pubis to the outer part of the thigh (R. B. Todd). In this article the writer proposes, for convenience of de- scription, to deal first with the groin above Poupart's lig- ament, and afterward with that portion of it below which corresponds with the upper part of Scarpa's triangle. The Groin above Poupart's Ligament.-Surface Marks.-The spine of the ilium, which can always be felt, even in very fat persons, is the starting-point of measurements of the length of the lower extremity, as well as an important landmark in the diagnosis of inju- ries of neighboring parts. A line drawn across the abdo- men from one anterior superior spine to the other is about the level of the promontory of the sacrum. The spine of the pubes may be felt in the male by invaginat- ing the scrotum on the forefinger and reaching the spine from beneath ; in the female by abducting the thigh so as to put the adductor longus muscle on the stretch, and following up that muscle to its origin just beneath the pubic spine. The spine of the pubes is a guide to the position of the external abdominal ring, which lies to its outer side and slightly above it. In most cases the exter- nal abdominal ring will admit the tip of the little finger, so that by examination it can be ascertained whether the ring is or has been occupied by a hernial protrusion. The diagnosis of femoral from inguinal hernia depends upon the relation of the neck of the sac to the pubic spine ; in femoral hernia it lies outside the spine, in in- guinal to its inner side. The pubic spine is nearly on the same horizontal line as the upper part of the great trochanter, the femoral ring lying in this line about one full inch external to the spine of the pubes. The direction of Poupart's ligament is indicated by a line drawn from the spine of the pubes to the anterior superior spine of the ilium-not a straight line, but one with a slight downward curve. The internal abdominal ring is situated half an inch above Poupart's ligament, at a point midway between the anterior superior spinous process of the ilium and the spine of the pubes. The deep epigastric artery runs up- ward just to the inner side of this spot, in the direction of a line inclining toward the umbilicus. The spermatic canal lying between the two rings has a. downward and inward direction, its length being one inch and a half. The spermatic cord may be felt as it emerges from the external ring. Of its component parts the vas deferens may be recognized by its feeling like a piece of hard cord when rolled under the finger. Through the skin the superficial epigastric vein is seen passing downward over Poupart's ligament to join the internal saphenous vein. Above, the superficial epigas- tric vein often joins another vein that passes up into the armpit to join the axillary vein, especially when there is obstruction to the flow of blood in the vena cava. (See Abdomen.) The skin of the groin derives its nerve-supply from the lower intercostal nerves and from the upper branches of the lumbar plexus, the abdominal wall above Poupart's ligament being supplied by the former. The hypogastric branch of the ilio-hypogastric nerve supplies a small area immediately over the symphysis pubis, while its compan- GRIESBACH. One of the so-called Kniebis baths, in a high mountain of the Grand Duchy Baden. Its eleva- tion is about sixteen hundred feet above the sea. Its cli- mate is mild and exhilarating. The following analysis indicates the amount of salts in one pint, from each of its five mineral springs, in grains : Ferrous carbonate Drink spring. Antonius. New (stronger). o 44 fl <11 £ £ 0.322 0.015 9.024 0.322 0.998 4.582 0.053 0.314 tij ■ a tn £ fl 0.245 0.015 7.033 0.645 0.238 3.333 0.138 0.353 0.599 0.023 12.216 0.688 0.245 5.967 0.099 0.345 0.468 0.023 12.572 0.245 0.184 5.6911 0.168 0.399 0.452 0.015 8.839 0.552 0.268 5.303 0.076 0.360 Manganese carbonate Calcium carbonate Magnesium carbonate Sodium chloride Sodium sulphate Potassium sulphate Silicic acid Total solids Free carbonic acid (cubic inches).... 23.930 36.608 22.356 35.929 21 826 25.975 16.172 21.214 14.545 23.824 The water from these springs is used both for drink and for bathing. Owing to the quiet, pleasant surround- ings of Griesbach, and its salubrious climate, it is recom- mended chiefly as a resort for anaemic and nervous inva- lids. J. M. F. GRINDELIA, U. S. Ph. ; "Rosin Weed." The leaves and flowering tops of G. robusta Nutt., order Composita, a large, coarse, and very resinous perennial herb, with elon- gated sessile leaves, large, glounlar flowering heads, cov- ered with resin, and spiny with the spreading sharp tips of the involucre scales, and yellow, partly radiate flowers. It is a variable plant, and the line of separation between it and G. squarrosa, which is collected for the same uses, is not distinctly to be made out. The drug has rather re- cently come into favorable notice, and appears in the pres- ent revision of the " Pharmacopoeia " for the first time. The officinal description is as follows: "Leaves about two inches (five centimetres or less) long, varying from broadly spatulate or oblong to lanceolate, sessile or clasp- ing, obtuse, more or less sharply serrate, pale green, smooth, finely dotted, brittle ; heads many-flowered ; the involucre hemispherical, about half an inch (twelve mil- limetres) broad, composed of numerous imbricated, squar- rosely tipped scales; ray-florets yellow, ligulate, pistillate ; disk-florets yellow, tubular, perfect; pappus consisting of about three awns of the length of the disk-florets ; odor balsamic; taste pungently aromatic and bitter." The leaves are very easily broken or rubbed off, and commer- cial samples often appear to consist principally of naked stems and heads. G. squarrosa, which is smaller and lighter colored, is probably frequently collected with it. The composition of the Grindelias is still incompletely known, but this one evidently has the three classes of principles common to the order, viz., an essential oil, resin, and some bitter substance. Action and Use.-The principal employment of Grin- delia now is as a stimulant expectorant in chronic and subacute bronchitis and in asthma, where it certainly seems to be useful. In whooping-cough, catarrh of the bladder, etc., as well as locally in ivy-poisoning, burns, 387 Groin. Groin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ion nerve, the inguinal branch of the ilio inguinal, is dis- tributed to the skin of the inner part of the groin as well as to that upon the scrotum and penis in the male, or la- bium pudendi in the female. The crural branch of the genito-crural nerve gives sen- sation to an area corresponding in outline to the inner limits of Scarpa's triangle. It must be remembered that the genital branch of the genito-crural is the motor nerve of the cremaster muscle, which explains the fact that re- traction of the testis occurs when the skin over Scarpa's triangle is irritated (cremasteric reflex). The remaining parts of the skin of the upper part of the thigh are supplied by branches of the external middle and internal cutaneous nerves. The Fascia of the Groin.-The subcutaneous fat, or superficial fascia, is a single layer over the greater part of the abdomen, but in the groin it is divided into two strata by the subcutaneous blood-vessels, the lymphatic glands, the ilio-inguinal nerve, and the hypogastric branches of along the spermatic cord up toward the abdomen, from which it cannot descend into the thigh owing to the at- tachment of this deep abdominal fascia to Poupart's liga- ment, and to the fascia lata, while its progress up the sur- face of the abdomen is uninterrupted. The (/lands of the groin are divided into two sets : a superior or horizontal and an inferior or vertical set, both of which lie above the fascia lata between the layers of the superficial fascia. The lymphatics from the integument of the lower part of the trunk, gluteal region, perineum, and the genital organs are received by the superior set of glands which lie in a direction paral- lel with that of Poupart's ligament; the vertical set, placed along the course of the internal saphenous vein to the extent of two or three inches below Poupart's liga- ment, receive the superficial lymphatics of the lower ex- tremity. Irritation, therefore, of these above-named parts will show itself in the nearest gland ; thus a chancre on the penis or scrotum, or a boil in the perineum, or ulceration on the surface of the abdomen, whether syph- ilitic or malignant, may cause a bubo in the horizontal set of glands ; while the common cause of enlargement of the vertical set is usually some such irritation as an in- flamed corn, or a poisoned wound of the lower extrem- ity. The external ab- dominal ring is the slitintheaponeuro- sis of the external oblique through which the sperma- tic cord makes its way from the testis over the bladder to the prostatic por- tion of the Urethra. It is therefore the external opening of the spermatic canal. At each side of the slit the fibres are some- what thickened, forming the pillars of the ring, of which the upper, or internal, is at- tached to the ante- rior surface of the symphysis pubis, the lower, or in- ternal, which be- comes continuous with Poupart's ligament, to the pubic spine. The external abdominal ring is about one inch long and half an inch wide. In the male the spermatic cord is seen emerging from the ring resting upon its lower margin, obtaining a covering as it passes outward from the inter-columnar fascia derived from the margin of the ring. This fascia forms a thin layer over the apo- neurosis of the external oblique, and connects together its parallel fibres. At the external ring these fibres extend over the cord, and form one of its coverings. Inguinal Hernia.-To properly comprehend the course taken by an inguinal hernia without having a clear idea of the descent of the testis is impossible, and to do so it is necessary to regard the testis as an abdominal organ. In fact, in foetal life the testicle was situated behind the peritoneum, on either side of the vertebral column, immediately below the kidney. Its duct ran in a direc- tion parallel with that of the ureter. The spermatic artery was derived from the nearest part of the abdomi- nal aorta, just beneath that which conveys the blood to the kidneys, and the spermatic veins entered, the right one into the inferior vena cava, the left one into the left renal vein. The lumbar glands received the lymphatic Fig. 1414.-Deep Dissection of the Region of the Groin. (After Leveille.) o. b. Anterior layer of the sheath of the rectus abdominis ; c, the rectus abdominis ; <1, pyramidalis; e, internal oblique muscle: f, lower part of the aponeu- rosis of the external oblique muscle forming the crural arch ; A, i, aponeurosis of the pec- tineus; j, i, of the psoas; k. Gimbernat's liga ment; r, sartorius muscle ; o, adductor lon- gus; p, the femoral artery ; q, femoral vein. Fig. 1413.-Nerve-Supply of the Groin and Surrounding Parts. (From Flower.) the ilio-hypogastric nerve. Of these the subcutaneous layer contains fat, therefore varying in appearance and thickness in different individuals, and is continuous with the superficial layer of the fascia of the thigh, and with that of the abdomen generally. Toward the middle line this layer is continued over the penis and scrotum, chang- ing its adipose tissue for involuntary muscular fibre, and joining the deeper layer, becomes continuous with the dartos of the scrotum and the deep layer of the super- ficial fascia of the perineum. The deeper layer of the fascia of the groin (Scarpa's fascia), thin and membranous, is intimately connected with Poupart's ligament and the linea alba. This layer is continued upward on the abdomen and downward and inward over the penis and scrotum, where it becomes identical with the deep layer of the superficial fascia of the perineum. Toward the thigh it joins the fascia lata a little below Poupart's ligament. When an extravasation of urine takes place into the perineum, the fluid is directed through the scrotum, and 388 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Groin. Groin. vessels of the testicle, while the spermatic plexus of the sympathetic was connected with the aortic, as well as with the renal, plexus. Thus the organ in all its connec- tions is abdominal. At the seventh month of foetal life the testicles enter the internal abdominal ring on their way toward the scrotum, and by the eighth month have reached their destination. Previously, however, to this descent the scrotum was lined with peritoneum, behind which the testis was dragged downward. Shortly before birth this scrotal sac of peritoneum closes, the communication be- tween scrotum and abdomen being thereby cut off. The sac, which by this process is left in the scrotum, sur- rounds the testis, forming the visceral and parietal layers of the tunica vaginalis. The vestiges of the neck of the peritoneal sac remain as connective tissue upon the cord which is formed by the duct of the testicle, its vessels, and nerves, all of which have been dragged down after it from its original position within the abdominal cavity. The coverings which the testis and cord gain in their descent become the coverings of a hernia, when such a protrusion occurs through the inguinal canal. The spermatic cord in the abdomen consists originally of the duct-vessels, nerves, and lymphatics above named, which descend with it. Passing through the internal abdominal ring, a covering is derived from the fascia transversalis to which the term infundibuliform fascia has been ap- plied. Then, as the testicle passes under the internal ob- lique, it derives partly from it a musculo-fibrous sheath, the cremaster, which supports the testicle. From the edges of the split in the external oblique there passes over testis and cord a thin fascia, called, from its origin, the intercolumnar fascia. The testis is next covered by the scrotal tissues, the dartos, and the skin. From with- out inward, therefore, the coverings are: 1. Skin. 2. Dar- tos. This layer is, it has been said, continuous with the superficial fascia of the groin, perineum, and inner part of the thigh, and forms a distinct sac for each testicle. In its structure there is a considerable amount of un- striped muscular tissue. 3. The intercolumnar or ex- ternal spermatic fascia. 4. The cremasteric fascia, which is made up of bundles of striped muscular fibre con- nected together by intermediate areolar tissue. 5. The infundibuliform fascia. 6. The tunica vaginalis. The skin of the scrotum is loose, thin, and of a darker color than that of the surface generally, and by the action of the muscular fibres of the dartos beneath it is readily thrown into rugae. The subcutaneous tissue, remarkable for the total ab- sence of fat, is very lax, allowing extensive ecchymosis to take place within its structure ; hence leeches should not be applied to the scrotum itself, but to the more firm region of the cord. From this laxity of tissue, as well as from its dependent position, it follows that the scrotum is al- most always the first part of the body to show signs of dropsical effusion. The dartos is a thin layer of a peculiarly loose reddish- brown tissue, which, owing to the presence of a consider- able amount of unstriped muscular tissue, is contractile. As has been stated (see Abdomen), the dartos is continu- ous with the superficial fascia of the groin, with the superficial fasciae of the perineum, and with the deep ab- dominal or Scarpa's fascia, connections which determine the course of extravasated urine. A distinct sac is formed for each testicle, these sacs being united along the middle line to form the septum scroti. The dartos is very vascu- lar, but, in spite of this, it readily sloughs. Treves men- tions a case where too tight strapping of a swollen testicle produced an extensive slough. It must be remembered that the testicle receives its blood-supply from the abdo- minal aorta, and that consequently injuries or diseases of the scrotum have no influence upon its vitality. Of the remaining coverings of the cord the most im- portant is the serous coat, the tunica vaginalis. Origin- ally formed from the abdominal peritoneum, it is now a shut sac, and, like serous membranes generally, presents a visceral and a parietal portion. In this thin sac serous effusion frequently occurs, constituting a hydrocele. If the process of the peritoneum be completely closed, as is normal, then the fluid distends the tunica vaginalis, the swelling lying in front of and above the testicle. Such a collection of fluid, completely shut off from the abdomen, should be easily distinguished from a hernia, the cord be- ing free between the tumor and the external abdominal ring. When the peritoneal process from the abdomen to the testes does not close completely, but allows the serous secretion of the abdominal cavity to enter the tunica vaginalis, a congenital hydrocele is said to exist. Infantile hydrocele resembles infantile hernia ; the peri- toneal protrusion remaining open at all but one point, the effused fluid will not pass into the abdominal cavity. In encysted hydrocele of the cord the peritoneal tube is ob- literated at a few points only, leaving along the cord one or more isolated serous sacs. Such a sac may at any time, but usually at puberty, become the seat of an effusion, Au elongated elastic tumor is produced in the course of Fig. 1415.-Superficial Dissection of the Groin, showing the Spermatic Cord emerging from the External Abdominal Ring under Cover of the Fibres of the Intercolumnar Fascia. The integuments, with Scarpa's fascia, have been reflected. (Photographed from a cast of a frozen dissection made by Dr. W. H. Fuller, formerly Demonstrator of Anat- omy in McGill College.) the cord, oval in form, above the testis and distinct from it, usually transparent, freely movable, dull on percus- sion. Impulse on coughing is absent, and though the tumor may be pushed some distance up the inguinal canal, it cannot be thoroughly reduced. The tunica albuginea is the fibrous capsule of the tes- ticle. Its firm, unyielding nature is the cause of the in- tense pain experienced in acute orchitis. For the relief of this symptom the tunic is sometimes punctured. The convoluted tubes of the epididymis are continued upward as a firm tubular cord, the vas deferens, which forms the essential part of the spermatic cord, and ac- companies it as far as the internal abdominal ring, where the vas and the blood-vessels part company, the former, crossing the external iliac vessels, turns around the outer side of the epigastric artery, and eventually reaches the prostatic part of the urethra. Varicocele is not only more frequently met with on the left than on the right side, but when present on both is usually more developed on the left. Most probably the 389 Groin. Groin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cause lies rather in the better development of the muscu- lar system on the right side, than in the fact that the left spermatic vein enters the renal at right angles, or that the sigmoid flexure on the left impedes venous return. (See Testes, Diseases of.) Vessels and Nerves of the Scrotum and Cord.-1. The two external pudic branches of the femoral reach the front and sides of the scrotum, supplying the integument and the dartos. 2. The superficial perineal branch of the internal pudic supplies the posterior part of the scro- tum. 3. The cremasteric branch of the deep epigastric is chiefly distributed to the cremaster muscle. 4. The artery of the vas deferens which accompanies the duct. Thus, it will be noticed that the scrotum has a blood-sup- ply entirely distinct from that of the testis. Sloughing of the scrotum, therefore, has no effect on the vitality of the testis. The veins take the same course as the arteries. Those of the cord join with those of the testis to form the pam- piniform plexus, the continuation of which enters the ab- domen, and passing behind the peritoneum joins the renal vein on the left side, the abdominal aorta on the right. The lymphatic vessels of the scrotum pass into the superficial inguinal glands. Irritation of scrotal tissue produces a bubo in the groin, while disease of the testis itself is followed by enlargement of the lumbar glands. The nerves of the scrotum and cord are derived from long, situated a little above and parallel to Poupart's liga- ment. Its outer end is called the external abdominal ring. This opening lies above and to the outer side of the spine of the pubes, and is triangular in shape, not round, as its name implies. On either side it is bounded by the margins of the slit in the external abdominal oblique muscle, which are called the internal and external pillars of the ring. In the female the ring is small, and transmits the round ligament of the uterus. The internal abdominal ring is the inner opening of the spermatic canal. It lies beneath the lower margin of the internal oblique, and through it the fascia transversalis is prolonged around the cord and testis. The ring is round or oval in shape, situated at a point midway between the spine of the pubes and the spine of the ilium, one-half inch above Poupart's ligament. Above and to the outer side the ring is bounded by the lower arched fibres of the internal oblique and transversalis, below and internally by the epigastric vessels. In its whole extent in front the inguinal canal is Fig. 1416.-Diagram of the Inguinal Canal, showing its Anterior and Posterior Boundaries. (From Heath's "Practical Anatomy.") .4, fascia transversalis; B, conjoined tendon ; C, triangular fascia ; D, internal oblique ; E, cremaster muscle ; F, external oblique muscle. various origins. 1. The ilio-inguinal nerve issues from the external abdominal ring to supply the skin of the scrotum. 2. The ilio-hypogastric gives a small twig to assist the ilio-inguinal. 3. The superficial perineal branches of the internal pudic nerve accompany the ar tery of that name, supplying the under and back part of the scrotum. 4. The inferior pudendal branch of the small sciatic nerve supplies the skin of the upper and inner part of the thigh, and outer part of the scrotum * (or external labium in the female). 5. The spermatic branch of the genito-crural nerve passes with the cord through the inguinal canal, supplying the fibres of the cremaster. The Inguinal Canal.-The inguinal canal is never a clear opening. It is merely the split made by the testicle in its descent through the abdominal walls, and which has been immediately closed up by the adherence of its walls to the cord. There is, therefore, no distinct canal, but the passage of the cord obliquely through the abdom- inal parietes leaves a place which can easily be dilated by the finger of the dissector. A hernia bulges out this space and forces its way through it. This so-called canal is one and a half or two inches Fig. 1-417.-Dissection of the Inguinal Canal, from Wood " On Rupture." a. External oblique turned down ; b, b, interna] oblique ; c, transver- salis ; d, conjoined tendon ; e, rectus abdominis ; f, fasoia transver- salis ; a, triangular fascia ; h, cremaster muscle; i. infundibular fascia. bounded by the external abdominal oblique muscle, and in its outer third by the internal oblique. This latter mus- cle passes over the cord, joins the transversalis, and then passes down behind it to the crest of the pubes. The ca- nal is, therefore, said to be bounded above by the arched border of the internal oblique and transversalis. Behind, the cord rests upon the fascia transversalis along its whole length, on the conjoined tendon, and for its inner third on the triangular ligament. Poupart's ligament bounds the canal below. Between the two rings, but close to the inner margin of the internal ring, the deep epigastric artery takes its course ; immediately below it lies the external iliac artery. Surgical Anatomy of Inguinal Hernia.-In many cases the tube of peritoneum which follows the testicle in its descent does not completely close, so that there exists al- ready formed a diverticulum of the peritoneum into which a portion of intestine can readily insert itself. Such hernise are called congenital, though they by no means * The distribution of this nerve is thus explained on physiological grounds by Mr. Hilton, in his Lectures on Rest and Pain. "Looking again at this inferior gluteal (small sciatic) nerve, we see a curious branch passing inward toward the perineum, and ultimately to the penis. Upon reflection, I think one may see physiological reasons, associated with coitus and the action of the gluteus maximus muscle, why a cutan- eous branch should go to this organ. This is a delicate subject, however, which I do not wish to dwell upon, but merely direct your attention to the fact." 390 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Groin. Groin. necessarily occur at birth. Congenital laxity of the walls of the abdomen, and the presence of an unusually long mesentery, are, in such cases, predisposing causes. Among the causes of acquired hernia are the various artery springing from the external iliac lies at the inner side of the neck of the hernia. Oblique inguinal hernia may occur in the female, but it is of very rare occurrence. The protruded viscus fol- lows the round ligament, and after emergence from the external abdominal ring enters the labium pudendi. The seat of stricture in oblique inguinal hernia is usually at the inner abdominal ring, but the protruded intestine may be arrested in the canal itself or in the outer open- ing. The Varieties of Oblique Inguinal Hernia.-It has been stated that hernia is almost always, if not always, of con- genital origin ; but there is a variety to which the term congenital is applied with a special meaning. In this form the sac of peritoneum which lined the scrotum did not close. The scrotum and abdomen are consequently but the one cavity, and the hernia drops directly into the scrotum. These her- niae not uncommonly show themselves very early in life. The abdominal cavity in the infant is distended ; the liver is large, the pelvis small, and constant crying tends to bring pressure upon the rings. But ifi the majority of cases protrusion of the viscus into a congenitally dilatable canal does not occur early in life. This same persist- ence of the opening between the scro- tum and the abdomen accounts for the occurrence of a form of congenital hydrocele. The fluid in the sac occu- pies the same position as would be occupied by a piece of protruded intestine, and can readily be made to flow back into the abdomen. The common form of hydrocele in infants is not, however, of this variety, but occurs in the same manner as that of adults, and tends to spontaneous absorption of fluid and recovery. The coverings of a congenital hernia are identical with those of the testicle. Infantile Hernia or Encysted Hernia of the Tunica Va- ginalis.-When the peritoneal sac, which originally com- municated between the abdominal cavity proper and the scrotum, remains open except at one point, a hernia may be driven into the still pervious upper part, and a sac be formed which is driven down past the point of constric- tion-in most cases behind it. The sac in such cases has in front of it three layers of peritoneum. There are no clinical characters by which such a hernia could be recognized from the ordinary congenital hernia above men- tioned. Direct Inguinal Hernia.-If the an- terior wall of the abdomen were to be examined from behind, there would be seen upon it several prominent lines which on each side run toward the umbilicus. Passing underneath the peritoneum, from the umbilicus to the fundus of the bladder, is the urachus. Outside the urachus are the obliterated hypogastric arteries, and outside these again the epigastric arteries take their course from the external iliacs in the direction of the navel. Between the prominences thus made there are cor- responding depressions on the surface of the peritoneum. The space bounded by the deep epigastric artery, Pou- part's ligament, and the rectus abdominis muscle, is called Hesselbach's triangle. This is divided into two parts by the prominence formed by the hypogastric artery. Into either of these parts the herniated viscus protrudes, push- ing the peritoneum in front so as to form a sac of it, as well as of the transversalis fascia which lies outside it. Next, the hernia protrudes and stretches, sometimes passes through, the conjoined tendon of the internal oblique and transversalis muscles. Now, this conjoined Fig. 1420.-Diagram of a Congenital Hernia, the Sac being Contin- uous with the Tunica Vaginalis Testis. (J. T. Gray.) Fig. 1418.-Deep Dissection of the Region of the Groin, showing the Internal Saphenous Vein, and the Saphenous Opening. The abdomi- nal muscles are reflected, showing the deep epigastric artery and vein, and the boundaries of the spermatic canal. From a cast of a frozen dissection made by Dr. W. H. Fuller. trades and occupations in which there is sudden muscular effort. Stricture of the urethra, stone, the presence of a tight prepuce, constipation, are all conditions predispos- ing to the development of a hernia, owing to the amount of straining of which they are the cause. It is more than probable that all herniae are of congenital origin. Oblique Inguinal Hernia.-1The course of an oblique in- guinal hernia downward from the abdomen to the scro- tum is precisely that of the testis. The protruding viscus follows the course of the cord, consequently passes through ex- ternal and internal abdominal rings, as well as the inguinal canal between them. The peritoneum overlying the internal ring is first forced into it, forming a cov- ering for the protrusion, which is called the sac of the hernia. After this, one by one the hernia assumes the coverings of the cord, which have been already enu- merated, and makes its way into the scro- tum. From without inward, the layers which must be divided in order to reach the interior of the sac are : (1) the skin ; (2) superficial fascia ; (3) intercolumnar fascia ; (4) cremasteric fascia ; (5) infundi- buliform fascia ; (6) subserous areolar tis- sue ; (7) peritoneal sac. The spermatic cord is usually found be- hind the hernia, except in those cases in which the strand-like components of the cord are spread out over it; but even when the scrotal tumor is of large size the hernia and its sac do not extend below the testis. The deep epigastric Fig. 1421.-Diagram of an Infantile Her- nia, Showing the Tunica Vaginalis Prolonged in Front of the Sac. (J. T. Gray.) Fig. 1419. - Dia- gram of a Com- mon Scrotal Her- nia, Showing the Relation of the Sac to the Tunica Vaginalis Testis. (J. T. Gray.) 391 Groin. Groin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tendon lies just behind the external abdominal ring. The hernia, therefore, pushes it through the ring. The tumor then derives from the pillars of the external ring and cov- ering the intercolumnar fascia. Its position is then un- derneath the superficial fascia and the skin. In short, the coverings of a direct inguinal hernia from without inward are : 1, the skin ; 2, the superficial fascia ; 3, the intercolumnar fascia; 4, the conjoined tendon ; 5, the fascia transversalis ; 6, subserous areolar tissue; 7, the peritoneum. How does a direct differ from an indirect or oblique inguinal hernia ? 1. The course of a direct inguinal her- nia is not that pursued in fcetal life by the testis. It does not enter the internal ring at all, though it passes through the external opening. 2. The coverings of the hernia differ. The direct hernia has a peritoneal sac, and also that derived from the transversalis fascia; but it gets no muscular covering from the internal abdominal oblique muscle, because instead of passing under its arched border it impinges upon its tendon, which it forces before it. The common variety of direct hernia passes internally to the obliterated hypogastric artery ; the external or rare variety protrudes between the hypogastric and epigastric arteries. This latter presents more the characteristics of an inguinal hernia, inasmuch as it passes through a con- siderable portion of the inguinal canal, and has almost the same coverings. The spermatic cord is usually found behind the outer part of the hernia. Inasmuch as only one of the cover- ings of the cord, the intercolumnar, covers the hernia, it is separated from the vessels of the cord by the interposi- tion of the remaining coverings, viz., the cremasteric fascia, and that derived from the transversalis fascia. The Groin below Poupart's Ligament.-Surface Marks.-Poupart's ligament may be felt at the bottom of the furrow formed by the flexion of the thigh upon the abdomen. Scarpa's space is represented by a trian- gular depression immediately below Poupart's ligament, bounded on its inner side by the strong round ten- don of the adductor longus, which can be felt leading up to the spine of the pubes. On the outer side of the space the sartorius muscle may be made evident by raising the leg across the opposite knee. The direction of the femoral artery is represented by a line drawn from a point mid- way between the symphysis pubis and the anterior supe- rior spine to the tubercle for the adductor magnus, on the inner side of the condyle of the femur. The opening in the adductor magnus is situated at the junction of the lower with the upper three-fourths of this line. The femoral artery, as it passes beneath Poupart's ligament, lies upon the psoas muscle resting on the pectineal emi- nence, against which it can be compressed in a direction backward against the pubes and the adjacent ileo-femoral articulation. The femoral vein in the upper part of Scarpa's triangle lies immediately to the inner side of the femoral artery. The anterior crural nerve lies one-quar- ter of an inch externally to the trunk of the common femoral. At a distance of about one and a half inch be- low Poupart's ligament the common femoral divides into its superficial and its deep branch. The course of the profunda artery is identical with that of the femoral. The lymphatic glands may sometimes be felt in thin sub- jects, more especially in children. The saphenous open- ing in the fascia lata is situated below the inner third of the crural arch, and about an inch and a half external to the spine of the pubes. A femoral hernia makes its first appearance at this spot. " A good way to find the seat of the femoral ring with precision is the following: Feel for the pulsation of the femoral artery on the pubes ; allow half an inch for the femoral vein ; then comes the femoral ring" (Holden). The head of the femur lies just below the central point of Poupart's ligament. Superficial Fascia.-The superficial fascia of the groin is divisible into two layers, a superficial and a deep, the former being similar to, and continuous with, the fascia covering the rest of the body. The lymphatic glands and the superficial blood-vessels and nerves lie between the two fascia*. Superiorly, the superficial fascia of the groin is not connected with Poupart's ligament, but passes over it to become the superficial layer of the abdominal fascia. Internally it is continuous with the dartos of the scrotum joining the deep abdominal fascia. This fascia is thin and loose, permitting extreme distention, as is seen in cases of femoral hernia, and allowing collections of pus to point on the surface in Scarpa's triangle. The deep fascia of the groin is not to be clearly de- fined, except at the part where there are most vessels and lymphatics, as on the upper and inner aspect of the thigh near Poupart's ligament. Here it overlies the saphenous opening in the fascia lata, and is attached to its margins, forming the cribriform fascia ; it is also connected with the sheath of the subjacent femoral vessels. The cribri- form fascia is that part of the deep fascia which overlies the saphenous opening, and is perforated by the superficial vessels of the groin. The term superficial crural arch is, in works upon hernia, commonly applied to what is better known as Poupart's ligament, which is formed of the lowest fibres of the aponeurosis of the external abdominal oblique stretching from the spine of the pubes to the anterior superior spinous process of the ilium. Poupart's liga- ment is curved with its convexity downward in the un- dissected body. At the innermost part of the attachment of the superficial crural arch to the spine of the pubes its deepest fibres are prolonged backward to be fixed to the Fig. 1422.-Diagram of the Sheath of the Femoral Vessels. 1, 1, Fascia transversalis: 2, internal ring: 3, crural arch reflected (Poupart's lig- ament) ; 4, sheath of the femoral vessels; 5, saphena vein. (From Holden.) innermost part of the ilio-pectineal line for a distance of nearly an inch. In this manner a triangular layer is formed, commonly called Gimbernat's ligament, the con- cave external border of which is free and forms the outer boundary of the femoral ring. The deep crural arch is a name given to some dense fibres which are found strengthening the transversal is fascia as it passes beneath Poupart's ligament to form the front of the femoral sheath. These fibres begin at the middle of Poupart's ligament, come over the vessels, and are inserted into the pubic spine and pectineal line behind the conjoined tendon of the transversalis and internal ob- lique. The deep crural arch is closely connected with the front of the crural sheath, and is of great importance by reason of the frequency with which it forms the seat of constriction of the neck of the sac of a femoral hernia. The saphenous opening in the fascia lata is ah aperture formed by the folding of that part of the fascia lata which is attached to the pubes over that part which is attached to Poupart's ligament, and through which there passes the saphena vein. The border of the opening toward the inner side of the thigh is not well defined, owing to the fact that the portion of fascia lata forming it crosses be- hind the femoral vessels, but the upper and outer border is very distinct, and forms one of the points of constric- 392 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Groin. Groin. tion of the neck of a femoral hernia, requiring in some cases division for its relief. The saphenous opening is closed by the cribriform fas- cia, which extends from the outer limit of the aperture to the fascia covering the pectineus muscle. The cribriform fascia is really that portion of the deep layer of the fascia of the thigh which overlies the saphenous opening. The sheath of the femoral vessels is formed in front by a prolongation downward of the transversalis fascia of the abdomen, while its posterior portion is formed by the iliac fascia. The union of these two fasciae forms a fun- nel, with its upper and large end toward the abdomen, and its smaH end under the saphenous opening, where it becomes lost in the coat of the femoral artery and vein. The femoral sheath is covered in front by the iliac, behind by the pubic portion of the fascia lata. On the interior the femoral sheath is divided into three separate compart- ments of which the two outer are occu- pied by the artery and the vein. The innermost, which is empty, is called the femoral canal. The upper end of the femoral canal opens into the ab- domen, and is called the femoral ring. In front it is bounded by Poupart's ligament, behind by the pubic bone, cov- ered by the pectineus, internally by Gimbernat's ligament, on its outer side by the femoral vein. The femoral canal is short, its upper end barely large enough to admit the tip of the little finger, while its lower and smaller end ter- minates in a point half an inch below Poupart's ligament. The Course and Coverings of a Femoral Hernia.-A femoral hernia usually pushes through the crural ring a prolongation of the peritoneum which forms its sac. Next in order it is customary to name the subserous are- olar tissue which forms the septum crurale described by Cloquet, but which is not seen in the course of ordinary dissections. The hernia now lies under the saphenous opening, with the sheath of the femoral vessels'and the cribriform fascia in front. These it pushes outward, and passing through the saphenous opening, ascends upon the iliac part of the fascia lata and the femoral arch. The remaining coverings are those derived from the sub- cutaneous cellular tissue and the skin. The neck of the sac is necessarily very small, no mat- ter how large the hernia may be. It is bound down and constricted by three unyielding structures : the iliac por- tion of the fascia forming the curved upper margin of the saphenous opening, the deep crural arch in front, and the ligament of Gimbernat on the inside. The neck of the sac has important relations to blood- vessels. At the outer side of the ring there lies the deep epigastric artery, which occasionally (see Arteries, Anoma- lies of) gives off the obturator artery in such a manner that that vessel surrounds the femoral ring. A pubic vein has been known to take the same course. When strangulation occurs, and the cutting operation for its re- lief must be performed, the stricture, in consideration of these conditions, should be divided toward its inner side, it being more safe to make several small incisions rather than one or two large ones. Femoral hernia is much more commonly met with in women than in men. The reasons of this difference are the greater capacity of the inguinal canal in the male, and the larger size of the crural ring consequent on the greater breadth of the female pelvis. Repeated pregnancies and the efforts of parturition predispose to tlie accident. Femoral hernia is never congenital. The Femoral Artery in Scarpa's Triangle.-The triangle of Scarpa corresponds to the depression to be observed below Poupart's ligament. The apex is formed by the junction of the Sartorius and adductor longus, the two muscles which form its sides, while the base is formed by Poupart's ligament. The floor of the space is formed from without inward by the sartorius, the ilio-psoas, the pectineus, and adductor brevis. The roof is formed by the fascia lata and integument, the inguinal glands, and the superficial vessels. Within the limits of the space are contained the femoral artery with its branches, the fem- oral vein with its tributaries ; externally to the vessel, at a distance of half an inch, there lies between the iliacus and psoas muscle the anterior crural nerve. The femoral ar- tery in the upper part of its course lies internally to the neck of the femur, and is quite superficial; but lower down, three or four inches from its origin, it is crossed by the sartorius muscle. At Poupart's ligament the femoral artery is large, as large as the external iliac of which it is the continuation ; but at a distance of about one and a half inch below Poupart's ligament it suddenly becomes much smaller, owing to the giving off of its largest branch, the profunda or deep femoral artery. The femoral vein lies close to and at the inner side of the femoral artery, enclosed in the same sheath. As the artery passes downward the vein inclines backward, so that at the apex of Scarpa's triangle the vein is entirely posterior to it. The anterior crural nerve is not enclosed in the femoral sheath, but lies external to it, a point of importance, for psoas abscess is guided in its course under the psoas fascia by the direction of the anterior crural nerve. In such a case the sheath of the psoas, in fact the muscle itself, is converted into a pus sac, and the abscess points in Scarpa's triangle to the outer side of the femoral vessels, though in some cases it has passed beneath the sheath and opened on the inner side of the thigh. Psoas abscesses do not always point in Scarpa's triangle. Erichsen saw a case in which, guided by the fascia lata, the pus ran down the leg as far as the foot, and opened by the side of the tendo- Achillis. The psoas muscle passes directly over the hip-joint, from which it is separated by a bursa. This bursa may, in rare instances, become inflamed, giving rise to a tumor over the joint of a " resisting, elastic, if not fluctuating, character" (Holmes). This bursa, too, may communi- cate with the cavity of the hip-joint ; by this path psoas abscess has been known to work its way into the articu- lation. Compression of the femoral artery may be conveniently practised just below Poupart's ligament, where the artery is resting between the psoas and iliacus, just over the pectineal eminence of the os pubis. (See Arteries, Com- pression of.) Ligature of the femoral artery may be performed either just below Poupart's ligament (the common femoral), or at the inner margin of the sartorius muscle at the apex of the triangle. In the former situation a longitudinal or oblique incision is made just in the course of the artery, the surgeon being careful to remove any inguinal glands which may overlie the vessel, as well as to avoid wound- ing the crural branch of the genito-crural nerve. The sheath of the vessels is then divided one inch below Pou- part's ligament, and the aneurism-needle passed from the inner side around the artery, so as to avoid wounding the femoral vein, which lies to its inner side. The superficial femoral artery is commonly tied at the apex of Scarpa's triangle at the margin of the sartorius muscle, a point which corresponds to the junction of the upper and middle third of the thigh. The parts divided are then the skin, the superficial and the deep fascia. The edge of the sartorius is then to be sought for and the mus- cle drawn a little downward, when the sheath is discov- ered, usually with a small branch of the anterior crural nerve resting upon it. The sheath of the vessels having been opened, the aneurism-needle is passed around the artery from the inside. R. L. MacDonnell. Fig. 1423.-Diagram of the Femoral Ring and the Saphenous Opening. The arrow is in- troduced into the femoral ring. (From Hol- den J 1, Crural arch ; 2, saphenous opening of fascia ; 3, saphena vein : 4, femoral vein ; 5, Gimbernat's ligament: 6, external abdom- inal ring : 7, position of the internal ring in dotted outline. 393 Grosswardein. Growth. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. GROSSWARDEIN. A number of sulphur thermal springs, situated about three miles from Grosswardein, Hungary. Their temperature ranges between 98.6° and 113° F. The waters are used both for drinking and for bathing. Internally they are recommended in the treat- ment of gout, chronic constipation, and enlargements of the liver and spleen. For bathing, the waters are used for the most part in the institutions bearing the names of the Bischof and the Felix, each affording ample facilities for modern modes of bathing. The mild climate of the re- gion adds also to the claims of these resorts. Analysis of the waters shows them to contain, in one pint: 1. Growth, of the Foetus.-The difficulty of determining the age of the human foetus, and of obtaining specimens certainly fresh and normal, has prevented our having any very definite information on this subject. Preyer has com- piled the following table of the length of the human em- bryo in centimetres : Lunar month. Toldt (200 obs.). Hennig (100 obs.). Hecker. First 1.5 (1.3) 3.5 0.75 Second 4.0 Third 7.0 8.4 4 to 9 Fourth :.. 12.0 16.2 10 to 17 Fifth 20.0 27.5 18 to 27 Sixth 30.0 35.25 28 to 34 Seventh 35.0 40.25 35 to 38 Eighth 40.0 44.3 39 to 41 Ninth 45.0 47.2 42 to 44 Tenth 50.0 (49.0) 45 to 47 Grains. Calcium carbonate. 4.500 Calcium sulphate 3.563 Sodium carbonate 6.812 Sodium sulphate 6.4117 Magnesium carbonate 0.560 Magnesium sulphate 5.637 Silicic acid 1.15!) If the absolute length at the end of each month is di- vided by the increase during that month we obtain what Preyer calls the relative growth. Hennig's figures give the following relative growth for each month : First, 1,000; second, 0.812; third, 0.523; fourth, 0.419; fifth, 0.410 ; sixth, 0.219 ; seventh, 0.124 ; eighth, 0.093 ; ninth, 0.069; tenth, 0.037. All the above data are obviously inexact. Toldt's are evidently cooked up, and not de- rived from observation ; nor do the lengths mean the same thing, for of the early stages the head and trunk only were measured; of the later stages the head, trunk, and legs. A falser and more misleading device for study- ing growth has never been put in practice. The foetus, too, being spirally coiled in early stages, cannot have its length determined accurately. Far better would it be to always determine the weight. The growth of the foetus in weight has been most inadequately studied, although the weight is the only available measure of the growth of the foetus as a whole. Hecker's data are perhaps the best. The weights are in grammes : Great numbers of people from the surrounding country come, as on a pilgrimage, to Grosswardein, every spring, for the cleansing of their blood. After drinking freely of the water and remaining in the baths almost constantly for forty-eight hours, they return home, at least mentally relieved. J. M. F. Total 28.728 GROUNDSEL (Senegon, Codex Med.). Senecio vulgaris Linn., order Composita {Senecionida), the common groundsel of Europe, is'a low-branched weed, with pinnat- ified and toothed, clasping, glabrous leaves, and many- flowered, rayless heads collected in corymbose clusters. It grows naturally in Europe, but has been introduced into the United States, where it is found in waste places, about gardens, etc. The leaves or the herb are used, col- lected while the plant is in flower and dried. They have a peculiar odor and a disagreeable, bitter, saline taste. Groundsel is an antiquated remedy, having been used as a vulnerary, in internal haemorrhages, and also as an emmenagogue and cholagogue, for all of which purposes it probably has no value. It can be taken, if desired, in decoction, quite freely. Allied Plants, Etc.-The genus is an enormous one. Several pretty species occur among our wild flowers. Their properties are probably those of Composita in gen- eral (tansy, arnica, etc.)-bitter aromatic, and in large doses stupefying. A number of species are used in vari- ous parts of the world as vulneraries; one, S. canicida, is said to be very poisonous. For the order, see Chamo- mile. W. P. Bolles. Month. Maximum. Minimum. Average. Third.... 20 5 11 Fourth .. 120 10 57 Fifth .... 500 75 284 Sixth .... 1.280 375 (W4 Seventh . ... 2,250 780 1.218 Eighth .. ... 2,438 1.093 1,569 1,971 Ninth ... ... 2,906 1.500 Tenth ... 1,562 The range of the maxima and the minima suggests that errors in the determination of the ages may have oc- curred-such errors of a month are not rare with obste- tricians. Appended here are Hecker's data as to the weight of the placenta in grammes, and the length of the umbilical cord in centimetres: GROWTH. This article is divided for convenience into four sections : I. Human growth, statistically consid- ered ; II. The laws of mammalian growth ; III. Growth as a function of cells and tissues-in this section is in- cluded a short discussion of the principles of growth and a brief notice of the theory of death ; IV. Definition of growth. I. Growth of Man.-We know very little concerning the earlier period of the growth of man, since the growth of the foetus and of the infant has been but little studied. We have numerous observations on the weight of the child at birth, and on the growth from the fifth to the twentieth year (during the school age); some on the growth up to twenty-five years, referring chiefly to the upper classes (college and university students), and valuable statistics of men in armies have been compiled. As regards the growth and size of man, American investigations easily lead, for the anthropometric work of Gould and Baxter, and the researches of Bowditch, on Boston school chil- dren, have never been approached in value. Peckham's work in Milwaukee is also excellent. Quetelet, the pio- neer in this field, pursued an erroneous method, which led him to false conclusions, which are, nevertheless, still currently cited, especially in Europe. We divide the subject as follows: 1, Growth of the foetus ; 2, weight of the new-born child ; 3, growth of infants, 0 to 5 years ; 5, growth of children ; 6, size of adults. Third. . Month. No. of obs. 3 Placenta. 36 Cord. 7 Fourth.. 17 80 19 Fifth ... 24 178 31 Sixth. . .. 14 273 37 Seventh . 19 374 42 Eighth.. 32 451 46 Ninth ... 45 461 47 Tenth .. 62 481 51 2. Weight of the New-born Child.-It is subject to very considerable variations. For middle Europe the average may be held to be about 3,340 grammes for boys, 3,190 for girls, the latter being somewhat lighter. The varia- tions are very great, ranging from 1,000 to 5,000 grammes. For instance, the following table is given by Pfannkuch, who unfortunately jumbles the two sexes together : Kilos. Obs. 1.50 to 2.0 23 2.00 to 2.25 36 2.25 to 2.50 52 2.50 to 2.75 90 2.75 to 3.00 110 Kilos. Obs. 3.00 to 3.25 150 3.25 to 3.50 115 3.50 to 3.75 79 3.75 to 4.00 40 4.00 to 4.50 13 It will be noticed that the maximum number of cases (150) falls between 3.00 and 3.25 kilos., and that the further the weight is removed on either side, above or below, from this mean, the fewer are the cases. The tables by other au thors show the same general results, with usually slight differences in the quantitative values. For the most part these tables cannot be combined with one another, for they 394 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gro«»wardeiu. Growth. nearly all fail to fulfil some obvious requirement of good statistics; indeed, amateur statistics are generally provoking to the expert. It is, therefore, not desirable to attempt an analysis of the recorded data. As an ex- ample of statistics at once valuable and grossly defective, the following table is given after Siebold. The author gives the weights in pounds, but has neglected to say, as is necessary in Germany, what kind of pounds, hence the metric equivalents cannot be calculated. Moreover, the number of cases weighing even pounds and half-pounds is far in excess of those weighing pounds, and one-fourth or three-fourths, which shows inaccurate weighing, of course. To correct this the quarter-pound groups of the original table are condensed into half-pound groups : 1885) that the compilation of three hundred and thirty- three observations show that the children of women whose first menstruation is early are larger than the children of those whose first menstruation is late. Fifth and sixth, the influence of race and climate, which have not yet been subjected to any proper exact study. In conclusion, I may add that it seems to me probable that all these influences produce their effect principally by prolonging or abbreviating the period of gestation. In other words, the variations in the weight of children at birth are to be referred immediately to two principal causes: 1, Differences in the age at birth; 2, individual differences of the rate of growth in utero. 3. Growth of Infants.-(a) Alteration in weight during the first week. There is an interruption of the normal rate of growth during a few days after birth, both in man and other mammals, cf. § ii. It lasts for a variable period, and is variable in degree. In most cases, with the human species, it is so great as to cause an actual loss of weight, but frequently it shows itself only as retarded growth. A great many authors have written upon this subject, but there is not a single one who appears to have correctly understood the statistical relations. In fact, the discus- sion thus far has turned upon the question whether a loss or a gain of weight is normal and physiological. That question is of little importance, since it is now settled that the retardation of growth is constant. It depends on the degree of retardation whether there is merely a small gain or an actual loss. During the first month the aver- age daily increase is about thirty-five grammes (Fleisch- mann), but during the first two or three days, or sometimes more, the rate of increase is very much less, often even negative. Gregory, for instance, gives the following data: Weight in lbs. Boys. Girls. 4.0 to 4.5 4 10 19 24 5.0 to 5.5 44 5.5 to 6.0 .... 172 195 6.0 to 6.5 .... 220 235 6.5 to 7.0 .... 353 353 7.0 to 7.5 .... 286 240 Weight in lbs. Boys. Girls. 7.5 to 8.0 ... 286 200 8.0 to 8.5 .... 101 44 8.5 to 9.0 79 42 9.0 to 9.5 .... 15 14 9.5 to 10.0 7 2 10.0 to 10.5 1 10.5 to 11.0 1 The extremes recorded in medical literature are very far apart, and statements of excessively large size are by no means rare, but can be received with incredulity only, as, for instance, the case reported of a still-born child weighing 8,250 grms.! (Berlin. Klin. Wochenschr., 1878, No. 14). Vierordt gives as the accredited extremes 717 grms. (Ritter), and 6,123 grms. (Wright). The factors which determine the weight at birth are very obscure. It is, of course, safe to say, vaguely, that it depends on the nutrition of the foetus ; it is probable that individual differences in the rate of growth exist be- fore as well as after birth, and it is probable that the length of gestation is the most influential single factor, to judge from my own experiments on the growth of mam- mals. It has been demonstrated that the variations in the weight of the child depend upon various maternal cir- cumstances. First. It is correlated with the age of the mother, as is shown in the following table, giving the weight of the children in grammes according to three observers : Day 1 2 3 4 5 6 Number observed 33 33 33 33 33 33 Weight change, grammes .... -139 -64 +33 +50 +50 +36 The retardation of the growth is prolonged by defec- tive nutrition, of which the cause may lie either in the mother or the child, and by illness of the child. A healthy baby ought to get back to its initial weight by the sixth or seventh day, and failure to reach the initial weight by the ninth day may be taken as an indication of illness. The cause of the post-natal retardation is not fully elucidated. That it is not due to the mother's condition is shown by two considerations : 1, The retardation occurs also in chicks at hatching, although they are not dependent on the parent for nutrition ; 2, Ingerslev put sixteen chil- dren, just born, to wet-nurses, who had borne four to live days previously and gave abundant milk, nevertheless the children all lost weight. It seems probable that the loss is due to the establishment of respiration, and the in- creased expenditure (metabolism) of the body to maintain the normal temperature. During gestation and incuba- tion the parent supplies caloric to its young, but after birth (or hatching) the young is self-dependent, and rapidly wastes its tissues to keep up its body-warmth. (6) For the growth from the first to the fifty-second week we must depend chiefly on-1, the careful compilation given by Meek and quoted by Vierordt, in which, how- ever, neither the sex, nutrition, race, nor social condition of the children are considered, all factors which have a very great influence on the weight; 2, the observations of Albrecht (Central Ze it u ng f. Kinderheilkunde, 1879, No. 7), who followed the growth of eighty children at Berne. From Meek the following data are excerpted : Age of the mother. Ingcrslev. Fassbender. Petersson. 15 to 19 years 3,241 3,271 3,451 20 to 24 years 3,299 3,240 3,485 25 to 29 years 3,342 3,333 3,591 30 to 34 years 3,375 3,367 4,062 35 to 39 years 3,428 I 3 292 -j 3,591 40 to 44 years 3,326 3,676 From such tables we learn that very young mothers have the smallest children, and those of about thirty-five years the heaviest. It is much to be regretted that the tables do not show the correlation by single years, and also the number of observations. Second. The weight of the child increases with the weight (Gassner) and length (Frankenhauser) of the mother. Gassner states that the weight of the child is to that of the mother as 1 to 19.13, or 5.23 per cent, of the maternal weight. Frankenhauser states that if the height of the mother is less than 4 feet 6 inches, the child weighs 6 lb. 15 oz.; if it is 4 feet 6 inches to 4 feet 11 inches, the child weighs 6 lb. 25 oz.; if it is more than 4 feet 11 inches, the child weighs 7 lb. 3 oz. Third. The weight of the child increases according to the number of previous pregnancies, as indicated by the following table: Number of pregnancies. (Hecker.) Grms. (Ingerslev.) Grms. One 3,201 3,330 3,254 Two 3,391 Three 3,353 3,400 Four 3,300 3,424 Five 3.412 3,500 Six 3,353 Week. No. of ob- servations. Weight, grms. First .... 22 3.228 Second . 25 3.367 Third .... 31 3,412 Fourth .... 31 3,532 Seventh .... 33 4.103 Tenth .... 34 4,600 Thirteenth. ... .... 36 5,022 Sixteenth .... 34 5.529 Nineteenth ... .... 32 5.864 Twenty-second .... 26 6,497 Twenty-fifth.. .... 23 6,925 Week. No. of ob- Weight, servations. grins. Twenty-eighth .... 21 7,187 Thirty-first.... . 19 7,524 Thirty-fourth . .... 19 7,842 Thirty-seventh .... 18 8,126 Fortieth .... 17 8,344 Forty-third.... ... 17 8,583 Forty sixth.... .... 17 8,760 Forty-ninth ... .... 15 8,995 Fiftieth 9,102 Fifty-first .... 14 9,198 Fifty-second .. .... 8 (10,172)? Here again we encounter faulty statistics, for it is not shown that we have any other effect than that of age, for the conclusion claimed cannot be established until it is proved that primiparte have smaller children than multi- para; of the same age. Fourth, Negri has maintained (Annali di obstetricia, Albrecht states that in his experiments, taking the weight of the child at 3,300 grms. at birth, the fol- 395 Growth. Growth, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lowing is the average daily increase for each month in grammes : twelve and one-half in boys ; 2, the period of pr®-puber- tal acceleration, when the growth is much more rapid, lasting in girls from eleven to fourteen or fifteen, in boys from twelve and one-half to sixteen and one-half ; 3, the post-pubertal decline. In girls the pr®-pubertal accelera- tion begins earlier and is more marked than in boys ; hence, though during childhood girls are smaller than boys, yet from twelve to fifteen they outstrip them, and are both taller and heavier than boys of the same age. Puberty ensues later in boys than girls. The post- pubertal falling off in growth is more rapid in girls than boys ; accordingly, after the fifteenth year boys gain fast over the girls. That the acceleration is really pr®-puber- tal is shown by the fact that the age of the first catamenia Month 1 23456789 10 11 12 Grammes 30 29 29 24 20 18 14 11 11 9 8 7 The corresponding figures by Bouchaud are : Month 1 2 3 4 5 6 7 8 9 10 11 12 Grammes 25 23 22 20 18 17 15 13 12 10 8 8 By Fleischmann : Month 123456789 10 11 12 Grammes 35 32 28 22 18 14 12 10 10 9 8 6 The individual variations are very great, and the growth of any individual goes by fits and starts. A considerable delay in growth is not important, even if lasting for several, say three or four, weeks, as it is counterbal- anced by a subsequent excessively rapid growth. (c.) Concerning the Growth from the End of the First to the End of the Fifth Tear.-No statistics suf- ficiently extensive and accurate to be worth quoting are known to me. Quetelet's, which are often repeated, are misleading, because he weighed only children which in his judgment were well devel- oped ; hence, his figures do not give a true average of anything except Quetelet's notion of what a child ought to be, which is now definitely known to be essential- ly different from what children are. 5. Growth of Children.-Con- cerning school children we pos- sess a good many valuable data. The best statistics by far are those of Bowditch. The average weights obtained by him are given in the accompanying table in kilo- grammes ; the clothes make up about eight per cent, of the weights as given. The average standing heights, without shoes, is given for both sexes in the same table. These data refer to nearly twenty-five thousand meas- urements on the school children of Boston, Mass. Fig. 1424,-Graphic Representation of the Growth of Boston School Children, based on the whole num- ber of Bowditch's observations, irrespective of nationality of parents. averages in Boston about fourteen and one half years, so far as determined by the present imperfect statistics. Pagliani has proved the same relation in Italy. IMost conclusive is the record of the growth of individuals, which demonstrates that the first menstruation is pre- ceded by rapid, and followed by slower, growth. Dr. Bowditch has shown, also, by his statistics that the children of American-born parents are, in the community of Boston, taller and heavier than children of foreign- born parents, a superiority which depends probably chiefly on the greater average comfort in which such children live and grow up, and partly upon differences of race and stock. The children of the well-to-do classes are taller and heavier than those of poorer classes. Amer- ican (Boston) boys are taller for their age than English boys, concerning whom we have statistics, and are also heavier in proportion to their height ; the comparison holds between the laboring classes and the upper classes both, as well as between boys taken without distinction. Incidentally it may be said that the popular conception of a " Yankee," as tall and slim, has no foundation in life, the Yankee, on the contrary, being stouter than the Eng- lishman. In general it may be said that growth is favored by healthful conditions ; it is impaired by illness, probably, of any kind, but, of course, by some diseases much more than by others. It is favored by country more than by city life ; by out-door more than by sedentary occupa- Boys. Girls. Age. Height in ctms. No. of obser- vations. Weight, kilos. Height in ctms. No. of obser- vations. Weight, kilos. 5 to (i years.... 105.6 848 18.64 104.9 605 17.99 6 to 7 years.... 111.1 1,258 20.49 110.1 987 19.63 7 to 8 years.... 116.2 1,419 22.26 115.6 1,199 21.53* 8 to 9 years.... 121.3 1,481 24.46 120.9 1,299 23.61 * 9 to 10 years.... 126.2 1,437 26.87 125.4 1,149 25.91 10 to 11 years.... 131.3 1,363 29.62 130.4 1,089 28.29 11 to 12 years.... 135.4 1,293 31.84 135.7 936 31.23 12 to 13 years.... 140.0 1,253 34.89 141.9 935 35.53 13 to 14 years.... 145.3 1,160 38.49 147.7 830 40.21 14 to 15 years.... 152.1 908 42.95 152.3 675 44.65 15 to 16 years.... 158.2 636 48.56 155.2 459 48.12 16 to 17 years.... 165.1 359 54.90 156.4 353 50.81 17 to 18 years.... 168.0 192 57.84 157.2 233 52.41 18 to 19 years.... 169.3 84 60.13 157.3 155 52.24 Growth of Boston School Children. * In Bowditch's tables, as printed, incorrect numbers are given. The results are more easily followed in the graphic rep- resentation. Fig. 1424; the ordinates represent the heights or weights, the absciss®, the ages. We can distinguish three periods : 1, the steady growth of childhood, up to ten and one-half or eleven years in girls, to twelve or 396 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growth. Growth. tions; by summer more than by winter; by vacation more than by attendance on school. A considerable body of statistical material on these and similar points is avail- able, but unfortunately it is much scattered and has never been collated. The growth of the organs calls for much further in- vestigation. At present we can only compare the adult with the new-born child, but even of these the data are few. From Vierordt's compilation the following table is taken : Table of Ages and Corresponding Heights (without Shoes) of 190,621 American-born White Men found Fit for Military Ser- vice. Age. Number of observations. Height. Inches. Metre. Under 17 years 468 64.11 1.6284 17 years 937 65.67 1.6675 18 years 30.456 66.39 1.6863 19 years 14.994 67.07 1,7036 2(1 years 11,526 67.51 1.7148 21 years 14,146 10.479 67.78 1.7216 22 years 67.92 1.7252 23 years 8.907 68.01 1.7275 24 years 7,335 68.02 1.7277 25 years 7.940 68.05 1.7285 26 years (>,986 68.09 1.7295 27 years 6.351 68.11 1.7300 28 years 6,033 68.13 1.7305 29 years 4,447 68.17 1.7315 30 years 6.256 68.18 1.7318 31 years 5.562 68.20 1.7323 32 years 4.635 68.20 1.7323 33 years 3.939 68.29 1.7346 34 years 2,782 68.35 1.7361 35 years 4,966 68.47 1.7391 36 years 4,138 68.28 1.7343 37 years 4,172 68.26 1.7338 38 years 4,014 68.24 1.7333 39 years 3.402 68.23 1.7330 40 to 45 years 15,750 68.23 1.7330 New-bobn Child. Adult. Weight in grammes. In per cent, of the body weight. Weight in grammes In per cent, of the body weight. Skeleton 445 16.7 11,560 15.35 Muscle 625 J 23.4 i 1 .... f 29,880 J 43.09 Tendon Skin 337 1L34 4,011 2.37 brain 8.0 Suprarenals 8.5 0.31 0.014 Thymus 9.4 0.54 5.0 0.0086 Thyroid 6.5 0.24 29.1 0.05 Lungs 2.16 2.01 Heart 0.89 •••••• 0.52 Liver 4.39 2.77 Kidney 0.88 0.48 Alimentary canal. 2.53 2.34 These tables show that it is necessary to be extremely cautious in fixing upon any year to mark the adult age, for the cessation of growth is so gradual that its ending cannot be determined. In practice, it is convenient and sufficiently accurate to call twenty-five the adult year ; for women it ought probably to be somewhat less. That the tables are far from what we could wish, is true, chiefly owing to the inherent defects of the original ob- servations ; we must also regret that Baxter did so much less than his material would have permitted. But, on the other hand, both Baxter and Gould are far in advance of their predecessors. Anthropometry has been much writ- ten upon. Baxter gives an excellent review of the sub- ject, with sketches of the many mystical laws announced by older authors upon human proportions, but we still lack a good general treatise upon vital statistics. II. The Laws of Mammalian Growth.-Growth is a subject as yet but little investigated, and this section is based on my own unpublished experiments, made chiefly on guinea-pigs, but including also rabbits and chickens. The weights in grammes and the percentages are from different authors. There are certain observations on the growth of organs, notably by Lorey, Frerichs, Bischoff, Bambeke, and Thoma, but the number of cases heretofore recorded is so small that no satisfactory statistics are pos- sible. It would be very interesting to know how the chemi- cal composition of the body changes with age, and it is to be hoped that we shall soon have complete analyses of bodies at various ages. 6. Size of Adults.-No available statistics in regard to women are known to me, those referring to men, and taken from armies are very extensive; the best worked out are the data in regard to the American army, as dis- cussed by Gould and Baxter. The former had the ma- terial collected by the Sanitary Commission during the Rebellion; the records were hastily and inaccurately made by the single States, but the number of observations was so large that the errors may have corrected them- selves to a considerable extent. Baxter, whose material was much more extensive and reliable, has not thought it worth while to tabulate the weights in proportion to age, but gives good tables of the stature. Gbowth of Male Guinea-pigs. Age. Number of observa- tions. Average weight. In crease over last measure- ment. Average daily in- crease. Daily per cent, in- crease. Grammes. Grammes. Grammes. Grammes. 0 day .. 200 70.8 Ito 3 days.. 138 70.8 i.o 6.6 6.6 4 to 6 days.. 133 82.6 11.8 3.9 5.6 7 to 9 days.. 142 96.2 13.6 4.5 5.5 10 to 12 days.. 148 109.7 13.5 4.5 4.7 13 to 15 days.. 150 126.2 16.5 5.5 5.0 16 to 18 days.. 152 141.7 15.5 5.2 4.1 19to 21 days.. 151 158.4 16.7 5.6 3.9 22 to 24 days.. 152 173.2 14 8 4.9 3.1 25 to 27 days.. 145 187.8 14.6 4.9 2.8 28 to 30 days.. 141 203.8 16.0 5.3 2.8 31 to 33 days.. 140 215.6 11.8 3.9 1.9 34 to 36 days.. 136 226.9 11.3 3.8 1.7 37 to 39 days.. 129 240.2 13.3 4.4 1.9 40 to 50 days.. 149 272.9 32.7 3.0 1.2 55 to 65 days.. 155 327.1 54.2 3.6 1.3 70 to 80 days.. 155 383.9 56.8 3.8 1.2 85 to 95 days.. 152 434.4 50.5 3.4 0.9 100 to 110 days.. 102 481.6 47.2 3.1 0.7 115 to 125 days.. 75 522.8 41.2 2.7 0.6 130 to 140 days.. 67 529 8 7.0 0.5 0.1 145 to 155 days.. 72 562.9 33.1 2.2 0.4 160 to 170 days.. 75 590.5 27.6 1.8 0.3 175 to 185 days.. 76 604.7 14.2 0.9 0.2 190 to 200 days.. 70 627.0 22.3 1.5 0.2 205 to 215 days.. 61 663.3 36.3 2.4 0.4 8 months 672.0 8.7 0.3 0.05 9 months 53 737.7 65.7 2.2 0.3 10 months 56 761.6 23.9 0.8 0.1 11 months 68 770.3 8.7 0.3 0.04 12 months 68 793.9 23.6 0.8 0.1 13 months 66 754.9 -39.0 -1.3 -0.2 Age. No. of obser- vations. Weight, lbs. 16 216 121.03 17 .... 446 128.02 18 1,100 183.93 19 . ... 1.150 137.05 20 1.357 141.38 21 .... 1,446 143.06 22 1,351 143.60 23 1,108 144.31 24 .... 1,059 146.31 25 745 146.84 26 599 147.05 27 551 146.93 28 512 147.21 29 386 145.51 30 395 147.62 31 ... . 242 147.65 32 298 146.00 33 225 148.53 34 225 148.29 35 339 145.57 Gould's Table of the Mean Weights of White Soldiers. Age. No. of obser- vations. Weight lbs. 36 .... 184 149.29 37 .... 167 148.81 38 .... 153 147.22 39 123 146.38 40 .... 98 150.01 41 .... 61 146.30 42 .... 102 146.97 43 ... 73 145.62 44 .... S3 152.79 45 147.06 46 .... 37 146.97 47 .... 19 145.05 48 .... 35 146.S2 49 .... 10 145.19 50 . .. 21 138.06 51 .... 12 144.25 52 .... 10 139.49 53.. 11 151.15 54 .... 8 159.60 Over 54 .... 20 143.49 From this table the increase in weight is seen to con- tinue up to about the thirty-fifth year, but the figures of the weights are irregular after the number of observa- tions falls below 600. That the period of growth reaches to this age is more clearly shown by Baxter's table of the height at different ages. 397 Growth. Growth. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The preceding table summarizes the most important gen- eral results of these experiments ; the table refers only to male guinea-pigs, it not being necessary to include the females or other animals. The last column but one shows that the daily increase during the first three days is zero. This is due to the post-natal retardation, which is very marked in guinea- pigs, as it is also in man. The exact data are : second addition takes only 1.5 day ; the succeeding ad- ditions occupy increasing periods, overlooking slight ir- regularities. In other words, the older the animal the longer it requires to add ten per cent, to its weight. In this table, also, we see the decline progressing during the so-called period of development. The same law of decline holds true of rabbits and chick- ens, and also of man. In man there is a very noteworthy modification, produced by the very marked prae-pubertal acceleration of growth, during which the decline is inter- rupted, as shown by my calculations from Bowditch's tables; but compared with the whole course of decline the interruption is but slight, and is counterbalanced by an over-rapid post-pubertal decline. No essential importance is to be assigned to this phenomenon, since it is well known to embryologists that during development there are often displacements in time and in the growth of individuals. I observe that an accidental quickening or slowing of growth is followed by a reverse period, in the first case of slowing, in the second of quickening. There appears, therefore, no objection to the conclusion that in man also the period of apparent development is a period of real decline. This leads us to the corollary that the stoppage of growth is not due to the reaching of maturity, but is merely the final term of a series of losses. It has been asserted by Herbert Spencer, Carpenter, and others, that there is an inherent opposition between growth and re- production, because the assimilative processes cannot perform enough to supply material for the growth of mother and offspring both. These authors and tl^ir fol- lowers see in the commencement of reproduction the be- ginning of a tax upon the organism which stops it£ growth; but as Minot has pointed out, the cause is mis- taken for the effect, and probably the loss of vital force is the stimulus causing reproduction. Certainly the de- cline, which goes on from birth, cannot be caused by a phenomenon which begins only when the decline is nearly completed. Direct observations show that Spencer's view is erroneous, for growing guinea-pigs will bear one-third of their own weight of young while growing, and still reach as full an adult size as those producing no young (Hensen). My own experiments suggest that they be- come even larger. We thus learn that the fundamental conception on which Spencer's theory rests is imaginary -that conception being, that the assimilative power is ap- proximately equal only to the needs of the growing ani- mal. In reality there is a large excess of assimilation possible within normal limits. The next point to be noticed is that animals tend, as they grow, to approximate to the special size of the spe- cies. This shows itself by the fact that the range of va- riation is less for adults than for the young. The follow- ing table shows this : The first column gives the age ; the second column gives the average variation above the mean weight for that age, the variation being expressed as a percentage ; the third column gives the variation be- low the mean-averages being based on 4,200 observa- tions in all : Weight. Grammes. Increase. At birth 70.8 One day 68.9 -1.9 Two days 70.0 1.1 Three days 73.4 3.4 Four days 77.3 3.9 The daily gain slowly increasestill about the fourteenth day, and then slowly but steadily falls oft'. The observa- tions are so few in number that there are many irregu- larities, which need not be heeded in this article. Usually the absolute increment is taken as the measure of the rate of growth, which is not justifiable.' To show the rate of growth-as well as the observations permit-is intended by the last column, which gives the daily increase for each period, calculated at a percentage of the weight at the beginning of that period. We thus secure values for le- gitimate comparisons, because the absolute increment during any period is the product of the amount of grow- ing material multiplied by the rate of growth ; hence, if the rate is to be found, the growing amount and the abso- lute increment being known, the amount must be divided by the increment; this wTas done, and the fractions so ob- tained converted, for readier comparison, into percentages. This convenient and obvious expression of the rate of growth seems to have never before been used. As re- gards the guinea-pig, it shows at once that as soon as the animal has recovered from the post-natal retardation its rate or power of growth declines steadily. This fact leads, of course, to the assumption that the vital powers undergo a steady decline, and that instead of there being a period of development, followed at maturity by a period of decline, there is a continuous decline, of which the final term is the natural death of the organism. We must, in fact, fundamentally change our conceptions of the phases of life. A man builds a wall, which keeps growing, but as the man becomes tired it increases more slowly, and stops when he is worn out. So the vital forces build the body, which develops, but all the while the forces are losing their power. The comparison is somewhat faulty, but may help to a clearer conception of decline during development. The constant loss in the rate, which I consider the fun- damental law' of growth, at least in mammals and proba- bly in all metazoa, may be shown in another manner very strikingly. If we calculate at what age after birth the animal wull have added ten per cent, to its original weight, and then the age at which it will have again added ten per cent, to its weight at the end of the first period, and so on, we obtain the following table : Growth of Male Guinea-pigs. Male Guinea-pigs. Weights in- creasing at the rate of ten per cent. Age at which they fall. Differ- ences. Weights in- creasing at the rate of ten per cent. Age at which they fall. Differ- ences. Grammes. Days. Grammes. Grammes. Days. Grammes. 70.86 0.0 244.34 38.8 5.2 77.88 4.1 4.i 268.77 43.7 4.9 85.66 5.6 1.5 295.64 50.2 6.5 9-1.22 7.7 2.1 325.20 59.2 9.0 103.64 9.6 1.9 357.72 68 6 9.4 114.00 11.8 2.2 393.49 77.3 8.7 125.40 14.0 2.2 432.83 88.6 11.3 137.94 16.2 2.2 476.11 100.7 12.1 151.73 18.7 2.5 523.72 120.0 19.3 166.90 21.7 3.0 576.09 160.6 40.6 183.59 25.3 3.6 633.69 201 3 40.7 201.94 28.7 3.4 647.05 258.2 56.9 222.13 33.6 4.9 766.75 298.3 40.1 Age. Variation above. Variation below. Per cent. Per cent. 0 to 0 day 19.51 19.49 1 to 15 days 18.95 18.99 16 to 30 days 17.13 16.87 31 to 65 days 15.68 16.31 70 to 140 days 12.12 13.31 115 to 215 days 7.52 7.48 8 to 12 months 10.66 9.72 13 to 17 months 10.38 11.41 18 to 24 months 12.10 10.82 The variation of adults is barely over half that at birth in range. Remarkable is the low variation from 145 to 215 days, and from 8 to 12 months. The higher val- ues for older periods is perhaps due to variations in obesity, which we know from common observation in- creases in the human species with age. The growth of an individual also indicates the existence of this tendency to attain the typical adult size ; if the growth of the animal is retarded by illness, after recovery the growth is accelerated to make up. This has practical To make the first addition of ten per cent, requires long, 4.1 days, owing to the post-natal retardation ; the 398 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growth. Growth. importance, for, unless the illness of a child is very pro- longed, no permanent effect upon its size is to be antici- pated. The size of an animal or the limit of its growth de- pends upon, first, the rate, and second, the duration of its growth. This is well shown by comparing man with the rabbit and the guinea-pig, as to the average daily growth. A man acquires a weight of about 63,000 grammes in twenty-five years; a rabbit, of the larger breeds, about 2,500 grammes in one year, and a guinea-pig about 750 in the same period. For man add 280 days, for rabbits 30 days, for guinea-pigs 68 days, on account of the period of gestation. cause of a loss in the power of growth, and since we may regard death as the final event, resulting from the loss of the powers of the individual, we reach, as our final con- clusion, the theory that organization is the cause of natural death. * It at once becomes interesting to inquire whether low and simple organisms, such as amoeba, can go on multi- plying indefinitely, because they never advance in organ- ization. It is possible that they can do so, but no obser- vations to decide this beyond question have yet been made. If lower organisms can go on multiplying indefi- nitely, they, of course, have no inherent cause of death, and are potentially immortal; and if this is true, death must have been evolved perhaps as a penalty or price paid by the higher organisms for the very possession of a higher organization. We referred above to the growth of single cells, a sub- ject which has as yet hardly been touched upon by inves- tigators. There are a few observations on the growth of unicellular vegetables, and upon the changes in size of animal cells, and a good deal of incidental information may be gleaned from researches directed to other prob- lems. In general it may be said that the newly formed cell is small, and subsequently enlarges, and unless it un- dergoes a specialization it divides again after a certain period, and after having attained a certain size. In gen- eral terms we may say cell-division produces small cells, which grow to the normal size and, again divide. Of course, the growth depends on the nutrition, and on va- rious external conditions of light, temperature, etc., and is apparently chiefly dependent upon the nucleus, for, as Gruber and Nussbaum have shown, if a unicellular ani- mal be artificially divided the parts which contain no portion of the nucleus do not grow, but the nucleated portions do. We see, too, in young cells the nucleus rela- tively large, and the protoplasm forms the principal in- crement as the cell grows, as if produced under the in- fluence of the nucleus. It is possible that the nucleus is the organ of nutrition for the cell. Cells vary considerably in the size they attain, accord- ing to the tissue to which they belong ; thus the leuco- cytes are very small, the liver1 cells of medium size, the adult motor ganglion cells of very large size. In certain cases the cells acquire what may be fairly called gigantic dimensions ; these may always, so far as I am aware, be connected with one of two causes : 1, Modification of the process of cell-division, such that the nuclei are divided and the amount of protoplasm increased, but the actual division into separate cells delayed ; the result is a large multinucleate protoplasmatic mass, a so-called giant-cell, examples of which are by no means rare ; there are many protozoa which are essentially giant-cells for a period, e.g., opalina. In vertebrates examples are afforded by marrow (myeloplaxes or osteoclasts), the large decidual cells, and by striated muscle fibres. 2, Accumulation of assimilated material (enclosures, formed material) for fu- ture use, of which the ovum offers the most remarkable and familiar instance, and gland-cells another not less noteworthy. The growth of a cell may be unequal in its different parts, so that not only may it alter its shape, but also the proportions of its components. Its growth may also be accompanied by histogenetic changes, so that the cell alters its organization also as it grows. Such changes are described in the numerous embryological articles of the Handbook ; see also Differentiation. IV. Definition of Growth.-The term growth has at present no perfectly exact significance, but is used so variously that it is impossible to give a precise definition. It implies in a general way an increase in the number or size, or in both, of the histological elements ; and it also, but more vaguely, implies that the elements advance, or at least remain stationary in the scale of organization. A unicellular organism grows when the cell enlarges. A multicellular organism may grow, 1, by simply multi- plying the number of cells, which all remain nearly of Man 6-3,000 grammes -+- 9,1-39 + 280 = 6.69 grammes per diem. Rabbit 2,500 grammes -+■ 365 -f- 30 = 6.30 • " " " Guinea-pig... 750 grammes365+ 68 = 1.73 " " " Man grows about as fast as a rabbit, but becomes much bigger, because he grows longer; but the rabbit is bigger than the guinea-pig, because he grows much faster. This is matter of common observation ; all that we gain from our calculation is a quantitative expression more suited for ready comparison. Of course, the whole shaping of the organism depends upon variations in the growth-rates of the single parts, but what causes such variations is unknown. Many writers have sought to account for the variations by purely mechanical factors, principally strain and press- ure ; but although such assumptions have been very fre- quently put forward by His, van Beneden, Kolliker, and a host more, they must all be condemned as more or less ill-considered speculations. A growing trout assumes a certain form ; why ? because it is its inherited tendency ; of the physiological nature of that tendency we know hardly anything, except that is is not mechanical, but only an unexplained growth-force. III. Growth as a Function of Cells and Tissues. -It is evident that the growth of the organism is the sum of the growths of its tissues, and the growth of the tissues depends on that of the cells; hence growth ultimately rests upon, first, the increase in size of single cells, and second, the multiplication of cells. Now, since the rate of growth gradually diminishes, of course diminution must be traced to the cells. We know that the cells of the young organism are smaller for the most part than those of the adult; but sufficiently numerous and exact data for statistical comparisons are not yet available. The ganglion cells and the ova offer perhaps the most marked differences to be found between cells in the young and the same cells in the adult. The skeletal muscles have small fibres in the child, much larger ones in the adult, and probably the growth of muscle after birth depends mainly on the enlargement of the fibres. Now, since the muscle makes 23.4 per cent, of the body at birth, and 43.09 per cent, in the adult, it is evident that a large part of the growth of a child depends upon the expansion of the single muscle-fibres. The increase in size of the tissue elements is undoubtedly a considerable factor in growth, nevertheless we must still regard the multiplica- tion of the cells as the main factor. It follows that if the rate of growth be expressed as a function of cells, we must say that the rate of cell-multi- plication diminishes with the age of the organism, and this must, I think, be considered the essential phenomenon of the process of growing old. Moreover, as soon as the new individual is formed it possesses a great power of growth, which fades away gradually, but also from the start. We know further, that the progress in age is accom- panied by a gradually increasing specialization or organ- ization of the parts, or cellular differentiation, to be more exact. It is natural to suppose that the two processes are causally connected. The supposition is confirmed by the observation that the less a tissue is specialized the more does it show traces of cell proliferation ; while in the most highly specialized cells, such as ganglion cells, no evi- dence of any division can be found. Accordingly, the conclusion is forced upon us that organization acts as an impediment to cell division, and is, in fact, the direct * This theory will be discussed more fully in another publication, more suitable for detailed consideration of so complex a problem. 399 Growth, Growths. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. one size, as in many algae ; 2, by the growth of the single cells already formed, for example, the growing child grows chiefly by the enlargement of the histological ele- ments ; 3, by the co-operation of both factors, which is the usual method of animal growth. Some kinds of enlarge- ments of the cells are generally regarded as not being true growth ; thus the accumulation of fat is distinguished from growth, although it depends on the dilatation of the cells, and causes an increase of weight to the body ; the obese cells are held by nearly all writers to have passed to a lower plane of organization. In cells we can distinguish three classes of constituents : 1, The protoplasm proper, which forms a net-work in the cell and its nucleus, and probably to be included here the chromatin of the nucleus; 2, the enchylema or enclos- ures embedded in the protoplasm, and which correspond in part to the so-called ' ' formed material " of Beale and the "deutoplasm" of van Beneden; 3, the products of degeneration-fatty, hyaline, mucous, etc.-which result from the breaking down of the protoplasm, or perhaps of both the protoplasm and enchylema. We might call 1, constructed material; 2, material for further construc- tion ; 3, material undergoing destruction. Growth we understand to be an increase of either, or both 1 and 2. An increase of 3 is not growth, although, when it is pro- duced, its weight and volume may exceed that of the ma- terial from which it is derived, or which it replaces, as is the case with fat. It is evident, therefore, that we must have more knowledge of the essential phenomena of de- generation in general before growth can be adequately defined. Literature.-The only general works are the very important treatise of Vierordt in Gerhardt's " Handbuch der Kinderkrankheiten," Bd. 1, Abth. 1, pp, 219-290, and the useful summaries given by Preyer in his " Physiologie des Embryos," and by Hensen in the sixth volume of Hermann's "Physiology." The number of special papers is very large ; a few references are given below ; for addi- tional ones consult Vierordt. I. Growth of Fcetus.-See Preyer's Specielle Physiologic des Em- bryo for a synopsis of the observations and references to the literature. Pagliani: Lo Sviluppo umano, per eta. sesso, etc., 8vo, Milano, 1879. II. Weight at Birth.-Rumpe: Arch. Gyn., xx., 117. Ahlfeld : do., xii., 489. Lorey: Jahrb. Kinderheilk., N. F., xii., 260. Ingerslev: Nord. Med. Ark., vii., 1875. Frankenhauser : Monatschr. Geburtsk., xiii., 170. Elsasser: Henke's Zeitsch., xxxvii., 2. Wagner: Centralbl. £tynak., 1885, 359. Negri: do., 1886, p. 58. III. Growth of Infants.-Hesse: Arch. f. Gyntek., xiv., 491, and xvii., 150. Petersen: Schmidt's Jahrb., Bd. 196, p. 31. Hofmann: Neue Zeitschr. Geburtsk., xxvi., 145. Siebold: Monatschr. Geburtsk., xv.. 337. Pfeiffer: Jahrbucher f. Kinderheilk., xix., 142. Biedert: do., xix., 275. Woronoff: do., xxii., 254; abstract in Schmidt's Jb., Bd. 205, p. 47. Wolff: Centralbl. Gynak., 1885, p. 16. Rezmarozky : Arch, f. Gyn., v. For further literature see Vierordt, 1. c. IV. Growth of Children.-Bowditch: The Growth of Children, Boston, 1877 ; also. The Growth of Children (a supplementary investiga- tion), Boston, 1879; both republished from Reports of the Massachu- setts State Board of Health. Peckham : The Growth of Children, from Sixth Annual Report State Board of Health of Wisconsin. Pagliani: Lo Sviluppo umano per eta, sesso, etc., Milano, 1879 ; and Sopra alcuni fattori dello Sviluppo umano, Torino, 1876. Malling Hansen : Gewicht der Kinder, Kopenhagen, 1883; and Tagliche Wagungen, etc., Kopen- hagen, 1884. Theile: Nova acta, xlvi., 3, 1884. Menard: Gazette Med., Paris, January 9, 1886. V. Anthropometry.-See the General Treatise of Roberts; Gould's Statistics, published by the U. S. Sanitary Commission : and Baxter: Statistics of the Provost-General's Office, 2 vols., 4to, Washington, 1876. Baxter gives an extensive bibliography. VI. Growth of Animals.-Minot : Proc. Society of Arts, Boston, p. 50. 1884. Hensen und Edelfsen: Arbeiten Physiol. Inst. Kiel, pl. i. Kehrer; Arch. f. Gyn., i., 224. VII. Theory of Death.-Minot: Growth as a Function of Cell, Proc. Boston, S. N. H., xx.. p. 190; also, in Science, iv., 398 : and Re- searches on Growth and Death, 1. c. under vi. Weissmann, I.ebens- dauer : Ueber den Tod, etc., being several pamphlets published at Jena. Biitschli: Zool. Anz., v., 64. Goette; Ueber den Tod. Mobius: Biolog. Centralbl., iv., 389. Charles Sedgwick Minot. the acute and chronic swelling of the spleen is spoken of as splenic tumor. In considering the subject from a strictly anatomical standpoint, we shall exclude not only many of the pathological processes which are clinically spoken of as tumors, but also those swellings which are caused by the accumulation and retention of fluid or cell- ular substances. Virchow included these among the tu- mors, and called the whole group retention cysts. They are the accumulations of blood, or haematomas, of inflam- matory transudations, hydroceles, and hygromas, the fol- licular or mucous cysts, atheroma, and the various secre- tion cysts of the different glands. Excluding these formations we have only those left which are produced by an actual new formation of tissue, the essential neo- plasms. We might define the tumor in this narrow sense as a non-inflammatory new-growth, which makes the im- pression of a foreign, accessory, more or less independent structure ; and we might add that by this new formation no physiological purpose is served. By this definition we shall exclude all the inflammatory swellings and the hy- pertrophies, but we have still included a group of forma- tions which seem to represent the transition stages be- tween the inflammations and the neoplasms. AH these have a certain similarity in their structure, and still more in their etiology. Most members of the group we know to be infectious, and for others this infectiousness, if not clearly proven, is highly probable. From the similarity of their histological structure to the granulation tissue, Virchow designated them granulation tumors. Klebs, rightly regarding infectiousness as the characteristic which distinguishes them most sharply from other new formations, has called them infectious tumors, and we shall consider them under this head. Formerly no attempt was made at a proper classifica- tion of tumors. They were only divided according to their size and gross appearance. Afterward, when it be- came evident that some of them followed a benign and others a malignant course, the division into benign and malignant was made. Virchow says, in reference to this division, that it would be just as sensible fora botanist to make two great classes of plants, i.e., those which had poisonous properties and those which had not. Later, names were given most of them which had no reference to their anatomical structure, but to what seemed most striking either in their gross appearance or in their man- ner of growth. Thus many which had the tendency to invade and destroy neighboring tissues were included un- der the head of lupus. The name of cancer was given to another group, from the fancied resemblance of the dilated cutaneous veins covering them to the outstretched claws of the crab. Galen calls especial attention to this appear- ance. Then, again, according to differences in their shape, they were sometimes called nodes, sometimes nodules, tubercles, or polypi. As a next step it was seen that certain tumors agreed in their general characteristics with certain normal tissues ; that one was composed of bone, another of fatty tissue, etc., and the names of these tissues were given to the tumors. Abernethy saw that some were composed of numerous complex tissues, or systems of tissue, which had their analogues in the normal body, and he was the first to recognize as a special division those tumors which we now know under the name of teratoma. It was seen, however, that there were many tumors whose structure did not agree with that of the normal tissues, and thus we had two great groups formed, which were known as the accidental new formations, and the growths sui generis. Bichat and his scholars, among whom we find the re- nowned names of Dupuytren, Laennec, and Cruveilhier, were principally active in advancing these views. Lob- stein, the celebrated clinician and pathologist in Strassburg, first introduced the terms homoplastic and heteroplastic growths, the first term designating those conforming to the normal tissues in their structure, and the latter those whose structure "was different. In accordance with the view that was held at that time, that all tissue was formed from lymph, he assumed that the homoplastic tumors were formed from one sort of lymph, and the heteroplastic from another. The homoplastic lymph he called, from GROWTHS, PATHOLOGICAL, OR TUMORS. In a general consideration of this subject we are met at the outset with the difficulty of giving a clear and definite meaning to the word tumor. Clinically the increase of a part in size, due to any one of a great number of patho- logical processes, has been, and is now, designated as a tu- mor. Even pathological anatomists have been accustomed to the use of the word tumor in this vague manner ; thus 400 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growth. Growths. the general benign character of the growths formed from it, euplastic, and the heteroplastic, from the more malignant character of the tumors, kakoplastic. This division of the tumors into the homologous and the heterologous was taken up by most of the German pathologists. The more malig- nant heterologous tumors were attributed to a change in the blood, a dyscrasia, and after the microscope came into something like general use the whole world expected there would be found some chemical or morphological substance which could be regarded as their causative agent, and which might serve as a diagnostic mark. Even Rokitansky thought that a kakoplastic substance could be found in albumen, and squght in diseased albu- men the true cause of all malignant tumors. The publication of the work of Johannes Muller, on "The Minute Structure of the Pathological Growths," marks the beginning of a new era. Here, for the first time, the attempt was made, and made, too, by a great master, to form a scientific classification of tumors on a basis of histological, chemical, and clinical facts. The effect of this work of Johannes Muller was felt in the whole domain of pathological anatomy. He gave us a law on which it may be said that our whole knowledge of tumors depends. This law is, " The tissue of which a tumor is composed has its type in the tissues of the ani- mal body, either in the adult or in the embryonic condi- tion." Notwithstanding this law of Muller, the correctness of which no one would now dream of doubting, since his publication, made so early as 1838, we have had the most active search made for specific elements in tumors. Le- bert's tubercle corpuscle, and the spindle-cell, which was almost universally considered for a long time to be the specific element in cancer, were both discovered after Muller's publication. This search for specific elements might be justified if the tumors were independent para- sitic growths ; but we must always remember that they form part of the animal body, and have arisen from this same animal body. Virchow extended the views of Jo- hannes Muller still further, and in his most remarkable and exhaustive treatise, " Die Krankhafte Geschwtilste," not only gave us a classification on a true scientific, that is, a histo-genetic basis, but several laws which are scarcely less important than that of Muller. Virchow asserted, as a general principle, that tumors were gov- erned in their growth and development by the same laws which govern the normal body, and that they always agreed with the type to which the body conformed in its structure and development. Thus we could never have feathers in a tumor which developed on a mammal. Vir- chow, like Bichat, also divided tumors into the homol- ogous and the heterologous, though under his hands these terms came to have altogether another meaning, and were only to be used in connection with place. A tumor, he says, is homologous when its structure conforms to that of the part on which it is seated. There are no heterologous tumors in the sense of Bichat; we are only to understand under this head those which conform, indeed, with some structure of the adult or embryonic body, but not with that of the part on which they grow. Thus the same sort of tumor can at one time or at one place be homologous, and at another the extreme of heterologous. Peris has suggested the use of the word heterotopia to designate a local heterology, and heterochronia a heterology in point of time, as when mucous tissue or cartilage develops in a place where it should normally only appear in the embry- onic period. Virchow divided the true new formations into three great groups : First, the histoid, those into whose struct- ure only one tissue of the body enters ; second, the or- ganoid, those into whose structure several tissues enter, so that a complicated structure with a fixed typical arrange- ment of the parts arises ; third, the teratoid, those into whose structure whole systems of the body enter. In addition to these three divisions he makes two others. The first includes those tumors which are formed from constituents of the blood, the extravasation and exudation tumors; the second, those which are formed by the retention of some normal secretion, the re- tention cysts. Those pathological productions which are included in these last divisions should, however, be ex ■ eluded from the true neoplasms. It is easy to make a systematic division of the simple histoid tumors. They represent a repetition of the nor- mal tissues in the shape of tumors, and we can classify them accordingly. They can be divided into four groups, which represent the four great groups of primitive tissues -the epithelial, nerve, muscle, and connective tissues. We have more difficulty in classifying those which depart from the type of the normal tissues from which they are derived in the arrangement of their elements. These are the sarcomas and carcinomas. In a classification based on the anatomy and genesis of tumors it will be well to leave out altogether the word cancer, which the clinician has come to use as particularly designating the malignant tumors, and to use the word carcinoma only to designate certain tumors which have a definite construction and which are derived from epithelium. It is true that many authors differ in their views regarding the origin of the carcinoma ; but the view of Waldeyer, regarding it as an epithelial growth, differing from the normal epithelial structures only in the arrangement of its elements, is be- coming more and more prevalent. The sarcoma certainly belongs to the group of connective-tissue tumors, but is distinguished from the others in the group by the ex- cessive development of the cellular elements. In the histoid tumors we frequently meet with forms which differ somewhat from the normal type of the tissue. We find fibromas frequently in which the whole tumor, or a part of it, shows a much greater development of cells than we find in the ordinary fibrous tissue, but still a de- velopment not sufficient to enable us to call it a sarcoma. In such a case we are accustomed to add the word sarco- ma to designate this tendency to a departure from the typical form, and to speak of a fibro-sarcoma, a myxo- sarcoma, etc. There is one tumor which seems to occupy a place between those derived from the connective tissues And those from the epithelium. This arises from the en- dothelium, and in its structure very closely resembles the carcinoma. The classification which we have adopted is, with some modifications, that used by most German patholo- gists. I. Tumors which consist of connective tissue and are derived from tissues belonging to the connective-tissue group. Fibroma.-A tumor composed of fibrous tissue, the physiological type of which is found in the ordinary fibrous or areolar tissue. Myxoma.-A tumor composed of mucous tissue, the type of which is found in the vitreous body in the adult, and in the umbilical cord in the foetus. Glioma.-A tumor composed of a peculiar connective tissue, the type of which is found in the connective tissue of the central nervous system, the neuroglia of Virchow. Lipoma.-A tumor composed of fatty tissue, the type of which is found in the subcutaneous fat. Osteoma.-A tumor composed of osseous tissue, hav- ing its type in the adult or foetal bone. Enchondroma. - A tumor composed of cartilage, which may have its type in any of the varieties of car- tilage. Lymphoma.-A tumor composed of cytogenic tissue, the type for which is found in the lymph glands or in the bone marrow. Angioma, or Cavernous Tumor.-A tumor made up of blood-vessels, the type of which is found in the capillaries or veins. Lymph-angioma.-A tumor made up of lymph-vessels, the type of which is found in the ordinary lymphatics of the body. In addition to these tumors, all of which conform strictly in their structure to their physiological types, we have the group of sarcomas which also come from the connective tissue, but which, as said above, are distin- guished by the excess of cells over the formed material, in this conforming to the type of embryonic tissues. All of the above tumors can have mixed forms with the sar- coma. 401 Growths. Growths. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spindle-cell Sarcoma. - A tumor composed of spindle-cells, with little or no intercellular tissue. The type of this is found in the embryonic connective tissue. The cells of which the tumor is composed may vary greatly in size, and this has led to the division of them into the large spindle-cell sarcoma and the small. Round-cell Sarcoma.-A tumor composed of round- cells which have no special arrangement, and may or may not have a small amount of intercellular tissue. The type of this tumor is found in the indifferent cells of the mesoderm of the embryo before differentiation has taken place, or in the indifferent cells of granulation tissue. Alveolar Sarcoma.-A tumor composed of indiffer- ent cells, which frequently resemble the various forms of epithelium, and a variable amount of intercellular sub- stance. The cells are arranged in groups, which are sep- arated from each other by bands of connective tissue. Fibres are given off from these larger bands, which pass into the groups of cells, and, in a measure, separate them from each other. All of these forms of sarcoma may contain, along with their other elements, large masses of protoplasm with many nuclei, which are known as giant-cells, and such tumors are most often designated as giant-cell sarcomas. Melano-sarcoma. - A tumor which may have the same histological structure as any of the three forms of sarcoma, and whose cells contain a dark pigment, which is apparently of the same nature as the physiological pig- ment. These tumors are to be distinguished from those in which haemorrhage has taken place, and wrhich in con- sequence contain blood-pigment. Chloroma.-A very rare tumor, agrees in structure with the round-cell sarcoma, and contains in its cells a bright green pigment. II. Tumors which are composed of muscular tissue, but which may or may not originate in this : • Rhabdomyoma.-A tumor composed of striated mus- cular fibres similar to the striated muscular tissue of the adult or embryo. Leiomyoma.-A tumor composed of non-striated mus- cular fibres similar to those of the muscular tissue of the uterus or intestinal canal. III. Tumors which are composed of nervous tissue and originate in this : Myelenic Neuroma.-A tumor composed of nerve- fibres wdiose type is to be found in the spinal nerves. Amyelenic Neuroma.-A tumor composed of non- medullated nerve-fibres whose type is seen in the nerves of the sympathetic system. IV. Tumors whose essential constituents are epithelial cells, and which originate from pure epithelium. Papilloma.-A tumor whose chief constituents are epithelial cells, but which also contains vascular connec- tive tissue, the whole being formed in accordance with physiological types. These types are the papillae of the skin and the villi of the intestine. According to their seat they are divided into the hard and soft papilloma. Adenoma.-A tumor composed of glandular epithe- lium and vascular connective tissue, generally agreeing in the arrangement of its elements with some of the glandu- lar structures of the body. Epithelial Carcinoma (Epithelioma).-A tumor having its origin in, and principally composed of, epithe- lium similar in character to the covering epithelium, but in the arrangement of its elements agreeing with no typ- ical structure in the body. The cells are arranged in masses, which are separated from each other by vascu- lar connective tissue. Neither the fibres of the connec- tive tissue nor the blood-vessels penetrate the masses of cells. Glandular Carcinoma.-A tumor having its origin in, and principally composed of, glandular epithelium, agreeing in its general structure with the epithelial carci- noma. Endothelioma.-A tumor arising from the endothe- lium, and agreeing in the general arrangement of its ele- ments with the carcinomas. Teratoma.-A tumor into whose structure a whole system of the body may enter, and which arises from parts where the tissues found in the tumor do not nor- mally exist, they being always heterologous in the sense of Virchow. The epidermic structures of the body are most often represented in these tumors. They form alone the third group given by Virchow, and cannot be subdivided. Although the simple follicular cysts which arise from the retention of the secretion of an already formed glan- dular structure should with right be excluded from the tumors, there is another class of cysts which represents true new formations, and must be included among the tumors. Such are the large, generally multilocular cysts of the ovary, which arise from a proliferation of the glandular tissue. They are called by Waldeyer myxoid kystoma, in contra-distinction to the simple follicular cysts produced by the dilatation of the Graafian follicles. The structure of tumors is not so simple as might be in- ferred from the above schema. Frequently, where two sorts of tissue are present, we may be in doubt as to the real nature of the growth. In the most common form of carcinoma of the mamma, the so-called scirrhus, we some- times find the connective-tissue framework so highly de- veloped that on a superficial examination the groups of epithelial cells may be overlooked, and one of the most malignant tumors be mistaken for one that has little or no malignity. We have seen that some of the tumors, in their histo- logical structure, depart from the type of the normal tis- sues. When we consider them in their macroscopic as well as in their microscopic characters, we find that they are all atypical. In some of the simple histoid tumors, for example, we cannot say, from a histological examination, whether wre have a tumor or normal tissue before us, but their atypical character becomes at once manifest when we consider them macroscopically. The lipoma does not differ in structure from the accumulation of fat which we find in obesity; but while in this the fat is distributed more or less over the whole body, the lipoma represents a circumscribed growth. The same is true of the fibroma and others of the class. Most of the tumors also depart from their physiological types in the character of their blood-vessels. Although we find here the same distribu- tion of arteries, capillaries, and veins, as in the normal tissues, the vessels themselves are much more irregular. The capillaries and veins are frequently very much di- lated, this change either involving the vessels throughout their whole extent, or manifesting itself in ampulla- like dilatations at intervals. In other cases they have no regular walls, but the blood seems to circulate in spaces or channels in the tumor. Such a condition is most fre- quently found in the sarcomas. Lymph-vessels have been shown to exist in most of the tumors. The re- searches of Schroeder van der Kolk, Ranvier, and Koster have added much to our knowledge on the lymphatic vessels of carcinoma. Even these vessels show the same tendency to atypical forms and arrangement as do the blood-vessels. In tumors in which two different sorts of tissue appear, as in the carcinomas, where we find a connective-tissue framework in which groups of epithelial cells are em- bedded, it is probable that this connective tissue repre- sents in part the interstitial tissue of the gland in which the tumor was developed. A large portion of it, how- ever, must be newly formed. That it does not play a merely passive part in its relation to the growth, is evi- dent from the frequency with which we find indications of active growth in it, in some cases the stroma appearing almost as embryonic tissue. With regard to the development of blood-vessels in tumors, we know almost nothing. We do not know whether they are developed from integral parts of the tu- mor, or whether they arise from the old vessels of the part by budding, and grow into the tumor. Judging from what we know of the development of vessels in granula- tions, the last view is most probably correct. Nerves have been shown to exist in many of the tu- mors ; that they should be newly formed in them is ex- tremely improbable. In carcinoma they play an impor- tant part ; the epithelial growth spreads along their 402 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growths. Growths. sheaths, and by the compression to which they are sub- jected the constant pain can be explained. As might be judged from their various sources of origin, we find many different cell-forms in tumors. All of the different forms of cells which are found in the adult or embryonic tissues are met with here, and from an exami- nation of the cell-forms alone no idea of the nature or origin of a tumor can be had. Even in the same growth the most varying cell-forms are met with. This may be partly accounted for by the different degrees of pressure to which they are subjected. All of the disturbances of circulation or nutrition, which we meet with in the ordinary tissues, can be repeated in tumors, and from the irregularity of their vascular sup- ply such disturbances are very frequent. One of the most common is haemorrhage, and this gives rise to the same conditions that we find in other parts. Pigmenta- tion of the tissues resulting from this is very common, and must be distinguished from the true melanotic pig- mentation produced by metabolic changes in the cells. As a rule, tumors always appear single ; some cases are seen, however, in which there will be a simultaneous ap- pearance of immense numbers. These are all of the same character and confined to the same system. Certain forms of fibroma and sarcoma often appear in this way. These multiple growths, which arise simultaneously and are confined to a single system, must be sharply separated from the metastases, which we will speak of later. Most often they belong to the simple histoid tumors, though some rare instances have been met with in which two carcinomas were found, both primary, at the seat of their appearance. The forms under which tumors may appear are mani- fold, and give us no certain criterion as to their nature. In parenchymatous organs we either find them as sharply cir- cumscribed nodules, or as infiltra- tions. In the nodular form the it was called a fungous growth, and a polypus when the main body of the tumor was connected with the surface by a small pedicle. When the tumor was formed by a series of projections, like the papilla? of the skin, it was called papillary, and when these projections were much longer and branched it was called dendrate. We know but little about the growth of tumors. They have been more studied in their histology as completed structures than in reference to their development ami manner of growth. When we consider, moreover, how incomplete our knowledge of the growth and develop- ment of the normal tissues is, notwithstanding the amount of study that has been spent upon them and the oppor- tunities which are given for such study in the ease with which embryos at any period can be obtained, it is not surprising that we should know so little about tumors. We know from recent investigations that cell multiplica- tion takes place in about the same manner as Flemming has shown to be the case in the normal tissues. The ten- dency, however, which all tumors have to depart from the normal type is shown even in the cell multiplication. Instead of the simple division of the nucleus, we have often a three- or four-fold division. There are two principal opinions held as to the manner in which tumors grow. One is that the growth takes place from the tumor itself, and the cells of the surround- ing tissue play only a passive part; and the other is, that the cells in the neighborhood of the tumor change into cells corresponding to those of the tumor. This last the- ory has been variously modified. Stricker and a number of others assert that the cells in the normal tissue, in the neighborhood of the tumor, first return to their indiffer- ent or embryonic form, and then differentiate themselves into those of the tumor. Others hold that the change is direct without this intermediate process. This supposed metamorphosis of normal tissues into those of the tumors has been studied in various tissues. There are numerous publications describing the metamorphosis of muscular fibres into the alveoli of carcinomas. Analogous changes have been described in nerves, and, in fact, for every tis- sue, even one as highly differentiated as the ganglion cells of the central nervous system. All of these appearances can be interpreted to mean something else. In the case of the muscles we know that the sarcolemma can be in- vaded and tilled up with the cells of a tumor, the muscu- lar substance simply disappearing before them. We also know that they can be taken into the bodies of other cells ; the appearances described by Virchow as endo- genous cell-formations are most probably to be explained in this way. In such an organ as the liver, the cells in the neighborhood of a tumor are often made spindle- shaped from pressure, and this has been taken for their change into the spindle cells of sarcoma. We know now that most of the changes which have been described in cells as indicating active growth, such as the biscuit-shape of the nucleus, etc., if they mean anything, are as likely to refer to retrogressive as to progressive changes. Flem- ming has shown that by certain changes, which take place in the nucleus-the caryokinetic figures-we can certainly recognize cell division, and until all our studies on the growth of tumors are regulated by this, our knowl- edge on the subject will always be limited. We know that inflammatory processes are always to be found in the neighborhood of tumors; new connective tissue is thus produced, and in this way many of the slowly growing tumors become encapsuled. Virchow advanced the view that the connective-tissue corpuscles played a very active part in the growth of tumors. As one evidence of this, the presence of small carcinomatous nodules at a distance from the parent nodule has been cited. As a fact these can generally be shown, by means of a series of microscopic sections, to be connected with the parent nodule by lines of cells that most probably represent lymphatic vessels which have become tilled up with the growth. Even in cases where this connection cannot be traced, we have no right to assume that they have arisen independently, for we know that the cells of most tumors, even those of carcinoma, are capable of amoeboid movements, and they may have wandered from Fig. 1425.-Scheme showing Forms of Tumors, a, Infiltrated ; b, nod- ular form ; c, peripheral growth by infiltration ; d, by dissemination ; e, tuberous form ; f, tuberous form of miliary size; g, fungus ; h, poly- pus ; i, papillary and verrucose; and A, dendrate form. line between the tumor and the normal tissue is sharp, and we get the impression that the tumor grows as a solid mass, pushing before it and compressing the nor- mal tissues. In the infiltrated form this line is not so sharp, and projections from the tumor seem to penetrate the normal tissue; by their growth the tissue between them is destroyed by pressure or by insufficient nutrition. In this way the central body of the tumor increases in size, and the infiltration continues to advance. Fre- quently numerous small nodules will be seen in the neighborhood of a large one. These increase in size, and finally meet the parent nodule, minute ones continuing to appear at the periphery. This is called growth by dis- semination, and is best seen in the formation of the large solitary tubercles of the brain. Tumors which are seated on the surface of organs, as in the skin and mucous membranes, soon project above the surface, and various names have been given to characterize the form of these projections. If the projection merely took the shape of a rounded elevation, a tuberosity was spoken of. The name tubercle was given to the smallest of these, though this name was afterward used to designate growths of a fixed histological character. When the tumors pro- jected above the surface in such a way that the summit was broader than the base, and hung over it like a roof, 403 Growths, Growths. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the parent nodule into the tissues, and in this way have produced by multiplication the small nodule. Tumors cause various changes in the tissue around them. The most frequent of these are atrophy and the various degenerations caused by pressure or a diminution in the blood-supply. In this way absorption of bone and of the densest tissue is brought. about. The resistance oifered to the growth of a tumor by the neighboring tissues de- pends, in great measure, on the nature of the opposed tis- sue. The loose connective tissue offers the least resist- ance ; dense fibrous tissue, fascia, etc., the greatest. Arteries may be classed as among the most resistant tissues, though even their walls are frequently broken through. All sorts of retrogressive changes are common in tu- mors. The irregular nature of their vascular supply leads to frequent haemorrhages, from the giving way of the vessels. Thrombosis, both of arteries and veins, is also frequently met with. From the pressure which one part of a rapidly growing tumor exerts on the vessels which supply another portion of the growth, we may have the circulation cut off entirely, and in consequence have ne- crosis. Sometimes the cells seem predisposed to fatty and other degenerations, independent of vascular disturb- ances. Such are carcinomas originating in parts where the cells in their physiological activity tend to fatty change, as in the mamma. The skin covering tumors seated immediately below it is very apt to ulcerate. This is caused both by the anaemia which the pressure of the tumor causes, and by the elevated portion of the skin being more exposed to friction and traumatic influences than any other part. As we have said, tumors in. their general growth and nutrition follow the same laws that govern the rest of the body, though in a certain sense they seem to grow as in- dependent structures. And it was this that gave the old pathologists the idea that they were parasites. Just as the state of nutrition of the host seems to exercise little or no effect on the parasite, so the state of nutrition of the bearer has ho effect on the growth of the tumor. A tumor, as a whole, never seems to suffer from a want of nutrition, no matter how low may be the nutrition of the body. This is particularly striking in the case of the lipoma. It is no uncommon thing to find a large lipoma in a consumptive, which has been growing steadily, not- withstanding the fact that elsewhere in the body no trace of redundant fatty tissue can be found. This fact has excited the attention of all writers on tumors in ancient and modern times. In this they differ most markedly from the ordinary hypertrophies and hyperplasias. A my- oma of the uterus increases more rapidly in size during the hypersemia and hypertrophy of the whole organ in preg- nancy ; but when pregnancy is over and involution of the organ takes place, with fatty degeneration of its mus- cular fibres, the myoma experiences no degeneration in its muscular fibres. It is characteristic of some tumors that after their growth has been for some time limited to the place of origin, other remote, and generally internal, organs be- come affected. These secondary growths are termed metastases ; they always present exactly the same struct- ure as the primary growth, and where this is much de- generated the histological characters of the growth can best be studied in the metastasis. In some tumors they appear very shortly after the primary growth, in others years may elapse before they appear. Few tumors are exempt from this metastasis, but in some it is the rule. The histoid tumors are generally exempt, but in the simplest of these, the lipoma, a few cases of metas- tasis are reported. None of the internal organs are free from a secondary attack. The liver and lungs are the organs most frequently invaded. This metastasis does not take place at random, but always follows definite paths, and the seat of the primary tumor determines where the metastasis shall take place. In carcinomas the lymph-glands belonging to the affected part are first at- tacked, as the glands of the axilla in carcinoma of the mamma. This involvement of the lymph-glands can be accounted for by the intimate relation which the alveoli of the carcinoma have with the lymphatics. In other tu- mors, as in the sarcomas, the lymph-glands are frequently passed over. The metastases following tumors in the re- gion of the portal circulation generally take place in the liver. Frequently these metastases are so large in pro- portion to the primary tumor that the latter is over- looked. Many tumors of the liver, which have been de- scribed as primary growths, were really only metastases from small carcinomata seated in the rectum or elsewhere. It is easily seen that the primary tumor acts as a focus of infection, and there has been a great deal of contention as to what constitutes the infectious properties of a tu- mor. Were the infectious materials of a soluble character, given off from the tumor, then we should have the sec- ondary growths taking place at random all over the body, or we should have to assume, as long as this is not the case, that certain organs have a particular affinity for these materials. But we know that there is no such af- finity. The lymph-glands are almost always attacked in carcinomas, but only those are attacked which stand in a direct relation to the part where the tumor is seated. We do not have, for example, the lymph-glands of the in- guinal region affected in carcinoma of the mamma, and this should be the case if soluble infectious materials were given off from the tumor, for which the lymph-glands in general had a particular affinity. For this material would then get into the blood and be transported to all the lymph-glands. When we study the metastases more closely we find that such a view would be untenable. The metastases are caused by living portions of the tu- mor which get into the lymph- or blood-stream, and are carried to distant parts of the body, where they take root. They are due to emboli of cells or portions of the tu- mor. We frequently find masses of the tumor actually growing in the lumen of vessels, and emboli in other parts where they could only have been carried by the blood-current. This was first seen in the enchondroma by Virchow and Paget, who each had a case in which a large mass from the primary tumor was seen growing into the iliac vein. Numerous arteries of the lungs were occluded by emboli which agreed in character with the primary tumor. Since then similar cases have frequently been seen. The writer once saw a case in which the course of the metastasis was beautifully marked. The primary tumor was a carcinoma of the uterus ; from this the post-mesenteric lymph-glands became carcinomatous, and the thoracic duct in its whole extent was changed into a solid carcinomatous cord. The cervical lymph- glands were also affected, and a nodule projected into the right subclavian vein ; there were innumerable nod- ules, generally miliary in size, in the lungs. From these there was infection of the lymphatics of the pleura and the bronchial glands. There were no metastases in the liver nor elsewhere in the body. When a carcinoma of the stomach grows through into the peritoneum we fre- quently find a miliary carcinosis here, and we can see that the growth has in every case taken its origin on the surface of the peritoneum, and not from the blood-ves- sels. In other cases of general carcinosis, where the whole body is strewn with small tumors, we can, in the great majority of cases, trace the way in which the infectious substances have entered into the general circulation. It is by no means infrequent in such cases to find a nodule growing on the endocardium of the left heart. As a proof that the infectious matter in carcinomas is soluble, or at least that it does not consist of cells or por- tions of the tumor, the well-known case of Friederich is often cited. In this case there was a carcinoma on the left knee of a foetus, and the mother, during pregnancy, acquired a carcinoma of the liver, which produced very widespread metastases. From Friederich's description of the case, however, it is more than probable, in view of the difference in the size and character of the cells in the tumor of the mother and that of the foetus, that both tu- mors should be regarded as primary, and as having origi- nated independently of each other. In these metastases we have the best proof that the tu- mor grows from itself, and that the surrounding tissue only plays a passive part. They are always sharply cir- 404 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growths. Growths. cumscribed, this being best seen in metastatic nodules in the liver, where the white tumors make a sharp contrast with the dark liver tissue. We can hardly assume that the embolic masses exert an infectious influence on their surroundings. This power of infection could only be as- sociated with the cells of the tumor, and we should have to assume that they entered into conjugation with the cells of the normal tissue, the resulting cells taking the form and characteristics of one parent. We have no anal- ogy for any such belief. We must consider the metas- tases to be due to the living activity of the tumor cells, which are carried to remote parts by the lymph- or blood- streams, or by their own amoeboid movements. They then have the power of growing in a foreign tissue at the expense of this tissue. We know that the epithelial cells in normal tissue have the greatest power of growth, and to this fact must be attributed the greater malignity of the tumors which proceed from them. The effect which a tumor exerts on the organism as a whole, varies with the nature of the tumor and its seat. In no case does it exert a favorable influence, nor can it be of the slightest benefit to the body. Even in the case of the lipoma, the fat here cannot be used to supply the wants of the organism, as can the fat elsewhere. In most of the rapidly growing tumors a state of impaired nutri- tion of the body is soon brought about, marked by anae- mia, loss of appetite, and a peculiar yellow or earthy ap- pearance of the complexion. Many of the conditions that a tumor gives rise to conspire to bring this about. We must consider the constant loss of blood from haemor- rhages, which are almost invariable in some tumors ; then the large amount of valuable nourishing material which a tumor draws away from the rest of the organism. The size of a tumor gives us no just criterion of the rapidity of its growth, for the processes of decay, by which parts of it are removed, may be nearly as active as its growth. The constant pain which so often accompanies malignant tumors, and the loss of sleep and mental agitation thus brought about, are all factors which contribute to mal- nutrition. The peculiar color of the complexion spoken of generally comes on at a very late period, and points to involvement of the liver by metastases. In some cases the position of the tumor and the mechanical disturbances to which it gives rise are sufficient of themselves to ac- count for the malnutrition of the bearer. Such, for in- stance, are carcinomas of the pyloric orifice of the stom- ach with stricture, carcinoma of the oesophagus, rectum, etc. In addition to all these causes we have enumerated, we must also think of the processes of decay which are going on constantly, and the injurious effect of the ab- sorption of these products. When tumors are seated on surfaces, ulceration is very prone to take place, with ex- tensive necrosis and sloughing, and these ulcers so aris- ing are generally of the most foetid, offensive character, and, from the absorption of their products, ichorrhaemia and septicaemia are often brought about. In some cases death takes place from this alone, and abscesses with emboli of micrococci are found all over the system. In view of these facts, we think that the cachexia can be ex- plained without it being necessary to assume that any specific influence is exerted on the system by the tumor. Very many tumors, when removed from the body, have a tendency to return in the place of removal. This must not be attributed to any change which has taken place in the tissues of the part, by which they are rendered pe- culiarly prone to form such tumors, but to the imperfect- ness of removal. This recurrence is most often seen in carcinoma, and when we consider the relation that the glandular carcinoma bears to the surrounding struct- ures, we can easily see that a complete removal must be often extremely difficult, and in many cases impossible. The lymphatics are affected, and when the neighboring glands are removed with the tumor, the lymph vessels cannot be, and these are often entirely filled with the growth. In those tumors which are sharply circum- scribed, and surrounded by a capsule, extirpation is usu- ally complete and not followed by a return of the tumor. We are still very much in the dark in regard to the etiology of tumors. It is certain that we must look to the tissues themselves in seeking this ; the old belief that there was a pathological condition of the blood, a dys- crasia, that caused them, has not now a single adherent. Nor does the neuro-pathological theory of their origin fare any better. Schroeder van der Kolk cut the sciatic nerve in the leg of a rabbit, and then, on breaking the tibia, he found that a large irregular mass of tissue was developed instead of the ordinary callus. This mass he took for a medullary cancer. Virchow showed that this was but inflammatory tissue, produced by the constant irritation to which the" broken leg, deprived of its nervous supply, was subjected. Virchow supposes that some predisposition of the tis- sues is necessary for the development of a tumor. This predisposition, he says, may be inherited or acquired ; it frequently only makes itself manifest at certain periods in life, such as the climacteric period in women. To ac- count for this predisposition he assumes that the tissue has not been properly formed ; its arrangement is such that in consequence of certain outer influences it does not react as ordinary tissues do, but gives rise to an excessive production of a lower grade of tissue, and thus we have the tumor. Certain influences tend to bring about such a condition, old age playing a prominent part. As such predisposed tissue must be reckoned scars, then parts which have been the seat of frequent inflammations, and such as only reach their development late in life, viz., the milk-glands, the uterus, ovaries, and the like. Given this predisposition of the tissues, another factor is necessary, and that is irritation at the place where the predisposition exists. Here Virchow has collected a large amount of evidence, which at first sight would seem very convincing in favor of the irritation hypothesis. He points out the frequency with which tumors are formed at places which, from their anatomical character, are subject to continual irritation. Such are the stomach, the oesophagus, the sexual organs, and the different orifices of the body ; in the digestive tract the constrictions, as the ileo-caecal valve. It can be readily understood that .such openings and constrictions are more subject to irritation than other parts, for here any irritating substance acts in a more concentrated form. He points also to the numerous cases in which a trauma has been alleged to be the cause of a tumor. It is certain that most tumors occur, especially the malignant ones, at the places mentioned by Virchow. In the statistics compiled from the Civil Register of the De- partment of the Seine, between the years 1830 and 1840, there were 9,118 deaths from tumors. Of these, seventy- eight per cent, were seated in the uterus, stomach, mam- ma, colon, or small intestine. Other statistics show about the same figures. The uterus is the seat in nearly- one-fourth of all the fatal cases. A strong argument in favor of the irritation theory of the cause of tumors has always been found in the so-called smokers' cancer, the epithelial carcinoma of the lower lip. This is much more frequent in men than in women. Burgono's sta- tistics, which are about the best that we have, give 219 cases in men to 10 in women. Sibley gives 27 to 3. Further, it has been shown that these tumors occur much oftener in the lower classes of society, among the people who smoke pipes, than in the upper classes, whose mem- bers smoke cigars. It is supposed that the mechanical irritation of the dependent pipe has more effect than the heat and smoke of the cigar. So striking as this may appear at first sight in favor of the irritation hypothesis, it loses much of its ground on a more critical examination. We must remember that any statistics made by comparing the frequency of the tumor in the smokers and non-smokers are not worth much, in view of the fact that almost everyone smokes. Certainly all the men in the lower classes who enter the hospitals for treatment, and from whom the statistics are made, do so, and further, they all smoke pipes. The cigar-smok- ing classes scarcely enter into the statistics at all. More- over, statistics show that in a number of other places of the body men are more subject to carcinoma than women. From the same statistics of Burgono, we know that car- cinoma is more frequent in the males than in the females, 405 Growths. Guaiac. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the oesophagus, tongue, pharynx, parotid region, anus, and bladder. In all these places there is no reason to assume that men are more subject to irritation than women. The face of a man is more subject to irritating influences than that of a woman, from a variety of rea- sons, among which must be reckoned the constant irrita- tion of shaving, and yet in women carcinoma of the face is more common than in men. As- another example of the production of a tumor by irritation, the chimney-sweeper's cancer of the scrotum is given. Pathological growths similar to these appear on the hands and arms of the laborers in paraffine and other tarry products, but it is by no means certain that such lesions should be ranked among the tumors at all. We cannot explain the frequency of tumors in the uterus on the ground of irritation, for, apart from the occasional physiological irritation, this organ is very little subject to irritating influences. Then, too, tumors appear in it most often when such an age has been reached that even the physiological irritation has ceased. Nor do statistics show that uterine tumors are more frequent in prostitutes than in other women, and it is known that certain tumors, as myomas, are most common in elderly unmarried women, in whom we must assume that even physiologi- cal irritation has been at a minimum. We see that a more careful examination of the facts which have been brought forward to bear out the irritation theory shows that they will not bear scrutiny. With regard to the causative influence of traumas, Boll's statistics in Langenbeck's clinic show that among 344 cases of carcinoma that were operated on, in 42, that is, in about twelve per cent., a trauma was given as the cause. In 574 cases of all sorts of tumors which were operated on in the Berlin clinics, from 1870 to 1880, in but fourteen per cent, was there a preceding trauma. Winnewarter gives as the statistics of mamma carcinoma, from Billroth's clinic only, 7.06 per cent.; and Maas, of Berlin, from 278 tumors of all sorts operated on in his clinic, but 1.44 per cent. We see that we have but this extremely small percentage, even where special investi- gation was made in reference to traumas. In all such cases, where traumas are alleged as a cause, we must re- member how prone people are to mistake a post hoc and a propter hoc. A woman in some way injures her breast. Under ordinary circumstances it would be forgotten, but after an interval of time a tumor may develop there, and she at once refers it to the blow. Although there is very little ground to believe in the irritative or traumatic theory of the causation of tumors, still it is a belief that is deeply rooted in the minds of surgeons, and a belief that is held by a great number of intelligent men must be re- spected. Another view has lately been brought forward by Cohnheim. It is not in all respects original with him, but he has widened and extended it. This is known as the germinal (Keim) theory, and briefly stated is as fol- lows : In the course of embryonic development more material is laid down for the development of the differ- ent parts than is used up. This material remains in its undeveloped, undifferentiated state in the organism, re- tains its embryonic power of growth, and may at any time begin to grow, forming a tumor. This excess of material may be laid down in any period of life, either at the time of the first differentiation of the germinal layers, or when the different organs are developed from these. Liicke, several years before, had accounted for the tera- tomas in this way, regarding them as due to the inclu- sion of the embryonic cells of one part in another. This existence of embryonic tissues in the adult has been proven to exist. Virchow has found islands of cartilage included in the shafts of the long bones of adults, and there is every reason to believe that the enchondromas spring from these masses. The embryonic character of the tissues of many tumors, particularly the sarcomas, speaks in favor of this view ; those whose tissue is the least differentiated, as the round- cell sarcoma, having the most rapid growth and the great- est malignity. We know, also, that frequently there are supernumerary parts formed, in which cases we must as- sume that the excess of material has reached a full typi- cal development. The inheritance of tumors is best ex- plained by this theory. Just as supernumerary parts are often inherited, as is the case with supernumerary fingers and toes, just so can the excess of formation leading to the development of tumors be inherited. That such embryonic tissues, when included in normal tissues, do have the power of unlimited growth, we know from the experiments of Zahn and Leopold. They have in- troduced pieces of embryonic cartilage into the aque- ous chamber of the eyes of adult animals, and a vig- orous growth of the tissue leading to the formation of actual enchondromas was the result. Similar pieces of adult cartilage, introduced under precisely the same con- ditions, simply underwent atrophy, and were absorbed. The occurrence of congenital tumors also speaks in favor of the germinal theory, and if we include under these the naevi and all tumors which prove fatal in the first year of life, their number'is not a small one. It is not necessary in this theory to assume the actual presence of such masses of embryonic tissue ; it is only necessary to as- sume that a certain portion of a tissue has retained its power of embryonic growth. We know that the founda- tion of all growth is laid down in the embryo. We can- not distinguish, histologically, the tissue of the uterus from that of any other unstriated muscular fibre of the body. Yet the uterus retains the power of enormous growth. That this does not depend on any special nervous influences, but is due to the tissue itself, we know from the fact that dogs whose spinal cord was cut have con- ceived and borne. Most of the giants have come into the world the same size as ordinary children, and sometimes their excessive growth has not commenced at all until some years after birth. Those cases are still more inter- esting in which a single extremity has taken on enormous growth. Cohnheim has shown also that the occurrence of tumors in certain places, where at the time of develop- ment certain complications existed by which opportunity for the formation of excessive tissue would be given, is in favor of his theory. Thus he shows that carcinoma of the rectum does not occur at the anus, which is essen- tially the seat of irritation, but two inches higher up, where the entoderm joins the invagination of the outer skin. Again, carcinoma of the oesophagus occurs at the juncture of the upper and middle third, where the tra- chea buds off from the primitive alimentary canal. This theory of Cohnheim's cannot be regarded as proven ; indeed, it is only a theory, but many of the phe- nomena of tumors which were incompatible with other theories become plain by this. Tumors are certainly hereditary, or better said, there often exists a family predisposition to their formation. There have been a number of cases reported in which this has been made very evident. Paget found carcinoma of the uterus in a grandmother, mother, and daughter ; Sibley, carcinoma in a mother and daughter, and in another case carcinoma of the left mamma in a mother and her five daughters. By far the most interesting case pointing to a family predisposition to carcinoma is that reported by Broca : First generation : Madame Z died from uterus car- cinoma in 1788, sixty years old. Second generation : four married daughters. A died of carcinoma of liver, sixty-two years old, 1820 ; B died of carcinoma of liver, forty-three years old, 1805 ; C died of mammary carcinoma, fifty-one years old, 1814 ; D died of mammary carcinoma, fifty-four years old, 1827. Third generation : Madame B had five daughters and two sons. Her first son died young ; the second son died of carcinoma of stomach, sixty-four years old ; the first, second, and third daughters died of mammary car- cinoma ; ami the fourth daughter died of liver carcinoma, all at ages between thirty-five and forty. Madame C had five daughters and two sons. The sons were not affected. All five daughters died, three of them from mammary carcinoma, one from uterus car- cinoma, and one from liver carcinoma, at ages between forty and sixty years. In the case of the histoid tumors, hereditary predispo- 406 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Growths. Guaiac, sition plays possibly a more important role in the carci- nomas. From an histological examination of the tissues of a tumor it is often very hard to form a correct opinion as to its malignity. The essential signs of malignity are rapid growth, invasion of surrounding tissues, and formation of metastases. We know that carcinomas always possess these properties ; but other tumors which agree with each other in their histological structure are in some cases ma- lignant, in others not. In normal growth no tissue, no matter how vigorous its growth may be, can overcome the resistance to its growth that a neighboring tissue offers. Epidermis, when implanted in the subcutaneous tissues under the most favorable conditions, will for a time have a limited growth, but soon atrophies and dis- appears. The same thing happens when pieces of peri- osteum are implanted in places where periosteum does not normally exist. Experiments made with the inoculation of tumors show the same thing. Such inoculations have not only been made from man on the lower animals, but from animal to animal. In the most malignant tumors, where we know the effects produced on the bearer when particles of the tumor enter into the circulation, cells and juices from such tumors have, with every precaution, been injected into the circulation with negative results. A few positive results have indeed been claimed, but their number is too few, in view of the frequency with which such experiments have been made, to lead us to have much confidence in them. Cohnheim assumes that the malignity of a tumor depends more upon the nature of the tissues of the bearer than upon any other moment. There must be a weakness, a want of resistance to the growth in the other tissues, to constitute malignity. This condition may be inherited or acquired. Age seems to be a predisposing moment, and Thiersch seeks in this want of resistance in the connective tissue, brought about by age, the cause of carcinomas, in that the connective tissue cannot resist the growth of the epidermis. Ac- cording to Cohnheim the germ of a tumor may remain quiescent for years, nay, it may never come to develop- ment, because it cannot overcome the physiological re- sistance of the tissues ; but when from any cause this re- sistance is lowered or taken away, then we have the tumor ; and a tumor is malignant just in the degree that this resistance is wanting. Inflammation may act in the same way by lowering the resistance, and if inflammation and traumas have any action in causing tumors it is most probably in this way. Naturally the malignity of a tumor depends much upon its seat. A tumor which in one place might be carried a lifetime without ill results, will in another be sure to produce death. The glioma might be considered in its general characters a benign growth. It grows slowly, has little tendency to invade other parts, and does not, as a rule, give rise to metastases, yet its frequent seat in the central nervous system makes it malignant. No tumor is, strictly speaking, benign; it can never be of any use to the organism, and there is no tumor which cannot result fatally. The simplest and most typical adenoma is devoid of function, and though usually not so malignant, can, under circumstances, show a degree of malignity not to be surpassed. In general, in the con- sideration of the malignity of a tumor, we can say, the more vascular a tumor is, the richer it is in cells, the more it departs from a typical character, the less ten- dency it shows to a higher degree of development as evi- denced by the presence of formed tissue, the more malig- nant it is. The reverse of all these speak, of course, in favor of its benignity. IF. T. Councilman. grows also, either wild or introduced, in the West Indies. Guaco has a great reputation among the inhabitants of many South and Central American countries as an anti- dote to snake-bites, and as a sort of corollary it has been supposed to be useful in hydrophobia, cancer, cholera, epi- lepsy, syphilis, etc. In the second, third, and last of these diseases, it has been recently recommended. Faure sepa- rated an amorphous bitter principle (which is probably not chemically pure) which he has called guacin. An odorous principle that appears to be present in the fresh, must be mostly dissipated in the dried, leaves. There is nothing in its chemical or evident physical properties that should lead one to regard Guaco as other than a tonic of the Eu- patorium order. In its native regions it is preferably given in the fresh state, one of the green leaves being infused in a cup of water, as a dose to be frequently repeated in case of snake- bite. Here the dried leaves may be prepared in any of the usual ways, and rather freely administered. Allied Plants.-Several other species of Mikania, growing in various parts of America, have similar re- puted virtues. M. scandens Linn., a slender woody climber of the United States, like the rest, is a sort of bit- ter tonic, but not in use. The genus is considered by many botanists to be only a section of Eupatorium. For the order see Chamomile. Allied Drugs.-The number of medicines that have been reputed to be antidotal to the venom of snakes, spi- ders, and centipedes is large. Of them none is proved to have any physiological or fully established clinical basis for its reputation. W. P. Eolles. GUAIAC (Guaiaci Lignum, U. S. Ph.; Lignum Gua- iaci, Ph. G.: Guaiaci Benina, U. S. Ph.; Gayac, Codex Med.; Lignum vita). The heart-wood and resin of Gua- iacum officinale Linn.; Order, Zygophyllacea. This is a small, evergreen tree, attaining eight or ten metres (twenty-five or thirty feet) in height, with a freely branching deliquescent trunk, and numerous, flexuose, Fig. 1426.-Section of Guaiacum Wood. (Baillon.) smooth, gray or green, conspicuously jointed stems. Leaves opposite, consisting of four or six pairs of oppo- site, oval, smooth and shining leaflets, the upper pair be- ing the largest. Flowers in umbel-like clusters from between the leaves, about two centimetres across, regular pentamerous, complete and perfect. Corolla spreading ; petals purple. Stamens ten. Ovary stalked, two-celled, several ovuled. Fruit obcordate; seeds two. It is a na- tive of the West India Islands, and the northern part of South America. It has been introduced into Southern Europe, where it is cultivated for ornament or curiosity. Guaiacuni wood was carried to Europe soon after the discovery of the West Indies (early in the sixteenth cent- ury), and made a rapid reputation for itself as a remedy GUACO. The drug at present known by this name is only one of a number of products known by it in tropical America; it is the leaves of Mikania Guaco Humb., Bonpl.-, and Kunth; Order, Composite (Eupatorium par ci- florum Aubl.). The genus is in most respects a Eupa- torium, but differs in habit and appearance from that ge- nus in having climbing woody stems, petiolate leaves, and depauperate flower-heads of only four flowers, and four involucre-scales. It is a native of South America, and 407 Guaiac. Gum Arabic. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. for syphilis and gout, a reputation that it unfortunately, very soon lost again in great measure. Two products of the tree are imported-the wood, which if of fair size and soundness goes to the turners to be made into pulley- sheaves, mallets, mortars, tool handles, etc., and the crude resin, rudely obtained from the living tree or fresh wood. The wood comes in logs several feet in length, and from two to six or eight or more inches in diameter, often irregularly crooked and branching ; they consist, except- ing the smallest, of a bright yellow, hard alburnum, and a greenish-brown, exceedingly hard and heavy heart, con- sisting of very much thickened wood cells, and an abun- dance of a peculiar composite resin. This wood is almost as hard and heavy as ivory, and turns the edges of tools not especially sharpened for it. That which reaches the drug market consists principally of the turn- ings and refuse of what is manufactured for the purposes above named. It should consist only of the brown or green heart-wood. Upon the addition of nitric acid, if it has not been deprived of its resin, it should give a dark, bottle-green color. The resin, which is partly obtained by incising the trees, and partly as a spontaneous exudation, also some- times forced out from the wood by heat, is a crude and impure substance. The officinal description is as fol- lows : "In irregular masses, or subglobular pieces, green- ish-brown or reddish-brown, internally of a glassy lustre, transparent in thin splinters, fusible, feebly aromatic, somewhat acrid ; powder grayish, turning green upon ex- posure to air, soluble in solution of potassa, and in alcohol; the alcoholic solution is colored blue on the addition of tincture of chloride of iron." Guaiac resin is very brit- tle, and insoluble in water. Composition.-The heart-wood contains about twenty - five per cent, of resin. This substance, which has just been described, contains about seventy per cent, of gua- iaconic acid, a yellow or brown, brittle, amorphous resin ; ten of guaiaretic acid, which is crystalline ; nine or ten of " beta resin," something like guaiaconic acid, and three or four of gum, besides ash, coloring matter, and various impurities (Hadelich). Action and Use.-Guaiac is an inactive substance, not producing any definite physiological disturbance. Its reputation depends upon clinical evidence entirely, and has had spells of waxing and waning. The high estimate early placed upon it in syphilis has disappeared since the real efficiency of mercury and iodine has been established. In gout, although perhaps useful, it is certainly no speci- fic ; as an emmenagogue it is no better nor worse than many others. In chronic and mild subacute rheumatism, and in rheumatic arthritis, the evidence in its favor is strong. It is perhaps one of the best remedies for these intractable maladies. Its use is purely empirical. Administration.-The dose of Guaiac (resin) is from half a gram to two grams (8 to 30 grains). It may be given in pill or powder, but the tinctures, of which there are two, one simple (Tinctura Guaiaci, U. S. Ph., strength I), made with alcohol, and one associated with am- monia (Tinctura Guaiaci Ammoniata, U. S. Ph., strength |), made with aromatic spirit of ammonia, are more gen- erally used. Both become turbid upon mixing with wa- ter, and are oftenest given in milk. Guaiac Wood is used as an adjuvant in the Compound Svrup of Sarsapa- rilla. Allied Plants.-Guaiacum sanctum Linn., of the West Indies, as well as of the southern part of Florida, contributes also to the sum of Guaiac. Allied Drugs.-Guaiacum belongs to the ill-defined class of medicines called alteratives. See Sarsaparilla. IK. P. Bolles. ovate, hairy, introrsely hooked scale, nearly as large as the petal itself. The eight stamens arise around the base of the pistil, from the apex of a short, thick, obliquely placed gynophore. Pistil single, three-celled, three-ovuled, developing into an ovoid, pointed, one-celled, and -seeded fruit ; the other two cells and their contents disappearing (as is common in this order) by abortion. Fruit, a cap- sule, one and a half centimetre or so (half an inch) in diameter, six-ribbed, andthree-valved. Seed large (one centimeter in diame- ter), globular or spheroidal, with a flattened base, and a slightly pointed apex. Its surface is dark-brown and very shiny, excepting the large chalaza at the base, which is light-colored, and before it is disturbed, covered with a large aril. It is exalbuminous and entirely filled by the large fleshy embryo. In general appearance and structure it may be described as a miniature horse-chestnut. Paullinia is a native of the northern and western parts of Brazil, the Orinoco Valley, and probably of other parts of South America, and is employed to make a stimulating beverage or food by some of the aboriginal tribes, which fills the place that tea, coffee, and coca do among other peoples. For this purpose the seeds are dried in the sun, pounded tt» a coarse powder, moist- ened with a little water, and made into compact balls or other masses. These are then dried by the fire and constitute " Guarana." From these cakes such portions as are wanted are scraped or rasped off in tine powder.* Although long in use by these savages, Guarana is only re- cently familiar to Europeans and ourselves, and has only been employed here as a medicine for about twenty-five years. Its use was never extensive, and is not increasing. Description.-Guarana has appeared in the market, like caoutchouc, gutta-percha, and other products of semi- barbarous people, in various fantastic shapes - snakes, crocodiles, birds, etc.-but comes now almost always in balls, cakes, or cylinders, the latter by far the most com- mon. These are of various sizes, from three to five cen- timetres in diameter, and fifteen to thirty in length, with rounded ends, and smooth but uneven surface. They are very hard and brittle, much heavier than water, and break with an uneven fracture, displaying by its mottled sur- face the coarsely-powdered elements of which they are composed. The resemblance of one of these sticks to some kind of German sausage, both in size, shape, color, and marking, is very striking. The odor of guarana is faint but peculiar, resembling that of cocoa-seeds ; taste bitter, astringent, something like that of raw coffee. Water and alcohol extract its properties. Composition.- This substance stands at the head of caffet//^-yielding products, containing, as it does, from three to five per cent, of that alkaloid, combined with tannic acid, of which it also contains a considerable amount. Besides these, an unimportant amount of fat, a little essential oil, considerable starch, and other ordinary plant constituents are present. The caffeine of this drug was first isolated in 1826, by Martins, who considered it to be a new alkaloid, which he named " Guaranine." Its identity with caffeine was demonstrated in 1840by Berthe- mot and Dechastelus, and confirmed by numerous chem- ists since then. Guarana is not always pure Paullinia seeds, cocoa, starch, and sometimes less agreeable sub- stances being often added, either to better it according to the taste of its South American consumers, or as an adulteration. Its composition, therefore, is variable. Action and Use.-If, as stated above, caffeine and tannin are its only active principles, the action of this drug should be exactly that of coffee and tea, without their aromatic principles ; that is, it adds the quality of a little astringency to the action of the alkaloid caffeine, to Fig. 1427.-Paullinia Seed, natural size. (Baillon.) Fig. 1428.-Section of the same. GUARANA, U, S. Ph.; Codex Med. A hard paste made by certain tribes of South American Indians, principally or wholly from the seeds of Paullinia sorbilis Martins (P. Cupana Kunth) ; Order, Sapindacea. This is a climb- ing shrub, with a slender, angular stem and branches ; large, long-petioled, pinnate leaves, and long, axillary, spike-like panicles of small, slightly irregular flowers. Each of the four petals bears upon its upper surface an * There is in the museum of the Harvard Medical School, the palate or tongue-bone of some large fish, which had been used for this purpose. It is a very efficient file. 408 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Guaiac. Guilt Arabic, which the reader is referred. As the contained dose of tannin is a small one, it is, in fact, a mode of giving caffeine, and little or nothing more. Its principal clin- ical reputation lies in its value in nervous and sick head- aches, of which there is considerable evidence. It has been the foundation of several widely known secret reme- dies for these afflictions. Administration.-The powdered drug can be given in gram doses or more, repeated once an hour, until the headache is relieved, or until several doses have been given. The fluid extract (Extradum Guarana Fluidum, U. S. Ph.) is rather neater, and of the same theoretical strength. Milk is a good vehicle for either. Allied Plants.-The genus contains eighty species, several of which are reputed to contain caffeine; some are said to be poisonous. The order is a moderately large one, but of little medical interest. It contains the horse-chestnut, buckeyes, and maples. Allied Drugs.-Coffee, Tea, Cola, Paraguay Tea, etc. See Caffeine, also, more remotely, Theobroma (cocoa) and Coca. W. P. Bolles. one from Sennaar, and a darker and still poorer grade from the vicinity of the eastern coast. The gummiferous acacias flourish in dry, sandy, and barren or rocky soil, and the yield of gum is greatest in the dry season. Although named from the great desert peninsula of Arabia, but little gum is really produced there and none exported. Before it reaches the consumer Gum Arabic is carefully sorted several times, so that lots of it show the greatest uniformity in appearance and color, although originally large and small, dark and light, and clean and dirty tears and fragments came mixed together. Varieties.-Besides the artificial grades established as just indicated, by sorting, there are a number of well- marked varieties of gum dependent upon the location of growth or the species of Acacia. The following are some of the principal : 1. Senegal Gum, from the same A. Senegal, growing in the province of Senegambia, in large sherry-colored, irregularly-shaped tears, with but few of the innumerable fissures characteristic of Gum Arabic from Nubia. 2. Suakim Gum, the product of one or two other Acacias growing near the east coast of Africa. 3. A North African or Barbary Gum, from the place of that name where it is collected, a brittle, much-fissured kind ; and 4, the Australian gums, from half a dozen other species. The so-called East India gum is really an African one which passes through Bombay in its course here. None of these is suitable for use in medicine, but they are consumed in enormous quantities in sizing- cloths for printing, etc. The Australian gum has a small amount of tannin in it. The common appearance of this substance is so familiar as to make a description unneces- sary, but the limitations and tests of the Pharmacopoeia are as follows : "In roundish tears of various sizes, or broken into angular fragments, with a glass-like, some- times iridescent fracture, opaque from numerous fissures, but transparent and nearly colorless in thin pieces ; nearly inodorous ; taste insipid, mucilaginous ; insoluble in alcohol, but soluble in water, forming a thick mucila- ginous liquid. Aqueous solution acid, precipitated by subacetate of lead and alcohol. Ferric chloride also pre- cipitates it." Composition.-Clean white gum consists almost en- tirely of a combination of Arabic acid with calcium. These may be separated by a mineral acid which, uniting with the earth, sets the Arabic acid free. It may be so obtained by placing the solution in a dialyzer, when the salt will pass through, leaving the arabin behind, still in solution. If this is now treated with alcohol it is precipitated, and may be dried to a white powder, but once dry arabin will not dissolve again in water without the addition of some earth, like lime. The ash-excepting that in combination-the coloring and odorous substances, are very unimportant. Action and Use.-Gum is an innutritions and useless food which used to be added to water in preparing anti- phlogistic drinks for fever patients. It has been also given as a demulcent in renal congestion and vesical ca- tarrh, as well as in pharyngitis and bronchitis. For these purposes it is still a little given. In pharmacy it is more useful, being employed to hold insoluble substances in suspension, as an ingredient of pills and troches, as a pleasant and adhesive vehicle for cough mixtures, in emulsions, etc. There is no dose ; it can be taken ad lib- itum, but should not be prescribed in connection with al- cohol, lead salts or borax, or anything that may precipi- tate it. The officinal mucilage {Mucilago Acacia, U. S. Ph.) contains thirty-four per cent. The syrup {Syrupus Acacia, U. S. Ph.), a pleasant vehicle consisting of one- fourth mucilage and three-fourths syrup, is frequently used in prescriptions. It does not keep well. Allied Plants.-Besides the dozen or more species which contribute some sort of gum, the genus comains numerous astringent ones of local use in tanning, etc. Catechu is the product of one, A. Catechu Willd. For the order, see Senna. Allied Drugs.-Various mucilages and gums ■ Tra- gacanth, Elm, Marshmallow, etc., and more remotely, the starches. See Tragacanth for the composition, etc., of gums iu general. IK P. Bolles. GUILLON. A mineral spring in France, the tempera- ture of which is 55|° F. The analysis of its water, by Henry, indicates the prepuce of a little more than one- tenth grain of calcium sulphide in each pint, together with a small amount of free sulphuretted hydrogen. The bathing establishment of this place is one of the most tastefully equipped in France. Especial action on the lymphatics and the mucous membranes is attributed to the water of Guillon. J. M. F GUM ARABIC {Acacia, U. S. Ph.; Acacia Gummi, Br. Ph.; Gummi Arabicum, Ph. G.; Gomme arabique vraie, Codex Med.-Senegal Gum, Gomme du Senegal, is also official in France). In a loose way Gum Arabic is the term used to designate the hardened tears of a number of species of Acacia, growing in various parts of Africa and in Australia, but in a properly restricted sense, as un- derstood in the pharmacopoeias, it means only the better and whiter qualities, obtained in the Upper Nile region of Eastern Africa, principally from Acacia Senegal Willd. (A. Derek Guill. et Perrott., Mimosa Senegal Linn.), order, Leguminosa {Mimosa). This is a small, straggling tree, with slender, irregular, crooked branches and tortuous twigs, with swollen prickly nodes. Leaves alternate, bipinnate with opposite, minute, narrow pinules. Flowers small, in long, lax axillary spikes, with minute calyx and corolla, and very numerous long, yellow stamens, which form the most conspicuous part of the flower. Ovary simple, minute, hidden among the stamens. Fruit a large, flat, four-or five-seeded legume. This Acacia grows in abundance, both in the western part of Africa, where it is the source of the coarser, yellow Gum Senegal, and in the eastern part, from the sources of the Nile to the coast. It is in this latter region that the finest quality of clean, white " Kordofan," etc., Gum is obtained. There are few articles which have been used from a more remote antiquity than Gum Arabic, as the following instances, condensed from the Pharmacopoeia, will show: It was brought from the Gulf of Aden as early as the seventeenth century b.c. In the treasury of Ramses III., at Medinet Abu, there are representations of gum-trees, together with heaps of gum. The Egyptians used it (as we do now) largely in painting. It is mentioned by Theophrastus (third century Brc.) as coming from Upper Egypt. Celsus, Pliny, and other early writers also men- tion it as an Egyptian product. Its use in Europe, how- ever, was not general until a much later period. Collection.-The gum, which exists in solution in the bark, exudes spontaneously, or as the result of punct- ures made by the negroes, somewhat as the cherry-tree gum does occasionally from our trees, and hardens in ir- regularly rounded tears. These are broken off from the stems or picked up from the ground, collected in baskets, and sent in an unsorted condition down the Nile. The best quality is obtained from Kordofan, a less valuable 409 Gu ruin a. Gumma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. GUMMA. The name gumma is given to certain of the late products of syphilis which appear in the form of more or less circumscribed tumors, and which are the most characteristic of all of the pathological lesions pro- duced by this disease. The name is derived partly from the firm and elastic consistency of the growths, and partly from the character of the fluid which exudes from some of them on section. The superficial gummata of the bones have been longest known. They appear in the form of elastic swellings, which on section empty a tough, sticky fluid, which was formerly considered as a free exudation lying between the bone and the periosteum. There are certain characters which are common to all gummata, and these we shall consider in detail. There are, however, differences in structure which depend on their situation in the different tissues. Probably the most typical and the most easily studied gummata are those which appear in the internal organs, especially those in the liver. These were first clearly described by Dittrich in 1849. He did not regard them as new formations, but connective tissue. In studying the gumma it is neces- sary to bear in mind its two components, the central mass and the connective-tissue capsule. The centre has a dry caseous appearance, and is very similar to the caseous mass found in the centre of a tu- bercle, but differs from this in being firmer, denser, and more elastic. It cannot be easily crushed between the fingers to a mortar-like mass, as can the tubercular prod- uct. On scraping, and examining the scrapings in water with a power of three or four hundred diameters, we shall find nothing but some irregular cells in which no nucleus can be made out, much granular detritus, and some re- mains of connective-tissue fibres, with here and there a spindle-shaped nucleus. On a thin section of the mass, after hardening in alcohol and staining, it will seldom be found of a homogeneous nature throughout. Some parts of it will stain more brightly than others, and bands of firm, pale connective tissue containing a few spindle-cells pass into it from the capsule. These bands of connective tissue are gradually lost in the caseation. Blood-vessels are not altogether wanting ; here and there one will be found in or alongside of the connective-tissue bands, and the remains of them will be seen in the caseation. Those that are preserved are distended with blood- corpuscles, showing that the circulation is very sluggish. The caseous mass is princi- pally composed of de- generated round- and spindle-cells, which are imbedded in a firm, homogeneous tissue. In some cases the capsule is sharply sep- arated from the central mass, in others it passes gradually into it, the cells gradually losing their power of staining, and the connective tis- sue its fibrillar arrange- ment. The capsule is of variable width, and can be roughly divided into three zones, which gradually pass into one another. The begin- ning of the capsule formation is found in liver-tissue, which ap- pears but little altered. There is first an in- crease of the connective tissue along the capillaries, and between the single liver-cells. This gradually in- creases in amount, and single liver-cells and groups of them become enclosed in the connective tissue. These cells degenerate, their nucleus disappears, and they fi- nally become transformed into irregular pigment masses. The cells in the connective tissue in this place are round or spindled and abundant. In the next zone the cells be- come distinctly spindle-slmped, and the fibres have a par allel course abound the central mass. As this is neared the cells become fewer in number, and the connective tissue denser. Just as in most forms of cirrhosis he- patis there is apparently an increase in the number of bile-ducts in the newly-formed connective tissue, so are they met with in the capsule in great numbers. It must here also remain a question whether they are newly formed. The zone of connective tissue is not a regular one, but large, dense bands run from it into the liver-tissue, generally following the course of the portal vessels. Fig. 1429.-Section of an Old Gumma in the Liver, a. Central caseous mass ; bb, bile-ducts ; cc, atrophied liver-cells enclosed by connective tissue. X 9. as exudations which had not become organized, and which were shut off from the surrounding tissue by a capsule formation. In many cases of constitutional syph- ilis we find in the liver dry, firm, caseous masses sur- rounded by a dense, pale connective tissue. They are of a light-yellowish color, and vary in size from a pin's head to that of a walnut. They are seated either on the surface of the organ, or deep in its parenchyma, and may occur singly or in great numbers. When they are pres- ent the liver seldom preserves its normal smooth appear- ance, but has deep, irregular furrows, which run in vari- ous directions over its surface, and give the organ a rough, lobulated appearance. On section it is seen that this condition is due to the contraction of bands of dense connective tissue which traverse the organ in various di- rections. In such bands of connective tissue the gum- mata are most frequently found. In other cases the or- gan is perfectly smooth on the outside, and on section one or twro nodules will be found which consist of a whitish central mass surrounded by a pale gelatinous 410 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gumma. Gumma. The blood-vessels in the outer zone of the connective tissue are abundant, but they become fewer as the centre is reached. The larger arteries are often occluded by a process which is most frequently as- sociated with syphilis, but is also found in other conditions. There is a formation of connective tissue which proceeds from the intima, and gradually tills up the entire calibre of the vessel. At the same time the adventitia and the muscularis become tilled with small cells, and gradually the entire aspect of the vessel is lost, and nothing remains to designate it but the folds of the elastic membrane. Even in the midst of the caseous material, irregular remains of the elastic coat show the former presence of the artery. There is also an in- crease in the thickness of the walls of the smaller vessels, which takes place at the expense of the lumen. Their walls are often changed into firm hyaline tissue. Their calibre is often further occluded by the press- ure of the connective tissue. Giant cells similar to the tubercu- lar giant cells are sometimes found. They are most frequent just outside of the caseation, though they may be found at any place in the capsule, and their remains are often to be made out in the caseous material. The development of the gumma is of great interest. It is only in rare instances that nodules are met with, so small, and in so early a stage, that this can be studied. It is seen best in the livers of children who die at an early age from syphilis. The first crease in the formation of this connective tissue differs from that in cirrhosis hepatis, which follows along the portal vessels. In the formation of the gumma, it takes Fig. 1430.-Occlusion of a Small Artery in a Case of Gummata of the Dura Hater. The artery is filled with a mass of connective tissue in which vessels have developed. The elastic coat is preserved. Adjoining the artery is a patch of hyaline degeneration. place along the capillaries, and between the individual liver-cells. As it in- creases in amount , the cells in the centre undergo degeneration and coagulation necrosis, and in this way the caseation begins. Frequently there are several centres of caseation which come to- gether, and in this way the separate areas seen in the large caseous masses arise. No very sharp line can be drawn be tween the formation of gummata and the connective-tissue hyperplasia, so often found in various organs in the late forms of syphilis. We would re- gard the formation of gummata as in- dicating a more severe form of the same process ; in their formation a co- agulation necrosis, a caseation, is added to the connective-tissue hyperplasia, and we would only call those forma- tions gummata in which we have the caseous central mass surrounded by indurated connective tissue. The two processes are often seen together in the same organ, in the liver in the large bands of connective tissue in which gummata are seated ; but possibly it can be seen better in the testicle than elsewhere. In one form there is a chronic interstitial inflammation of the connective tissue between the seminal tubules, most often associated with a thickening of the albuginea. Cones of dense, firm tissue pass in from the albuginea between the tubules, and gradually take the place of these, the testicle being changed into a firm Fig. 1431.-A, Syphilitic Testicle. There is a great increase in the connective tissue, with a corre- sponding decrease in the glandular elements. B, Gummata of Testicle. In the lower portion of the figure are some remains of the glandular tissue. thing seen is an infiltration of tliQ tissue with round-cells, which become changed into connective tissue. The in- 411 Gumma, Gurjun Balsain. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fibrous mass. When the process is more severe yellow caseous masses develop in this thickened fibrous tissue, and lie partly in the thickened albuginea and partly in the fibrous tissue of the testicle. At first these caseous masses are not sharply circumscribed, but later the tissue around them becomes denser and forms a sort of capsule. gummatous tissue is so closely connected with the pia that it is difficult to say from which membrane the growth originated. In one case seen by the writer there was a dense mass of connective tissue, from a line to a half-inch in thickness, between the dura mater and the brain cor- tex. On section there were found numerous oblong areas of caseation of various sizes, each surrounded by a capsule somewhat denser than the other tissue. The connective tissue of the dura mater passed directly into the growth. The pia was also thickened and in- timately adherent to the brain cortex, which was narrowed over the apices of the convolu- tions, and contained numerous small areas of haemorrhage and fat- ty degeneration. On microscopic examina- tion numerous areas of hyaline degeneration were found in the con nective tissue adjoining the caseation. In such places the connective tissue was changed into a firm, completely homogeneous, sharply refracting substance. There were no cells en- closed in this. It ap- peared in irregular patches of varioussiz.es, and retained its essen- tial characters even after it had become en- closed in the caseous mass. Gummata arc often found in the pia mater, and in this place reach a very considerable size ; those of the size of a walnut are not infrequent. These larger tumors are not solely confined to the pia, but they attack the brain-substance, the nerves, and the dura. They are found most often in the loose tissue on the base of the brain, in the region from the optic chiasm to the pons, and behind the pons on the crura of the cerebellum. The tumor is rare in the brain-substance. The writer has seen one case in which, along with advanced syphil- Fig. 1432.-Gumma on one of the Arteries in the Sylvian Fissure. In the small artery at the bottom there is an ob- literating endarteritis similar to that shown in Fig. 1430. In the arteries there is sometimes seen a true formtitioii of gummata forming hard nodules along the vessels. This may or may not be associated with an endarteritis, and is widely different from this. The growth takes place in the adventitia, and commences with an increase of the cells and a formation of granulation-tissue. As the process increases there are several points of coagula- tion necrosis and the formation of true gummata. This affection of the arteries is rare, and is chiefly met with in those of the brain. The gumma is not always so circumscribed as it is met with in the liver, but there is also a more diffuse form best studied in the dura mater. There may be a general increase in the thickness of the dura, a syphi- litic pachymeningitis, without any formation of gummata. The gummatous tissue may be seated either on the outer or on the inner side of the membrane. In the former case the dura is with difficulty separated from the inner surface of the skull, and in numerous places a yel- low caseous mass will be found, over which the surface of the bone presents an eroded, worm-eaten appearance. These patches may be small and circumscribed, or nearly the whole surface may be covered with such material. On the inner surface the Fig. 1433.-Formation of Gummata on the Internal Surface of the Dura Mater. itic processes in the liver, testicles, and other organs, two small, firm, yellowish nodules were found, one on each side of the fissure of Rolando. There was no con- nection with the pia mater, which was easily stripped off. 412 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. G u 111 ma. Gurjun Balsam. On section of the larger nodule it was found to involve the entire gray matter, which had disappeared, and its place was occupied by the growth. There was a central caseous mass surrounded by an area of connective tissue, and the brain-substance immediately in the neighborhood was sclerotic. The development was best stuclied on the smaller of the growths, where the caseation was not more than a line in width. The first change seen in the brain was an increase of the cells in the spaces about the ganglion cells, and in the neuroglia. With the increase in number of the small cells, the ganglion cells atrophied and disap- peared, the neuroglia became distinctly fibrous and formed a reticulum, the spaces in which were originally those occupied by the ganglion cells, but which had now be- come filled with small cells. There were also great num- bers of large cells filled with myelin drops. The caseous area was surrounded by a delicate connective tissue which contained large stellate and spindle cells. Wagner has described the gummata under the name of syphiloma, and considers as peculiar to them a feticu- lum of connective tissue in which small atrophic cells are found. Such a reticulum is found when the anatomical structure of the organ in which the gumma develops is of such a character that a reticular structure is easily formed. An approach to a reticulum is also found some- times in the liver, but in by far the majority of cases nothing like a reticulum can be made out. Nothing is characteristic of the gumma but the charac- ter of the caseation and the connective-tissue development around it. It approaches the tubercle both in its micro- scopic and macroscopic appearances. In both we have the central caseation, and around this, in the tubercle also, there can be some formation of con- nective tissue, but this never reaches the same extent that it does in the gumma. The first steps in the development of both are the same. In the tubercle, however, the cells do not reach the further stage of connective tissue. The consequence is, that the central caseous mass of tu- bercles is composed of round- cells with the remains of some old connective tissue, while the similar tissue in the gumma is composed of newly-formed con- nective tissue. It is this newly- formed connective tissue which makes the caseous mass of the gumma so much firmer, denser, and more elastic than the tubercle. The caseation is due in both to the same process, a coagulation necrosis, but in the syphilitic product the cells have a greater capacity for resisting the action of the virus. Neisser has advanced the idea that the central caseous mass is the true tumor, and the capsule around it is the product of a reactive inflammation, and forms just as a capsule forms around any foreign body, as around a bul- let or an old infarction. He says that he has been able to produce similar appearances in the liver by causing a circumscribed necrosis by the injection of various sub- stances into the parenchyma of the organ. We are not able to agree with Neisser, but must regard the capsule as forming just as essential a part of the gumma as the cen- tral caseation. A careful study of a number of gum- mata in the liver will show that the caseation advances in extent by the continual involvement of portions of the capsule. If only the older tumors were studied, in which there is apparently a cessation of growth, and the central mass is sharply separated from the capsule, the views of Neisser would seem probable. Virchow has extended his theory of the traumatic ori- gin of tumors to the gummata. As proof of this he adduces the fact of their appearing principally in those bones which lie closest beneath the skin, and which are, therefore, most exposed to traumatic influences. In the liver they most often occur in those situations -where traumas would be likely to be of influence, as beneath the suspensory ligament, and at points where adhesions have taken place with the diaphragm. Baumler advanced the view that the gummata de- pended on accidental influences acting on a tissue which was already influenced by syphilis. There is no doubt that there is some modification of the tissues produced by the action of the syphilitic virus, and that it is only in such tissues that this form of syphilis can be produced. This modification of the tissues shows itself in various ways, by the further non-susceptibility of the tissues to the earlier forms of syphilis, by the decided anaemia and cachexia, and further, by the tendency to amyloid degen- eration. Neisser accepts the view of Baumler, that there is a modification of the tissue, but claims that the forma- tion of gummata in such a tissue is not due to traumatic or accidental influences, but to the direct action of the syphilitic bacillus. Since the article of Neisser has been written Lustgarten has been able to find, by peculiar and complicated methods of staining, bacilli in all of the prod- ucts of syphilis, including the gummata. The bacilli are found in small numbers, and are very similar to the tubercle-bacilli. It would seem probable that something more would be necessary to the production of the gum- mata than the presence of the bacilli in the modified tissue. Were this not the case, then inoculation of such tissues with any product of syphilis containing the bacilli (as a mucous patch, or initial sclerosis) should produce a gumma. Such inoculation is known to be perfectly in- nocuous. It is possible that there is some change going on in the bacilli, but it is more probable that it is only under certain conditions, when the resistance of the cells is in some way lowered, that the gumma is produced. The caseation in the gumma is principally due to the action of the bacilli on the tissue. It is possible that the modifi- cation which the tissue has already undergone may pre- vent it from-reacting under the presence of the bacilli as it did in the earlier stages. It cannot be due merely to the influence of inflammation, for inflammation in such subjects does not ordinarily lead to the formation of gum- mata. There are many points which at present seem in- comprehensible, either with or without the assumption of a bacillus being the active agent in the virus. The dis- covery of the tubercle-bacillus has cleared many points in tuberculosis which previously were dark, and we may hope that a careful study of syphilis with the bacillus as its known virus will also shed some light on this dark ter- ritory. W. T. Councilman. Fig. 1434.-Guinma Seated on the Posterior Central Con- volution and Developed in the Gray Matter. GURJUN BALSAM ; Wood Oil. A viscid, copaiba- like turpentine, obtained from half a dozen or more ma- jestic Asiatic trees of the genus Dipterocarpus* The "balsam" is collected by making deep "boxes" or gashes in the trunk of the tree, scorching them, and fitting a bamboo spout to their lowest parts. The yield is very great, and the drug forms quite an important article of commerce in the East. It is officially recognized by the Indian Pharmacopoeia, and extensively used there as a substitute for copaiba. It is an intensely fluorescent, thick liquid, of a mild, terebinthinous odor, and a bitterish, aromatic taste. By transmitted light it is of a deep, sherry color, and per- fectly transparent; by reflected light it appears opales- cent and greenish-gray. It is soluble in chloroform and the essential oils, but not completely so in alcohol. It consists of thirty or forty per cent, of a mild-smelling essential oil associated with a composite resin, composed of a crystalline gurjunic acid, and an amorphous portion. As it is collected from several different trees, its appear- ance, and also probably its composition, are subject to considerable variation. Uses.-In India and Asia generally as a substitute for Copaiba in the treatment of gonorrhoea, etc., and as a varnish. It is occasionally to be got in this country, but is only prescribed as a novelty. Allied Plants.-The genus contains about twenty- * The following are mentioned in the Pharmacographia : D. turbinatus Gaertn., D. incanua Roxburgh, D. alatus Box., D. zeylanicua Thw., D. hispidua Thw., D. crlapalatus, and several others. 413 ourjun Balsam. Gyn. Examination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. five species of the most imposing trees of tropical Asia. Dryabalaiwps, which yields the Borneo Camphor, belongs in the order. Allied Drugs.-See Copaiba. W. P. Bolles. 120° F. it becomes very plastic, and maybe moulded into any shape and welded, resuming its hardness upon cool ing. Ordinary Gutta Percha is an impure substance, containing inevitably, by the method of its collection, a considerable amount of coarse admixture of vegetable tissue, chips, etc., besides the residues of the evaporation of portions of the liquid juice, imperfectly separated from it in coagulating. It is soluble in chloroform, turpentine, carbon disulphide, etc., but not in water, alcohol, acids, or alkalies. Its purification may be effected by solution in one of the above, or by mixing with hot water and straining. The sheets, in which form it is generally sold for surgical uses, are made by rolling it while hot between cylinders. Composition.-The principal portion, Seventy-five per cent, or so, of good Gutta Percha, consists of an amorphous white mass or powder having the general properties given above, named gutta. It contains, further, fourteen to six- teen per cent, of alban, a light flaky powder soluble in GURNIGEL. A village in Canton Berne, Switzerland, situated in a fertile plain on the steep northwestern slope of the Obergurnigel mountain, at an elevation of almost three thousand eight hundred feet, of interest on account of its gypsum-sulphur springs. The. climate of this region is healthful and invigorating, but, like that of all elevated regions, it is excessively cold in winter, and subject to sudden changes of temperature, even in summer. There are two principal sources of the water, one known as the Stock Spring, the other as the Black Spring. The water from the latter is usually mingled for use with that of a more recently discovered spring. The chief ingredient of the water is calcium sulphite, with small amounts of other earthy salts, and only a trace of sodium chloride. These waters contain, how- ever, abundant free carbonic acid, and some sulphuretted hydrogen. The Black Spring contains a larger amount of sulphates, and is, therefore, considered the more potent. Action and Indications.-In large doses (twenty-four ounces) Gurnigel water produces marked depression of the circulation, as well as a calming of the nervous sys- tem ; while still larger quantities (two pints) occasion irresistible drowsiness (Eulenberg). These waters have been recommended in chronic gastric catarrh ; in chronic constipation, particularly in that form dependent on a relaxed state of the muscular walls of the intestines ; in chronic diarrhoea ; in hepatic congestions, and in haemor- rhoids. They have also been used with benefit in the treatment of certain intestinal parasites, notably the taenia mediocanellata ; and are recommended alike for catarrh of the respiratory passages and of the genital organs; for uterine hypertrophies, and dysinenorrhcea. Many other diseases, it is claimed, subside under their action, some of which, as anemia and chlorosis, are not usually benefited by sulphur waters. Hysteria, hypochondriasis, migraine, and other neuralgias, hay-fever, Basedow's disease, alco- holism, eczema, and erysipelas are in the list. It is evi- dent, however, that not every case of these affections, particularly those in which an active hypersemia of the diseased organs exists, is amenable to treatment with water of so great potency; while certain other diseases, as tuberculosis, are ruled out by the severity of the climate. J. M. F. GUTTA PERCHA, U. S. Ph., Br. Ph., Codex Med. (Percha Lamollata, Ph. G.). This remarkable substance is admitted into the pharmacopoeias of most countries on account of the elastic varnish which can be made from it, and of its value in the making of plastic splints in sur- gery. It is a sort of resinous product which coagulates from the milky juice of Dichopsis Gutta Benth. Hook. (Isonandra Gutta Hooker); Order, Sapotacea, a large tree growing, now or formerly, in many parts of Southern Asia, and in the great islands of the Pacific. Gutta Percha was first brought into European use in 1842, having been previously employed by the aborigines in the manufacture of knife and weapon handles. From the vicinity of Sin- gapore, where it was previously abundant, from Penang, and other accessible places, the tree has been practically exterminated by the wasteful method of collecting its val- ued product. It still exists, however, in abundance in the Malay Peninsula, whence most of the Gutta Percha now comes, in Borneo, Sumatra, and other places. The method of collection is as follows • The trees are felled and the bark stripped off, when the milky product beneath it col- lects upon the surface of the wood, and is scraped off and put into a hollow leaf or other convenient receptacle." This juice quickly coagulates upon exposure to the air, and the putty-like curd is moulded while yet soft into blocks or cakes of various sizes and shapes. It is of a light or medium brown color, often gray upon the sur- face, sometimes, when nearly pure, white or ash-colored, of a peculiar rubber-like odor, and a rather flexible con- sistence at common temperatures. At something above Fig. 1435.-Dichopsis Gutta. (From Baillon.) boiling alcohol, and from four to six and a half of fluavil, which is rather more soluble than either of the above (Payen). Uses.-Gutta Percha is only employed in medicines on account of its physical properties. Its solution in chloro form (Liquor Gutta Percha, U. S. Ph with ten parts of carbonate of lead added to mechanically carry down coloring matters and impurities) is an excellent protec- tive varnish for abrasions, excoriations, and small wounds, to be used in the same way as collodion. The officinal mustard paper (Charta Sinapis, U. S. Ph.) is prepared with it. In sheets, from one-eighth to one fourth of an inch thick, it is to be had of the instrument makers as a splint material. For cases in which there is a good deal of irregularity of surface to be fitted, as in fractures of the jaw, the bones of the thumb or great toe, or the metacarpal or tarsal bones, it is very useful. Also in making splints that must be often taken off and reapplied. The form of the splint should be cut about one-fourth larger each way than the desired splint, as it shrivels when softened, and then thrown into water at a temperature of about 130° or 140° or more. The limb having been pre- pared by adjusting the parts, shaving, bandaging, etc , as 414 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gyn.Exami'naiion. required, the softened splint is laid on the part and quickly moulded by the fingers to form. A bandage where neces- sary is then applied, and cold water poured over all. When hardened it may be taken off, trimmed, and permanently reapplied. If it is desired to piece or weld the gutta percha, it should be softened by dry heat, as over a lamp or gas. The fingers may be wet while handling it. Its use in sub- marine cables and other electrical apparatus is very exten- sive. Allied Plants.-Other species of Dichopsis contribute a certain amount to the stock of Gutta Percha. So also do several other trees of the order, which produces nothing else of commercial importance. Allied Substances.-See Caoutchouc. In Surgery, also Collodion. As substances for making extemporane- ous splints, felt soaked in shellac, and sole leather are the nearest substitutes; but splints made of bandages satu- rated with starch and glue, dextrine, soluble glass, and plaster-of-Paris are much more used. W. P. Bolles. for the feelings of the patient, the thoroughness with which the pelvis can be explored when the abdominal muscles are relaxed by a few whiffs of an anaesthetic, ought to be a sufficient advantage to induce physicians to resort to it more frequently than they do, instead of making at their offices a superficial examination, under circumstances which render it almost as disagreeable for themselves as for the patient. The patient having consented to an examination, is conducted to the table, which should be placed behind a screen near a window. Table.-Whenever it is practicable, the patient should be placed upon a table, since it is important that the hips should rest upon a firm, unyielding surface; a sofa or couch is less desirable. There are, of course, circumstances under which it is necessary to examine patients in bed (in case of haemorrhage, acute inflamma- tion, etc.), but even then a substitute for a table may be extemporized by slipping a common lap-board between the sheet and mattress. The speculum must be used to a great disadvantage under these circumstances. Numer- ous costly and complicated tables, couches, and chairs have been devised, but none of these presents any advan- tages, save from an aesthetic standpoint, over an ordinary solid table, the dimensions of which are: length, four feet; height, three feet; width, two and a half or three feet. The foot of this table should be raised a couple of inches above the head, which may easily be effected by sawing off the upper legs to the necessary extent. Cas- ters are rather an objection, at least in private practice. Such a table as I have described is sufficient for every purpose, from an ordinary examination to an ovariotomy, and is the only one that has been in use in the Woman's Hospital for many years. The Examination.-This may be conducted either with or without the aid of instruments. In proportion as the examinee's tactus eruditus becomes refined his actual dependence upon instruments, as far as making a diag- nosis is concerned, will become less. We shall consider, first, the examination without in- struments. Unnecessary confusion has been introduced into English text-books by retaining the complicated Ger- man terms which describe the posture of the patient. No less than six or eight possible positions exist, but for prac- tical purposes the dorsal recumbent, and the left lateral, or latero-abdominal (Sims' position) will suffice. It is naturally repugnant to the feelings of a sensitive woman to be examined either in the genu-pectoral (knee-chest) or erect posture. It is only exceptionally that these will be insisted upon in private practice. English gynaecologists prefer to examine upon the side, their ordinary obstetric posture. There are special advantages in this position, to which reference will be made subsequently. With us a woman is first placed upon the back with the knees flexed, the nates are brought close to the edge of the table, and the thighs are abducted widely. Her clothing having previously been loosened and so arranged that both the external genitals and the lower part of the abdomen are accessible, she is covered with a sheet so as to scrupulous- ly avoid all exposure of the person. Of two equally com- petent practitioners he will certainly be the more success- ful as a gynaecologist who shows the greater consideration for the feelings of his patient in this respect. This is an attention which is appreciated by the most humble pa- tient, and, even as a matter of policy, if for no higher mo- tive, it is seldom thrown away. Is it absolutely necessary to have a nurse ? This question is an important one. As this is written, not for specialists, but for the general reader, a negative reply may be given. One thing is cer- tain, unless one is quite sure of his patient, it is highly desirable that a third party should be present at the ex- amination, especially if it is the first one. There are so many cases on record in which malicious charges (gen- erally without the least foundation) have been brought against reputable practitioners, that it is the physician's duty to guard himself in every way. A female compan- ion may also be of great assistance, in the absence of a nurse, by soothing a nervous patient, arranging her cloth- ing, holding the speculum, etc. GYN/ECOLOGICAL EXAMINATION. Anamnesis.- Before proceeding to the physical examination of a patient suffering with disease of the pelvic organs, it is always desirable to obtain a few facts with regard to her symp- toms. It is a mistake to assume that the elaborate sched- ules which appear in text-books on gynaecology need to be followed in every instance. As a man acquires more experience in this department of medicine, he comes to place less and less importance upon a lengthy history, and relies more upon the elicitation of a few accurate re- plies to his questions. A correct anamnesis will either show that the symptoms complained of are due to other than local causes, or it will at once point to the genital or- gans, at the same time giving the attendant some clue as to the condition which he will find on making a vaginal examination. It is unnecessary to enlarge upon the methods of obtaining a history. The man who shows the most tact and consideration for the feelings of his pa- tient will certainly obtain the most information. Noth- ing is gained by brusqueness or indelicacy. As a rule, a woman suffering with uterine trouble will state her symptoms with sufficient clearness, with an occasional hint from the questioner, because those symptoms are perfectly clear before her own mind. Pain is the symp- tom in gynaecological practice. Its character, seat, peri- odicity, or relation to the menstrual period should be carefully determined. Disorders of menstruation and the so-called " hystero-neuroses," or reflex ovarian symp- toms, should receive due attention. There will always be two or three points, such as constant aching or drag- ging pain in the back or sides, dysmenorrhoea, haemor- rhage, etc., which will furnish a clue to the true condi- tion. Other symptoms, as leucorrhoea or vesical irrita- tion, are so general, that it is not desirable to lay much stress upon them. In cases of appreciable abdominal en- largement the patient will at once refer to the most striking phenomenon, when the questions can be framed accordingly. For details as to the best methods of ob- taining and recording histories, the reader is referred to such manuals as those of Munde and Hart and Barbour. Whatever system he may choose to follow, whether his own or another's, he ought to adhere strictly to it. There is no branch of medicine in which habits of routine are so likely to guard their possessor against error as in gynae- cology. Local Examination.-Proposing an Examination. It may be safely assumed that few reputable women ap- ply to a physician for the relief of pelvic troubles until they feel obliged to do so, and that when they come they are prepared to submit to an examination. That prac- titioner will then display the most tact who does not ask a patient if she wishes to have such an examination, but who suggests it as a matter of course. It will seldom be refused to the man who, by his kind and dignified de- meanor has at once created the impression that he is a gentleman. Wherever practicable, it is desirable that un- married women (who are ' ' virgins indeed ") and very nervous or hyperaesthetic individuals should be examined under ether at their homes. Aside from a consideration 415 EX" <* ■ 11 ■ 11U 114" II* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Due order ought to be observed in the various steps of the examination. Exceptions to the rule are numerous, but in ordinary cases the reader is recommended to pro- ceed with, 1, the inspection of the external genitals; 2, the digital touch ; 3, the bimanual. Inspection of the External Genitals. This is rapidly effected by lifting the sheet and allowing the light to fall upon the parts. The presence or absence of any of the ordinary pathological conditions will be noted most read- ily by examining the genitals in order. Thus the appear anceof themons, the condition of the labia (as regards the presence of swelling, varicose veins, ulceration-simple, specific, or epitheliomatous)-the size, closure, or patency of the genital cleft, the'presence of haemorrhoids-all will be at once appreciable. The presence of complete proci dentia, of an extensive laceration of the perineum, or of an inguinal hernia or hydrocele will also be remarked. The appearance upon the external genitals of blood, pus, or a foul watery discharge, will be significant of some condition of the internal parts that requires a carefid in vestigation. Now separate the labia with the middle finger of each hand, reserving the index-fingers for further manipulation of the nymphae, if necessary. Note the size and degree of coaptation of the latter, the color of the mucous membrane, and the presence or absence of ero- sions or ulcerations. The state of the hymen will next claim attention. Is it intact, fissured (from coition, or other causes), or is it repre- sented only by the caruncula myrtiformes which remain after parturition ? A glance at the vestibule will show the condition of the meatus (whether there is a prolapse of the mucous membrane, a foreign growth, or signs of inflammation) ; the clitoris, unless hypertrophied, will hardly be seen unless the nymphae are widely sepa- rated. It may be enlarged, either naturally or as the re- sult of disease (masturba- tion, epithelioma, etc.). The condition of the perineal body should be carefully noted. There may be merely a rupture of the fourchette, or a partial or complete lace- ration of the perineum. On the other hand, a perineum which outwardly appears to be solid, often proves to be so thin (by reason of the atrophy of the tissues) that it consists of little save in- tegument and a small amount of fibrous tissue. The thickness of the perineal body, as well as the breadth of its base, should be tested by passing the right fore- finger into the vulva and pressing upon the body from above. (Fig. 1436, copied from Mundi's " Minor Surgi- cal Gynaecology," illustrates this point very well.) At the same time the rectum may be everted, so as to expose fissures or haemorrhoids. Other points are to be noted at this stage of the examination, such as the redundancy of the vaginal walls (cystoeele or rectocele), swelling of the vulvo-vaginal glands, the presence of cysts, suspicious discharges, etc. The association of a copious greenish- yellow discharge with marked congestion of the vulvo- vaginal and urethral mucous membrane, swelling of one or both of the glands of Bartholin, and hyperaesthesia of the parts, will awaken the suspicion of specific infection, which suspicion, it is scarcely necessary to say, the exam iner will refrain from expressing. Having completed the inspection of the external geni- tals, the physician should anoint the index finger with some lubricant (vaseline, glycerine, or sweet oil), the re- maining fingers are to be folded tightly, and the thumb ab- ducted (Fig. 1437, copied from Munde, op. cit.), prepara- tory to making a digital examination. It is not necessary to discuss here the relative advantages of the right or left forefinger. The gynaecologist should be ambidextrous ; but, as a rule, the left finger should be used when the pa- tient is in the dorsal posture, since the right hand can then be employed for palpating the abdomen or handling in struments. For examining a patient in the left lateral pos- ture the right finger is, of course, preferable. In the case of a multipara with a patent vulva, the finger can be read ily slipped into the vagina, but if the introitus is small, or the hymen intact, it requires some little experience to find the cleft and to introduce the finger under the sheet. Under these circumstances it is better for the beginner to Fig. 1437. separate the labia and nymphae with the thumb and finger of the right hand, while the tip of the left finger is gently insinuated into the opening. In this way the inexpert examiner will avoid the embarrassment to himself and the annoyance to the patient incident upon awkward fum- bling about the rectum or clitoris, as well as the pulling of hair or pinching of the nymphse-minor points, certainly, but not to be neglected, since they may at the very be- ginning of the examination inspire an intelligent patient with a strong suspicion regarding the dexterity of the at- tendant, especially if she has been previously examined by one more experienced. There are different ways of introducing the finger-the volar surface may be upward, or the finger-tip may be placed against the fourchette with the nail upward, and as soon as the hymen is passed the hand maybe turned so that the palmar surface will be up- Fig. 1436. Fig. 1438.-Bimanual Examination. permost. In the digital examination the following ob- jects are to be noted in order The hymen, the vagina, the cervix, and the anterior, posterior, and lateral fornices. As the finger passes through the opening in the hymen, or the introitus vaginae, the size, thickness, and degree of sensitiveness of that membrane are noted. A failure to enter the vagina does not necessarily imply the presence of an imperforate hymen, since the latter may be ren- dered rigid by a sudden contraction of the parts induced 416 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ex- <1 III 1 II <111 <> Il • by pain or hyperaesthesia. Under an anaesthetic the fin- ger may be passed without difficulty. In multiparae there will rarely be any difficulty in effecting an entrance. The points to be especially noted with regard to the va- gina are its direction, capacity, the condition of its walls, and the presence of any morbid growths, either within the canal itself or in the organs that are in immediate rela- tion with it. As the finger explores the vagina, the other hand should be placed upon the patient's abdomen, so that the physician may be ready to proceed with the bi- manual examination as soon as the cervix is reached. There is another practical advantage in allowing the hand to rest lightly upon the abdomen from the outset- the patient becomes accustomed to its presence, and al- though she at first involuntarily contracts her abdominal muscles, if gentle pressure is maintained by the finger- tips the muscles are soon relaxed. The axis of the va- gina may coincide closely with that of the pelvis ; it may dip downward in the direction of the coccyx, or it may approach the perpendicular. In the latter case the ex- aminer should depress his elbow as much as possible, and push the perineum upward with the three fingers which remain folded. The dimensions of the vagina are esti- mated with a tolerable degree of accuracy by sweeping the finger around its walls. Allowance must be made, especially in nulliparae, for the contraction of the sur- rounding muscles, which tends to narrow the canal. It may be abnormally short or long, may be narrowed con- genitally, as the result of cicatricial contraction, or by the encroachment of foreign growths. A loaded rectum will of course diminish the calibre of the vagina. Among the general features to be noted are the tem- perature, the condition of the mucous membrane, whether smooth or rough (granular vaginitis), dry, or covered with an excessive amount of secretion, and the presence of hyperaesthesia. The anterior wall should then be ex- amined, not only with a view of determining the presence or absence of cystocele or neoplasms, but in order to de- tect any possible abnormity about the bladder or ure- thra (calculi, fistulae, cystitis, or urethritis). The poste- rior wall is then touched in the same manner, beginning below at the perineal body and going upward to the pos- terior fornix. A complete laceration of the perineum, with the resulting rectocele, will then be better appreciated than by simple inspection. The presence of a recto-vagi- nal fistula, or of cicatricial bands in the posterior wall, may be overlooked in a hasty examination. An accumu- lation of faeces can hardly be mistaken for an abnormal condition, even by a tyro, but one or two small hardened masses may be regarded as foreign growths. A copious enema and an examination per rectum will clear up any doubts on this point. The normal cervix will usually be encountered at about the junction of the upper and middle thirds of the vagina; but in a deep vagina it may be by no means easy to touch it, especially if the patient's muscles are not thoroughly relaxed. The advantage in keeping the external hand upon the abdomen will then be appre- ciated, as by it the uterus may be depressed sufficiently to bring the cervix within reach. It is hardly necessary to caution the beginner that he must become thoroughly familiar with the physical peculiarities (as ascertained by the touch) and the direction of the normal cervix before he can hope to appreciate deviations from the normal. These deviations may be in the position, direction, size, and consistency of the cervix, or in the condition of the os externum. Instead of occupying a position in the axis of the va- gina some three inches from the outlet, the cervix may be touched just within the vulva (in prolapsus), or high up in the anterior or posterior fornix (in retro- or ante- version), or to one side of the canal (in latero-version, or from the traction of cicatricial bands in the vagina). The axis of the cervix is normally nearly at right angles with that of the vagina, the bladder being empty ; as that vis- cus becomes distended, and the uterus rises toward the perpendicular, this angle becomes more and more obtuse, until the two axes may correspond (see accompanying Fig. 1439, copied from Munde, op. cit.). In order to avoid error, the bladder should be emptied before the examination. If the cervix lies in the axis of the vagina, it may be assumed either that it is flexed, the body of the uterus occupying its normal position, or else that the entire uterus is displaced backward-a point to be settled at a later stage of the examination ; in an exag- gerated degree of cervical flexion, or in retroversion of the uterus, the os may look forward, or even forward and upward. If the cervix points backward, its axis forming an acute angle with that of the vagina, anteversion prob- ably exists. A lateral deviation denotes the presence o cicatricial bands, which by their traction affect the posi- tion either of the cervix alone or of the entire uterus ; the deflection may be due to the presence of some morbid growth or exudation in one of the lateral pouches. The cervix is subject to considerable variations of size within normal limits. Between those of the virgin, nulli- para, and multipara there are many shades of difference, even wdiere no pathological condition can fairly be as- sumed. The length of the portio vaginalis is an important ele- ment. A long, conical cervix is characteristic of the sterile condition ; it almost invariably co-exists with cer- vical or corporeal anteflexion and a ' ' pinhole " os. Hy- Fig. 1439. pertrophic elongation is a condition to be carefully differ- entiated from prolapsus. A small projection in the roof of the vagina represents the senile cervix. General hy- pertrophy points to some abnormal condition, as laceration, with resulting endotrachelitis ; the presence of a morbid growth, whether simple or benign, may lead to an enor- mous increase in this portion of the uterus, which will be readily appreciable to the touch. By the consistency of the cervix may be understood the indescribable sense of resistance which it offers to the touch. Slight deviations from the normal sensation con- veyed to the finger can only be appreciated after long practice, and by a careful study of the physiological changes of the part. The firm, elastic consistency of the nulliparous cervix, the peculiar softness of pregnancy, and the semi-cartilaginous consistence of old age, should all be perfectly familiar to the examiner before he essays to tell by the touch alone when either of the above condi- tions is present in excess. A hard, unyielding state of the tissue about the external os may be the result of traumatism (laceration, caustics, etc.), or it may awaken the suspicion of commencing malignant disease. On the other hand, extreme softness, accompanying a lacer- ation, will indicate eversion of the cervical mucous mem- brane. The presence of an exuberant cauliflower mass around the os, especially if it bleeds easily, will lead 417 Gynecological Ex- REPERENCE HANDBOOK OF THE MEDICAL SCIENCES. the examiner to think of epithelioma ; the peculiar nod- ules and excavations which mark the ulcerative stage of the disease are so characteristic that one has only to feel them once in order to recognize the condition from that time forth. Small irregularities in the cervix are gener- ally the retention cysts known as ovula Nabothi ; smaller granular bodies scattered over the everted mucous mem- brane are hypertrophied papillae. The os externum should receive the most careful exam- ination of all the objects within the vagina. Although it is directly accessible to the eye, the practised touch is com- petent to detect the slightest deviations from the normal. The " pinhole" os marking sterility, the fissured or deeply lacerated os of multiparae, or the firm " cicatricial plug" which occupies the seat of a former tear, are readily ap- preciable. It is even possible to detect the presence of endotrachelitis, where no traumatic condition is present, by the gaping os, from which protrudes a plug of thick mucus, by the eversion of the mucous membrane, and by the general softness of the entire cervix. If a laceration is discovered, its position, depth, and the condition of its edges should be carefully noted. The presence or ab- sence of pain on pressure, especially in the angles of the tear, should be established. The finger is now slipped in front of the cervix, and, aided by the hand upon the abdomen, maps out the an- terior fornix. A slight angle between the cervix and body will be readily detected, and still higher may be felt a round body, the fundus uteri, which in thin subjects may be grasped by the external hand and depressed upon the examining finger. With the patient in the dorsal posture, the fundus can seldom be touched through the anterior fornix, so that when it is distinctly felt it may be fairly assumed that there is an anterior displacement. The fundus may be enlarged from subinvolution, pregnancy, or the presence of an interstitial fibroid. The diagnosis of the latter con- dition is generally uncertain unless the tumor is of con- siderable size, and a distinct sulcus can be felt between it and the body of the uterus. Rarely a haematocele, or cellulitic deposit, may be felt between the uterus and the bladder. The posterior fornix is next explored. Within this limited region the gynaecologist meets with the most com- plicated problems presented in all the range of physical examination. Many years of experience may enable him to recognize conditions which at first seemed to be hope- lessly obscure, but the more accomplished the diagnos- tician, the more clearly will he realize the possibilities of error. The points to be determined during an exploration of the posterior fornix are whether or not some tumor is within reach of the finger, whether it is tender, fixed or movable, and whether there is any evidence of recent or former inflammation. The enlargement may be firm and elastic, in which case it is possibly the fundus of a retro- displaced uterus, a fibroid, or a semi-solid ovarian tumor ; or it may give a sense of fluctuation (clearly marked or obscure), in which event it may be a cyst (ovarian, tubu- lar, sanguineous) or an abscess. Although it will be im- possible in this brief article to discuss at length the ques- tion of differential diagnosis, the following ordinary con- ditions should be borne in mind : The tumor is continu- ous with the cervix uteri, the os externum being in the axis of the vagina or looking forward-it is either the fundus uteri, or the fundus plus an interstitial fibroid, or possibly it is the retroflexed and gravid organ ; it is firm to the touch and is continuous with the uterus, but a distinct sulcus may be felt below it-it is a fibroid ; a small al- mond-like body is felt behind and a little to one side of the uterus (especially when the latter is retroverted), fixed or movable, extremely sensitive to the touch-it is doubt- less a prolapsed ovary ; a round, elastic body is discover- ed, giving distinct fluctuation-it may be a small ovarian cyst, a hydro- or pyo-salpinx (the latter tumors generally lie more to the side of the uterus, and are more often ten- der to the touch) ; a diffuse, boggy mass, ill-defined, im- movable, and tender to the touch, is found-it is prob- ably a pelvic exudation, or an haematocele, according to the previous history of the case. Malignant disease of the pelvic bones, or exostoses, are equally accessible to the touch through the fornix. The above is only the alpha- bet of diagnosis. The gynaecologist has to determine the probable origin of a tumor, its size, mobility, whether it is surrounded by old or fresh adhesions, to what extent it has displaced neighboring organs, the possibility of re- moving it, and many other nice questions, the manner of answering which it is difficult to describe, since it is purely a matter of experience. But besides these gross abnormities, the presence of which would hardly be overlooked, even by the most in- experienced, there are others that can be detected only by the tactus eruditus, such as slight thickening in the utero-sacral ligaments, moderate enlargement of the tubes or ovaries without prolapse of the same, circumscribed foci of peri- or para-metritis, etc. It would seem un- necessary to warn the reader agafnst the error of mistak- ing scybala for small retro-uterine tumors (especially for prolapsed ovaries), yet the mistake is of daily occurrence. Scybala may be recognized by the fact that they are usually multiple, are not tender to the touch, and are doughy and impressible. When they are felt high up in the rectum, the chances of error are great. When acute inflammation is present, it may be impos- sible to complete the diagnosis because of the pain which is caused by the slightest pressure against the vaginal roof. During the examination of the posterior cul-de-sac the external hand renders efficient aid (in a patient with sufficiently thin or relaxed abdominal walls) by manip- ulating the uterus and tumor. The lateral fornices should be examined with care, because through them the bases of the broad ligaments are accessible. Inflammatory deposits in this locality are of frequent occurrence, es- pecially in connection with deep lacerations of the cervix. If recent, cellulitis will be recognized by an obscure, doughy feeling, associated with great tenderness and general symptoms of inflammation ; chronic exudations will appear as firm cords, or irregular masses, extending directly outward from the cervix, and tender on deep pressure. The reader will find that whenever he is unable, be- cause of the depth of the vagina or the contraction of the muscles, to touch the roof, by placing the patient in the left lateral position and examining with the right in- dex-finger he will be able to reach at least one-half inch higher than before, and to detect a prolapsed ovary or a small mass of exudation which could not be felt in the dorsal posture. It may be necessary under some circumstances (in a pa- tient with a rigid or imperforate hymen, or in cases of atresia vagina) to examine by the rectum. Symptoms of rectal disease, or the necessity of clearing up an obscure diagnosis, may also impel the physician to examine thus. Retro-uterine tumors and exudations are especially acces- sible through the rectal wall. Having secured a thorough evacuation of the contents of the gut, the examiner bids the patient strain as if at stool, while he passes his finger gently through the external sphincter and along the ante- rior wall for about three inches, when a large rounded body is felt (cervix); an inch or more above this the tip of the finger reaches a point opposite to the lower part of Douglas' pouch, the contents of which can frequently be mapped out with surprising distinctness, if the external hand in the meanwhile is employed in depressing the uterus backward, thus bringing the organ, with its ap- pendages and any neighboring tumor, nearer to the ex- amining finger. In the practice of the so-called vesical and vesico-ab- dominal touch the finger is introduced into the previously dilated urethra. By this manoeuvre one is not only en- abled to explore the interior of the bladder, but the an- terior surface of the uterus and the broad ligaments may be distinctly felt. Counter-pressure through the abdom- inal wall, the introduction of the other forefinger into the rectum, and downward traction upon the uterus by means of a volsella, are all recommended as valuable ad- junct? to the vesical touch. The liability of permanent injury to the urethra and neck of the bladder will deter most men from resorting to this procedure save on rare 418 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gynaecological Ex- amination. occasions. When it is evident at a glance that a patient has an enlargement of the abdomen, the physical exami- nation will naturally begin with this region, the vaginal touch being practised subsequently ; in some cases a tu- mor may be discovered during the vaginal examination, in which case the abdomen will be palpated last. As a monograph might be written upon this subject alone, it will be impossi- ble to give the reader more than a few hints as to the method of procedure; for details he will have to consult special works on ovarian and other tumors. Before making an examination of the abdomen, it is desir- able that both the rectum and bladder should be emptied. The patient should then be placed upon the back, with the thighs flexed and the entire abdomen bared. Palpation consists in using, notthe hands, but the tips of the fingers-a caution which applies also to the bimanual method. More will be accomplished by a gen- tle pawing, or poking, motion than by firm pressure. The contraction of the abdominal muscles may be overcome to some extent by requesting the patient to keep her mouth open and to breathe deeply, the fingers being sunk into the hollow in the abdominal wall during expi- ration. If unusual difficulties are met with, such as ex- treme rigidity of the muscles, hypersesthesia, or an exces- sive accumulation of adipose tissue, it is better to resort to an anaesthetic at once. The inexperienced examiner should never allow himself to be betrayed into giving a positive opinion with regard to the character of an ob- scure tumor until he has examined the patient under ether, especially if his decision involves the performance of a grave operation. Among the conditions which are ordinarily mis- taken for morbid growths are pregnancy, a dis- tended bladder, accumulation of faeces, fat in the abdominal wall, tympanites, and ascites. A care- ful history of the case, and a consideration of all the possible sources of error, will alone save the novice from blunders which the most skilful diag- nosticians sometimes commit. Ascites, general or encysted, is sometimes extremely difficult to distinguish from a large, thin-walled ovarian cyst. The presence of renal, hepatic, or car- diac disease, or cancer of the peritoneum, being eliminated, an exploratory puncture and a careful examination of the fluid may be the only means of clearing up the diag- nosis. The most common abdominal en- largements connected with the pelvic organs are ovarian cysts and uterine fibroids, or fibro-cysts. These are to be distinguished from morbid growths of the abdominal vis cera both from their history (especially from the fact that they begin in the pelvis and grow upward) and from the fact that they can generally be felt per vaginam. The recognition of the relations and adhesions of a tumor, of its division into loculi or sec- ondary cysts, and the decision as to the like- lihood of successful results from an opera- tion, all of these acquirements come with time-to some men ; to others they remain a closed book. The differentiation between a solid and a cystic tumor, through a thick abdominal wall, is by no means easy. Here, again, the judicious use of the hypo- dermic needle is permissible. Fluctuation is a sensation, a something to be felt, not to be described; therefore it is useless to enlarge upon it here. Much assistance may be gained by causing the pa- tient to change her position. As she assumes the lateral, erect, or even the knee-chest posture, a movable tumor or a free accumulation of fluid will shift its place, and in this way an obscure diagnosis may suddenly be cleared up. (b) Examination with Instruments.-The special instru- ments really required in making a gynaecological exami- nation are few, viz., the speculum, depressor, probe, sound, and tenaculum ; as accessories may be mentioned the urethroscope (or endoscope), curette, and aspirator. 1. The Speculum. A description of the different varie- ties of specula is uncalled for; their name is legion. With two, at most three, sizes of Sims' instruments, and any of the ordinary bivalve or tri valve specula, or a cylindrical one if preferred, the gynaecologist's armamentarium is complete. Where a nurse cannot be obtained, the reader will find that he can manage very satisfactorily with one of the self-retaining instruments, and can, after a little practice, perform minor operations (curetting, forcible dilatation, etc.) without assistance. Ehrich's modification is especially serviceable. Munde has devised a flanged speculum which serves to support the upper buttock. The object in using a speculum being to expose the cervix and the vagina, while at the same time the relations of these parts are disturbed as little as possible, it is evident that the best instrument is the one which most easily accomplishes this result. It is by no means necessary or expedient to use the speculum in every case in which a vaginal exami- nation has been made. Thus, in a nullipara with a marked anteflexion and a conical cervix, no additional in- formation will be gained by inspecting that cervix, still less if the condition present is a prolapsed ovary. In an unmarried female with a rigid hymen, in whose case the exam- iner is compelled to use the small- est-sized speculum, he will not only fail to obtain a clear view of the cervix, but, if he insists on at- tempting it at the first interview, he will simply increase the nat- ural nervousness of the patient, and will very likely in- spire her with such a dread of the manipula- tion that she will be averse Fig. 1440. Fig. 1441. to a second experiment. Certain mechanical obstacles- atresia, vaginismus, inflammation-will be self-evident. In describing the use of the speculum we shall limit our- selves to that of Sims, with the appearance of which no medical man can, in this age, be entirely unfamiliar. After the completion of the bimanual examination the 419 Gynaecological Ex- amination. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. patient is placed in Sims position, being so covered that only the vulva is exposed. Before introducing the spec- ulum, it is good routine practice, even where the previous examination has been satisfactory, to explore the pos- terior fornix carefully in the manner already described. The physician sits at the foot of the table, rather to its left side, with his instruments immersed in a basin of warm, carbolized water within easy reach of his hand. Nothing is more annoying than to be obliged to jump up and run about the room in search of a necessary instrument during the course of an examination. One blade of the instrument is grasped in the left fist, the thumb resting in the groove upon the back of the handle ; the outer side of the other blade is smeared with vaseline, and the right index finger is placed in its groove as a guide, the finger-tip projecting a little beyond the end of the blade. As the nurse or assistant raises the right buttock and labium, the tip of the blade is insinuated into the vaginal orifice ; if the lat- ter is small, the blade may be introduced with the convexity downward, the latter being turned backward as soon as the point has entered the vagina. The point is now turned slightly back- ward, and is pushed in along the posterior vag- inal wall until the angle between the blade and the handle rests against the perineum ; making traction upward and backward until the cervix is exposed, the physician delivers the speculum to the nurse, who grasps it by the handle and maintains steady traction, while with the left hand she continues to elevate the upper buttock. Beginners generally introduce the blade with the end too far forward, so that the latter slips in front of the cervix and entirely conceals it. The tip of the instrument should hug the posterior wall until it has reached the posterior fornix, when the cervix will be sure to lie in front of it. 2. The Depressor. This is essentially a spatula used in depressing the anterior vaginal wall, as the latter pro- jects into the canal and thus interrupts the view. It corresponds to the upper blade of a bi- or trivalve spec- ulum, and is absolutely indispensable in examining pa- tients with voluminous vagina?. Sims' and Hunter's instruments are the ones commonly used. The former consists simply of a wire loop; the latter is a double spoon, which, when silver-plated and well polished, acts as a reflector as well as a depressor. The latter will be found more generally useful. The manner of introducing the depressor is self- evident. In a capacious vagina, or where a cystocele is present,the blade should be placed in front of the cervix before the wall is de- pressed ; if pressure is made on the wall at some distance below the cervix, the folds which intervene between the end of the in- strument and the cervix will conceal the latter. By means of the speculum, assisted by the depressor, we are enabled to verify the diagnosis previously made by the touch. The condition of the vagina is now apparent, fistulae, cicatricial bands, acute inflammation, etc., being at once brought into view. The condition of the cervix is readily noted, the appearance of the os externum, the character and depth of lacerations, the amount of ever- sion of the mucous membrane, etc. By tak- ing a couple of tenacula, hooking one into each lip, and approximating the two so as to roll in the eroded mucous membrane, an idea may be gained of the original appearance of the parts previous to the occurrence of the lesion. 3. The Probe and Sound. The former is a flexible copper or silver wire mounted on a wooden handle. As it bends on meeting the slightest obstruction, it is im- possible to do harm with it. The sound, on the contrary, is a stiff metal rod, capable of being bent into any shape. It is graduated into quarter-inches. Two varieties of sounds are ordinarily used: that of Simpson, which has a knob at its end, and a shoulder two inches and a half above this point; and Peaslee's instrument, which has a larger diam- eter, and is of the same calibre throughout. The probe is used simply to determine the length and direction of the uterine cavity. After giving it a bend corresponding to the posed inclination of the uterus (as pre- vmusly determined by the bimanual method), the examiner steadies the depressor between the thumb and first two fingers of the left hand, while the right thumb and forefinger hold the probe. The point of the instrument is engaged within the os externum, and then the handle is carried forward or backward according to the position of the uterus. As soon as the tip of the probe meets an obstruction (such as a fold of the cervical mucous membrane) it is gently twisted about until it passes it, or it may be necessary to withdraw the instrument in order to change its curve. After the probe has been passed to the fundus, it is retained in position while the forefinger is slid along the instru- ment until it reaches the os ; on withdrawing the probe, with the finger in situ, the depth of the cavity is seen at a glance, or it may be measured in inches. The sound is a far different instrument from the probe, and much more care is required in using it. It is employed for the same purpose as the latter, and also to determine the mobility of the uterus, the presence of in- tra-uterine inflammation or morbid growths, and the size or patency of the external or internal os. It is hardly neces- sary to add that it requires no little practice to apply the sound to these various uses with ease and rapidity, and, at the same time, with safety to the patient. Authorities differ as to the contra-indications to the introduction of a sound into the uterus. The more conservative gynaecologists rarely, or never, use the instru- ment ; and the reader will do well to resort to sounding only when he is sure that, while im- portant information is to be gained, no harm can be done to the patient. The tyro should learn to estimate the range of mobility by his finger rather than by an instrument, and if he can recognize pathological conditions in (he same manner, so much the better. Pregnancy (even though it be only suspected) and the pres- ence of pelvic inflammation, as evidenced by tenderness on palpation, forbid the use of the sound. If there is any doubt as to the advisa- bility of sounding, it is better to err on the safe side. The probe will always indicate the depth and position of the uterus quite as well as the sound. The latter is especially valuable in cases of stenosis, where it is desirable to locate the seat of obstruction. Unlike the probe, the sound may be introduced entirely by the sense of touch, but this method is for the expert alone; the beginner will do better to pass it through the speculum. The technique is the same as in the case of the probe with this exception, that in intro- ducing the sound it is frequently necessary to steady the cervix with a tenaculum, especially if any resistance is experienced. There is one essential difference in the manner of introduc- ing the probe and the sound : a certain amount of force may be applied to the former in order to pass a small obstruction in the canal, but the sound should glide in gently and smoothly, almost by its own weight. Small pockets or folds of the mucous membrane will not arrest the lat- Fig. 1442.- Sims' De- pressor. Fig. 1444. -Uterine Probe. Fig. 1443.- Hunter's De- pressor. Fig. 1445.- Simpson's Ute rine Sound. 420 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Gynaecological Ex- amination. ter, provided that it has received the proper curve ; the principal resistance to its passage will be offered at the os internum or externum. If, as often happens in cases of anteflexion, the stenosis at the os internum is of a spas- modic character, the tip of the instrument should be kept to be excised. Tenacula are made of various shapes ; the most serviceable is an instrument with the end bent al- most at right angles to the shank, the latter being made of a single piece of steel with a covering of wood for the handle. (Fig. 1447.) The tenaculum is used, (1) to steady the uterus ; (2) to depress it. The point is hooked firmly into the vaginal mucous membrane covering the anterior lip of the cervix, which is comparatively in- sensitive, while the haemorrhage, if any, is insignificant. If the handle of the instrument be held between the left thumb and forefinger, and gentle traction be employed, suf- ficient counter-pressure will be made to allow of the application of some force, as in the introduc- tion of a sound through a narrow os, or of a curette in the adjustment of tents, stem-pessaries, cervical tampons, etc. Forcible pulling down of the uterus by means of the volsellum-forceps is hardly to be recom- mended as a diagnostic measure. A certain amount of downward dislocation may be ef- fected by the use of the tenaculum, and the lat- ter instrument is safer than the volsellum, since its point tears out if the traction is excessive. It maybe advantageous to practise this manoeu- vre in a limited number of cases, in order to de- termine the relation of the uterus to pelvic or abdominal tumors; but much care should be used, as adhesions may exist around the tubes and ovaries which may easily be torn. By de- pressing the anterior lip of the cervix in a case of ante- flexion, it is often possible to so straighten the canal that a sound, previously arrested at the os internum, will slip in readily. 5. The Curette. The dull-wire curette is the only one which can properly be used for diagnostic purposes. This consists simply of a piece of copper wire mounted on a handle ; at the end is a loop of flattened wire from one- sixth to one-fourth of an inch in di- ameter. (Fig. 1448.) Such a loop may readily be introduced through a multiparous cervix, and the endome- trium gently scraped, with a mini- mum of pain or risk. The one in- dication for the diagnostic use of the curette is liamorrhage ; this may be due to a retained placenta, to a morbid growth, or, most frequently, to endometritis fungosa. The tech- nique is extremely simple. Steady- ing the uterus with a tenaculum, as above described, the physician passes the curette, thoroughly disinfected, into the uterine cavity, having pre- viously given it a curve correspond- ing to the direction of the canal; and, holding the handle like a pen, gently scrapes the mucous mem- brane, and then withdraws the loop, bringing with it a small fragment of tissue which is submitted to the mi- croscopist. If this procedure is ex- ecuted carefully, no haemorrhage will follow which cannot be readily checked by the introduction on an applicator of a little cotton saturated with an astringent. There is no ob- jection to using the curette in this manner at one's office. Dilatation. This is a procedure which is now commonly practised as an aid to diagnosis. Dilatation may be rapid or grad- ual ; it may be applied either to the cervix uteri or to the urethra. firmly against the ob- struction, when after a few seconds the mus- cular fibres will relax and allow it to enter. The reader may fre- quently make the di- agnosis of stenosis in the case of a patient whose os, under the influence of an anaes- thetic, will easily ad- mit the largest sound. The failure to enter the cavity is often due to the fact that the physician does not carry the handle of the instrument far enough back- ward (in anteflexion) or forward (in retroflexion), after the tip has been well engaged in the cervical canal. When there is a decided retro-displacement it is often advisable to first introduce the sound with the knob pointing forward, and then, by a sort of tour de maitre, to reverse the direction, at the same time carrying the handle forward. Note that the instru- ment is not to be grasped in the fist, but is to be held lightly between the thumb and finger ; in this way the examiner will gain information regarding the condition of the endometrium, the presence of polypi, fungosities, etc. The sensation of a spongy, elastic mass given by the normal mucous mem- brane of the fundus should be clearly recognized. Having once reached the fundus, there is no ad- vantage in continuing to poke at it. The depth of the cavity should be noted, and the instrument slowly withdrawn. If the patient complains of unusual pain when the tip of the sound touches the fundus, or if there is an escape of blood on with- drawing it, there is probably some disease of the endometrium (endometritis, simple or hyperplastic, morbid growths). After having become expert in the practice of introducing the sound through the speculum, the physician may venture to use it by the aid of touch alone. The patient assumes the dorsal position, the left forefinger is placed against the posterior lip of the cervix, and the instrument is slipped along the upper (volar) surface of the fin- ger until the knob enters the os externum. The knob is gently slid along the canal until it reaches the os internum, when the handle is raised or de- pressed according as the uterus is retro- or ante- displaced. (Fig. 1446.) 4. The Tenaculum. This is a delicate hook of finely tempered steel used in steadying or depressing the uterus during manipulation of that organ. It is invaluable in operations, being used to pick up bits of tissue that are Fig. 1448. Fig. 1446. Fig. 1447. Fig. 1449.-Simon's Ure- thral Dilator. 421 Gyn. Examination, Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (1) Dilatation of the Cervix.-This is indicated as a pre- paratory measure to curetting, to allow of the introduc- tion of the endoscope, and of the pas- sage of the finger for the purpose of exploring the interior of the uterus. Rapid dilatation is effected by means of one of the varieties of branched steel dilators, or graduated sounds ; gradual, by the use of tents and rubber bags, the former swelling by the absorption of moisture, the latter, by reason of the pressure of the water which is forced into them. The description of these various instruments belongs properly to other sections of this work. Of all the methods devised for exploring the uterine cavity none equals the introduc- tion of the finger-tip, by which the presence of a foreign growth can be asr certained more positively than by the aid of any form of instrument. After the cervix has been properly dilated by means of successive series of tents, the vagina, cervix, and examining finger- tip are thoroughly disinfected, and the physician proceeds to work the finger gradually, but with the exercise of some force, through the canal - the patient being under an anaesthetic. The other hand, in the meanwhile, resting on the abdomen, strongly de- presses the uterus, crowding it down upon the finger within the os. (2) Dilatation of the Urethra.-This is effected by means of the finger or by special instruments. The object aimed at, from a diagnostic standpoint, in dila- tation of this canal, is to allow the in- troduction of the finger into the blad- der, with the view either of exploring the interior of that viscus or of practis- ing the vesical touch before described. As the urethra is an exceedingly sensi- tive tract, the patient should be anaesthetized before an attempt to dilate is made. An ordi- nary pair of dressing-forceps may be used to begin the dilatation until the tip of the little finger can be inserted between the opened blades. Simon's urethral dilators consist of graduated plugs of hard rubber, by the use of which it is claimed that perfect dila- tation, without laceration, may be ef- fected within five or six minutes (see Fig. 1449, from Munde). Opinions dif- fer as to the innocuousness of this pro- ceeding ; in skilled hands it may be un- attended by accidents, but there are certainly numerous cases on record in which dilatation of the urethra has been followed by either actual lacera- tion or permanent incontinence. 6. The Endoscope. The term endo- scope is applied in a general way to an ordinary tube which can be inserted into one of the canals of the body in or- der to examine it by actual inspection. In gynaecology the endoscope is used almost exclusively for the purpose of examining the bladder and urethra. Having passed the tube into the latter canal in the same manner as an ordi- nary catheter, light is thrown into it from a head-mirror, and the exact seat of an inflammatory focus or mor- bid growth is indicated. A glass at the end of the tube prevents the escape of urine into it. The interior of the bladder cannot be sufficiently illuminated to allow of a satisfactory exami- nation by means of the endoscope. The same instrument has been used in studying the interior of the cervical cav- ity, but the results have not been such as to warrant any dependence upon this method of arriving at a diagnosis. Fig. 1452.-Skene's Urethral Endoscope. Dr. Skene has devised special instruments to aid in the examination and treatment of morbid conditions of the urethra. His endoscope consists of a minute test-tube, into which may be introduced a small mirror set at an acute angle. On throwing a light into the tube the reflec- tion of the mucous membrane will be seen on the mirror. A certain amount of dilatation is necessary before the in- strument can be passed easily, and it is generally desirable to have the patient anaesthetized. 7. The Aspirator-syringe. An ordinary hypodermic syringe with a long, clean needle is all that is required. In cases of ob- scure cystic tumors (especially when these are small and in- tra-pelvic), by withdrawing a drachm of fluid and submitting it to proper chemical and micro- scopical tests, the diagnosis is often cleared up at once. This little operation, as a rule, is free from danger, especially if the cyst is tapped through the vag- inal fornix ; some judgment should be exercised in the case of tense abdominal cysts, the contents of which may escape through a needle-puncture and light up a fatal peritonitis. 8. The Microscope. Tn no de- partment of medicine is this in- strument more useful as an aid to diagnosis than in gynae- cology. For determinating the character of a cyst from an ex- amination of its contents, the presence or absence of malignant disease of the uterus from the inspection of a minute fragment obtained by the curette-in short, for furnishing an unerring confirmation of the diagnosis based on clinical data, the microscope is simply indispen- sable. The man who boasts that he can do without it is lamentably behind the age. Henry C. Coe. Fig. 1450.-Scale of sizes of Simon's Urethral Dilator. Fig. 1453. GYRENBAD. Two places in Switzerland bear this name. One, known as the Outer Gyrenbad, lies about five miles from Winterthur, at an elevation of 2,350 feet. Earthy springs afford drink and bathing and a whey-cure has been established. Inner Gyrenbad lies about ten miles south of Zurich, but is known for the most part as a whey-cure. J. M. F. Fig. 1451.-Urethral Endoscope. HABITATIONS; DWELLING-HOUSE CONSTRUC- TION. Perhaps the most important consideration affect- ing a dwelling-house is the site, including aspect, position with regard to adjoining land, and the character of the soil. By knowledge and forethought almost any site can 422 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ■ ■ «l 1<1 HO II » • be made suitable for a house, but without these a location which might be perfectly healthy may be so misused as to make a house standing upon it unfit for habitation; and the process of curing a bad site is usually a costly one. As a rule, the top of a small elevation furnishes the best position. The upper portions of higher hills are ex- posed to the wind, and houses placed there should have screens of trees and shrubs on the windward side. A hedge or fence will give some shelter over a large area, and to a distance above the ground much exceeding its own height. Next to the top of an elevation the side of a hill is to be sought, and the least desirable location is the bottom of a valley, into which moisture, cold air, and chilling mists descend from the surrounding slopes. If a situation can be obtained on a sidehill sloping to the south or east, the house will be excellently placed in re- gard to aspect, and will be sheltered from the coldest winds ; but the soil of sidehills is usually penetrated, especially in winter, with small springs, which follow the slope of the hill, and, being cut in digging the cellar, di- rect upon the foundation walls streams of water, which soon penetrate into the interior, and make the house damp and unwholesome. To avoid this it is desirable, when- ever a house is built on the side of a hill, to intercept springs from above, either by digging deep trenches above the house in a V shape, with the apex of the V pointing up hill, then filling with loose stones and covering over, so as to form a French or " blind" drain, with an outfall beyond the house on each side ; or, if the quantity of water to be disposed of is small, to dig the cellar a foot or two longer toward the upper end than the size of the house requires, and to fill in the extra space outside the cellar wall with loose stones or cinders, so as to intercept in the same way the springs descending from above be- fore they reach the house walls. In any case an outfall must be provided for the water collecting in the trenches, to drain it harmlessly away to some lower level. If the house stands in a depression, surrounded on all sides by higher land, the underground water will attack the walls on all sides, and an encircling trench, unless an outlet can be obtained to some distant lower level, only aggravates the evil by collecting and retaining the water. The remedy in such cases is to set the house as high as possible. Unless the depression forms a pond, the ground water, even in winter, will not rise to the surface, and by making banks or terraces around the house, and allow- ing a good height of underpinning above, the cellar bot- tom may be set almost at the natural surface of the ground without making the house look badly. Independent of the topography of the site, the char- acter of the soil is important in its influence upon the healthfulness of the house. The worst foundation in this respect is rock. Natural ledges are full of seams through which water usually flows, and the trenching absolute- ly necessary for the interception of the springs formed in this way is so costly that it is usually neglected, and cellars built on rock are in consequence generally damp. A clay soil is objectionable, partly from the springs which it usually carries, and partly from its forming an imper- vious enclosure just outside the cellar -walls, between which and the walls rain-water collects, and, being unable to escape outward through the clay, forces its way through the walls. This happens particularly while the house is new, and the tilling around the walls not yet settled ; but it may often be prevented by giving a few inches extra width to the trenches, and filling around the walls with gravel or cinders, or by sodding or concreting around the house. Gravel or sand usually makes an excellent foundation, unless there is a ledge so close beneath them that they are saturated with the water flowing over the rock. A thoroughly wholesome cellar and a cellar as usually built are two very different things. In cities, where such operations are under official control, basement walls are tolerably strong and impervious, but the foundations of country houses are almost always built "dry," with- out mortar, and only " pointed " inside with the smallest possible quantity of mortar daubed over the crevices be- tween the stones. The back of the wall bristles with projecting points of stone, which lead water into the cel lar, while the movements of the earth outside in freezing and thawing, engaging with these projections, dislocate the stone-work, soon throwing off the pointing and open- ing the way for the entrance of air and water from the exterior. As distinguished from this, the best, although a more expensive, mode of cellar building is to lay the walls throughout in mortar made either with cement.and sand alone, or with the addition of a cask of lime to each cask of cement, which in some places cheapens the mortar considerably without much injuring the quality. The ex- cavation should be made about eight inches wider all around than the outside of the cellar wall, so that the stone- work, while building, shall stand clear of the bank. The exterior face of the wall should be made as smooth as the inside, by selecting the stones, and the outside of the mor- tar joints should be well pointed and smoothed with the trowel, which the extra room in the excavation allows of doing. After this extra space is filled in with gravel, at the completion of the walls, rain-water running down the sides of the house, or soakage from the bank, will follow the smooth surface of the wall to the bottom with- out finding any crevice through which it can reach the interior, and will, if in small quantity and in a porous soil, be dispersed into the ground below the cellar bottom. If the soil is clayey or springy, the dispersion may take place so slowly that the water will rise in the trench, and either saturate the walls or force itself, by hydrostatic pressure, through them. Where this is to be feared, the wall must be drained at the bottom. If the probable ac- cumulation of water is small, it is sufficient, for a wooden building, to dig the trenches for the cellar walls two feet deeper than the cellar floor, and to lay the walls with dry stone for eighteen inches above the bottom of the trench. This will provide a reservoir under the walls, in which the water accumulating during a heavy rain may be re- tained below the cellar floor until it has had time to soak away into the ground. If, however, the soil is nat- urally springy, this under-drain must be supplemented by a trench or pipe drain, not communicating with a sewer, but leading from the bottom of the trench to some place where the water can flow freely away. With heavy buildings of brick or stone, there is some danger, in soft ground, that settlements may be caused by allowing wa- ter to run freely just beneath the wall, and it is better in such cases to use open-jointed pipe, placed just outside the footings of the wall, instead of the dry-stone drain beneath it. The material of which a cellar wall is built should be considered. The best stone is granite, which is nearly impervious to water, and some slates and limestones are almost as water-proof. Where sandstones, soft lime- stones, or brick are used, it is very desirable to coat the outside of the cellar wall, from the bottom of the trenches to the surface of the ground, with coal-tar, melted and put on with a brush. If the ground is springy, a strip of tarred roofing-felt a little wider than the wall should be laid upon the footings just below the cellar floor, and the stone-work continued upon it. This will prevent moist- ure from rising in the walls by capillary attraction from below, and with the coal-tar coat on the outside, a cellar with walls of porous material may be made dry and wholesome at small expense. Damp courses of tarred felt, asphalt, sheet lead, or vitrified clay are often laid in the basement walls of brick or stone houses just beneath the sidewalk line. In this situation they prevent moist- ure from rising from the ground into the superstructure, and staining or " saltpetring" the walls, but do nothing to keep the cellar dry, while the felt beneath the cellar floor, with tar on the outside, accomplishes both these objects. A damp cellar already built can be cured by surround- ing it with a drain of open-jointed pipes or loose stones, placed, if possible, two or three feet below the footings of the cellar walls. The trench for laying this drain must, with heavy buildings, be made three or four feet away from the walls, to prevent the escape of earth from under the footings into the trench ; and the drain must be carried to some proper outfall. In very springy soils, 423 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. transverse drains must be made across the cellar floor, and entered into those around the exterior. The construction of a house above the ground-line is of less importance in regard to its healthfulness than that of the substructure. It need hardly be said that the main things to be sought are sunshine, light, and good ventila- tion everywhere. The most efficient single method of securing all these advantages is to give the house a favor- able aspect, and to make the windows high, carrying them to within a few inches of the ceiling. Windows of this sort admit much more light and sun than those containing the same area of glass but terminat- ing two or three feet below the ceiling ; and on lowering the upper sash for ventilation, the current of air which enters is not only far above the heads of the occupants of the room, but striking, as it enters, upon the ceiling close by, it is so rapidly warmed by contact with the heated plastering as to occasion little annoyance by cold draughts. In very high rooms, sashes extending to the ceiling are inconveniently heavy, and must, perhaps, be dispensed with ; but the ventilation of the rooms suffers in conse- quence, since the air in the space above the tops of the windows, being little disturbed by the currents from them, becomes stagnant and foul, and affects by diffu- sion the fresher air in the lower portions of the room, and the atmosphere of low-studded rooms is therefore usu- ally purer. Such other means of ventilation as are provided for dwelling-houses ought to be as simple as possible. The general tendency of all the air in most houses is from the outside walls and windows inward toward the main stair- case, and up by this to the roof, from which it issues through the innumerable crevices between the slates or shingles. In cold weather this movement is quite decided, and it is generally best to utilize it for the general ventila- tion of the house, facilitating the outflow by providing openings through the roof above the staircase, protected by ventilating caps, and arranging the hot-air registers, which are usually the only fresh-air openings, in such positions in the room that the current from these shall traverse as large a portion of the room as possible be- fore escaping through the doorway into the common ex- traction shaft formed by the staircase and hall. In regard to insensible ventilation, or that which takes place through the structure of the house, tastes differ. Many persons are healthier and more comfortable in a house which admits the exterior air through innumerable crevices ; while others prefer to have their walls and roofs impervious, and to get fresh air only through the openings expressly provided for it. If these openings are sufficient, a tightly built house is probably as wholesome as an open one, and is much more easily kept warm. The points about a frame house most vulnerable to cold winds are usually the cornice and the junction of the wood wall and the stone underpinning. The latter por- tion can be protected by building upon the cellar wall, behind the wooden sill, a few courses of brick in mortar. These stop the currents passing between the irregular top of the underpinning and the sill. The cornice, which is usually made of wide boards and mouldings, is tolerably tight at first, but develops, after a few seasons of shrink- ing and warping, crevices which admit much cold air. As it is almost impossible to close these separately, the best way is to shut them all off at once by building a four-inch wall of brick and mortar on top of the plate which forms the top of the wall and supports the foot of the rafters, carrying it up until it meets the roof-boarding. This wall, besides its- use in keeping cold wind out of the house, is of some value in checking the spread of fire from below into the roof. The general surface of the walls is made wind-proof by papering outside, and by double plastering inside. In the colder portions of the country, the walls are al- ways covered with rough boards before the exterior finish of clapboards or shingles is put on ; and the paper is put over the boarding, just under the clapboards or shingles. Where the "edge-sprung boards," or worked sidings of various sorts, form the only exterior covering, the paper may be tacked to the studs. Cane-fibre paper is excellent for the purpose, and two thicknesses are often used with great advantage. Double plastering inside the walls is only eifectual when well done, and is then supe- rior to the ordinary brick filling. Where the walls are rough-boarded on the outside, the best way to back-plaster is to nail bits of lath to the in- side of the rough-boarding between the studs, and then to lath upon these pieces, and plaster in the usual way with a heavy coat of mortar. By keeping the laths, by means of the short pieces first put on, at a little distance from the boarding, the mortar clinches well, and, if brought well up to the studs on each side, a very thorough and permanent protection is secured. Care must be taken to have the coat continuous from sill to plate, behind all floor beams. Sometimes the roof is back-plastered in the same way between the raf- ters, but this is unusual. If the finished plastering is then well put on, carrying it everywhere down to the floor, in- stead of only to the "ground" for the base, some eight inches above the floor, the house will be well protected, especially if the exterior of the walls is covered with shingles, which give a warmer wall than clapboards. Many persons back-plaster only the north and west sides of their houses, but fail in this way to provide against the outflow of warm air which takes place in strong winds from the unprotected leeward sides of the building. In brick city houses draughts usually enter around the window-frames, and can best be checked by calking from the inside, before the window-trim is put on, with cotton-batting. If the house is made tight against undue intrusion of cold winds, care must be taken to secure a sufficient supply of the fresh air which is ad- mitted by invitation. As the atmosphere of any part of the house affects by diffusion that of every other, no harbor should be left anywhere for foul air to accumulate. At this day it is hardly necessary to say that plumbing work and the rooms in which it is placed can and should be made perfectly inoffensive to the senses, but the air of a house in which these are in best condition may be seri- ously affected by emanations from neglected store-rooms, pot-closets, vegetable cellars, and other foul places. The cellar is usually most at fault, and cannot be too close- ly inspected. Light should be freely admitted to every part, by numerous windows set in an underpinning at least two and one-half feet high. The floor should be cov- ered with not less than two inches of concrete, made of first-class hydraulic cement, clean sand, and washed peb- bles or broken stone ; and no dark corners should be al- lowed to exist in any part of it. If practicable, soft coal should be stored in a place outside the main cellar, shut off by a door, and provided with separate ventilation. This adds to the expense of the house, but the space under a piazza can often be utilized for the purpose. Piles of firewood, unless looked after, often become offensive, and throw off clouds of dry-rot spores into the air. It is becoming common to provide cellar windows with coarse wire nettings on the outside, so that the windows can be left open most of the year without fear that bur- glars or animals will get in, and fine wire guards to keep out flies are often added. Above the cellar, in a well- kept house, there are usually few sources of offence ; but where rooms are finished in the roof, the spaces behind the plastering and above the ceiling, being close and hot, and often tenanted by mice, are apt to be filled with foul air, which diffuses itself into the rooms unless disposed of by proper outlets. If the air in the house is free from internal sources of contamination, it is easy to make sure that that which comes from the outside shall be pure. In winter, where hot-air furnaces are used, a strong current is thrown into the rooms through the registers, after first passing through the hot-air chamber of the furnace ; and if this is well directed, and sources of contamination on the way are avoided, excellent ventilation is in most cases secured. The best position of the register for obtaining the full bene- fit of the heat, as well as for keeping the air pure, is in a vertical wall on the same side of the room as an open fireplace. Warm air entering the room from a register in this position is carried at once upward by its superior 424 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. lightness, and forward by the momentum with which it issues from the register, and sweeps across the ceiling to the opposite side of the room, where, being gradually cooled by contact with colder surfaces, it sinks, and, con- tinuing to lose heat and buoyancy, it finally spreads over the floor, from which it is drawn back into the fireplace and carried off, after a circuit which sweeps and purifies almost every corner of the room. With register and fire- place in a different relative position, a less thorough cir- culation is obtained. If there is no open fireplace to carry away the air after it has done its work, a flue of any kind will answer, if the opening into it is large, and placed as low down as possible. Ventilating registers near the ceiling are bet- ter than nothing, though they tend to draw off the warm- est and freshest air, leaving the cold and foul air behind. Without outlets of some kind, little or no current will enter from the register, and the room can neither be warmed nor ventilated. When wall registers are large, and the air from them is not heated above 110° F., the current from them is often felt as a cool draught, through the rapidity with which it evaporates the moisture of the skin ; and young children, playing on the floor near by, are sometimes seriously chilled in this way, so that it is often advisable to place screens in front of them to de- flect the current more quickly upward, or, still better, to make the register openings six feet above the floor. In the case of first-story rooms, which by reason of their distance (horizontally) from the furnace are not easily heated, this raising of the registers adds very materially to the force of the warm current. In order to keep the air delivered through the registers free from contamination, the supply to the furnace should be drawn directly from the exterior of the house, and conveyed to the furnace by a tight conduit. The com- mon practice of taking the air-supply wholly or partly from the cellar is very objectionable. Even the " cold- air box " through which the outside air is led to the fur- nace should be, where the expense can be afforded, of galvanized iron, as the wood commonly used soon shrinks so much as to admit cellar air to mix with the pure sup- ply. The area of the cold-air box should be one-sixth less than the aggregate area of all the hot-air pipes lead- ing out of the furnace, and the outside opening should, in cities or dusty places, be eight or ten feet above the ground. If there is danger that cold winds may blow too freely into the furnace, the cold-air box should be carried across the building, with an opening at each end, and a branch to the furnace at right angles to the main conduit. For houses not warmed by furnaces, an excellent sub- stitute is found in the stoves with exterior casings, such as those made by the Open Stove Ventilation Company, in New York, and, in rather larger sizes, by the New England School Furnishing Company, Boston, by John Grossius and A. Lotze's Sons, Cincinnati, and others. By means of a six- or eight-inch pipe brought from the outside of the house to the hollow base of any of these, a constant supply of pure warm air is delivered from the top, which, after circulating through the room, is drawn off through the stove-flue, and rooms may be both warmed and ventilated more thoroughly and far more economi- cally than by open fireplaces. A rather inefficient sub- stitute for one of these stoves may be made by surround- ing an ordinary heating-stove with a sheet-iron casing about two inches distant from the outside of the stove. Fresh air may be brought from the outside of the house to the space between the stove and the casing, and will escape into the room well warmed ; or, where this is im- practicable, the casing may be raised three inches or so above the floor, so that the air of the room next the floor will be drawn in, warmed, and returned to the room at the top of the casing. Although the atmosphere of the room is in this way simply warmed over and over, the circulation so main- tained is advantageous, and the heating power of the stove is considerably increased, while the usual scorch- ing radiation from it is intercepted. Where a room heated by a stove can be ventilated only by the win- dows, these may generally be kept slightly opened at the top. It is usually supposed that an opening at the top of a window will allow the warm air of the room to escape without admitting fresh air to take its place, but the pressure toward the interior of a warmed house is in win- ter so strong that nearly as much air generally enters by an opening at the top of the room as escapes by the same opening, and the two currents mix in passing in such a way as to take the chill from the fresh air and prevent the cold draughts which occur with openings in the lower portion of the window. Next to the purity of the internal atmosphere of the house, the cleanliness of the soil and air immediately about it are most important. Thousands of houses, clean and well kept inside, are always steeped in the foul exhalations rising from cess- pools and vaults in the immediate vicinity. It may be taken as certain that an ordinary privy cannot be con- nected with a house by any enclosed passage-way without influencing the air of the house. By making the seats and the enclosure of the vault air- tight, and providing a capacious and tight ventilator from beneath the seat to the top of the house, it is possi- ble to secure in cold weather an outward current strong enough to prevent any odors from rising through the opening in the seat during the short intervals when it is necessary to keep this uncovered ; but in summer the current is often reversed, and no care will prevent the fumes of putrefaction from creeping out and along the walls of the passage-ways into the house. If a privy is to be made inoffensive, it must, therefore, be entirely iso- lated from the house, exposing those who use it to dan- gerous chills in winter ; or the contents of the vault must be regularly removed or disinfected before they have time to putrefy. Of these two, removal is decidedly pref- erable. Disinfection by dry earth or ashes is popular, but it is impossible to make this effectual unless liquid wastes are kept out of the vault, and this, in dwelling- houses, is inconvenient. Daily removal of the contents of the privy to the com- post heap is most easily effected by replacing the ordinary vault by a simple enclosure above ground, with access from the outside, and providing two boxes, on wheels, fitting the space beneath the seat. By means of a handle or hook the full box can be drawn out, and replaced by the empty one, in a moment. In houses provided with water-closets and drains the inoffensive disposal of the refuse is nearly as difficult as where the privy is used, for the reason that the dilution of the wastes with water greatly increases the bulk of matter to be taken care of, and with it the extent of the offence and danger if this duty is imperfectly performed. In large cities nothing is necessary but to connect the house drains properly with the sewers, but in villages it is usually necessary to dis- pose of all the wastes on the premises. The common way of doing this is to discharge all the drainage into a leaching cesspool, consisting of a pit, with wall of loose stones, and stone or wood cover. In very open soils the impure liquids poured into this pit will be absorbed for an indefinite period, and pass away unchanged, often to poison the air or the drinking-water of families living on lower ground ; but in most cases the soil surrounding the pit becomes gradually clogged with greasy particles, and the cesspool then overflows, and, as no ordinary treatment will relieve the soil of such ob- structions, it is necessary to dig a new cesspool. This may happen every year or two, and a great extent of soil about the house thus becomes at last saturated with pu- trescent filth, while the overflow of the cesspool, if there are water-closets or set washtubs in the basement of the house, is apt to take place through these, floodipg the lower rooms with foulness which pollutes the air of the house for a long time. Many attempts have been made to dispose of house wastes in a less objectionable manner than this. The simplest mode is to make the cesspool with tight walls of brick laid in cement, and to set a pump in the cover, by means of which the liquid may be drawn out and applied to growing crops, for which it furnishes an excellent weak manure. 425 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. This process, however, requires labor in winter as well as in summer, and for small places it is preferable, instead of pumping the sewage on the surface, to discharge it automatically underground, near enough to the surface to be taken up by the roots of grass or other plants ; and by this means, as well as by the unexplained influences which operate only within the upper eighteen inches of the soil upon organic matter exposed to them, it is entirely decomposed and dissipated. The distribution of sewage through the upper stratum of the soil is effected by means of two-inch agricultural drain tiles, laid in long lines twelve inches beneath the surface, one-fourth of an inch apart, with a fall of one inch in twenty-five feet, and with the upper part of the joints covered, when laid, with a bit of tarred paper or a curved piece of earthenware, to prevent the soil from falling through and obstructing them. The lines of tile are spaced from two to ten feet apart, according to the irregularities of the surface beneath which they lie, and about five hundred feet will, in any soil, dispose of the sewage from a house containing bath- room, two sinks, two water-closets, and set wash-trays. The sewage must be collected first in a tight brick cess-, pool, of about one thousand gallons' capacity, in order to allow coarser matter to settle or dissolve, and the subsoil pipes may be supplied from this, either through the medium of a main outlet of four-inch glazed earthen- ware pipe, from which the lines of tiles proceed as branches, or the lines of tiles may radiate separately from the cesspool, which is a better though less common way. In order to secure the most efficient oxidation of the sewage, as well as to diminish the risk of stoppage of the outlet pipes by accumulation of sediment, it is best to make the flow through them intermittent-a strong dis- charge once or twice a day, which fills the pipes and flushes them out thoroughly, being followed by a period of rest, during which the liquid is absorbed and the pores of the ground are refilled with air. This intermittent action is generally obtained by means of a siphon, and the liquid accumulates in the cesspool until it reaches the top of the siphon, when, by means of a trap or weir at the lower end, this is brought sud- denly into action, and all the liquid in the cesspool, down to the level of the lower end of the siphon, is discharged at once. In many cases, however, a tumbling tank of galvanized iron or wood, working in a compartment of the cesspool in such a way that when filled it overturns and discharges its burden of liquids into the pipes, and then returns of itself to its former position, is preferable to a siphon, as being more readily accessible for clearing out, and less likely to become obstructed. With subsoil pipes properly put in in this way, there is no clogging of the ground, the decomposition of the organic portions of the sewage so close to the surface being a perpetual process, and no change in the absorp- tion ground is ever required. The pipes, however, in places where any check is given to the current through them by sudden turns or settlements in the lines, will slowly clog with sediment, and it is best every year, just before the ground freezes, to dig them up at the curves, or in other places where experience shows that obstructions are likely to occur, clear out the soft deposit, and replace them. This is a simple operation, costing much less than the clearing out of an ordinary cesspool, and noth- ing more than this is required to keep the system in work- ing order for an indefinite period. T. M. Clark. difficulty which could not have been wholly overcome without making statements and expressing views which would be at variance with what he believes to be the truth. This difficulty consists in the necessity of speak- ing of devices and apparatus which the author has him - self invented, and which are patented and sold under the name of "Sanitas" by the "Sanitas" Manufacturing Company. It may seem to some to be an easy matter to avoid the appearance of thus advertising one's own wares in a work of a semi-judicial character like the Handbook, by simply ignoring them and speaking only of the devices and apparatus invented by others for the attainment of the same ends. There are many cases where the author can properly do this ; and whenever he finds that he can commend the devices of others as suf- ficiently good for the purposes required, he will take pains to adopt this course. But there are not a few plumbing contrivances which are sold largely to-day, and are thought to be particularly free from objectionable features, and yet which do not fulfil the-conditions in re- spect of which they are generally believed to be especially effective. Under such circumstances the author has not hesitated to commend contrivances which do fulfil the conditions required, but which possess the unfortunate demerit-unfortunate under the present circumstances- of being inventions of his own, the results of prolonged and careful experimental researches, both in actual prac- tice and in the plumbing of buildings in use, and in a regularly organized plumbing laboratory. He has sub- mitted this difficult question to the publishers and edi- tor, and adopts the present course after consultation with them. A model specification has been added to supplement the explanations, and to call attention to such details as might otherwise be overlooked. General Principles.-The system of the disposal of wastes through water-carriage has now been brought to a high degree of perfection. The liquid and solid refuse are removed together instantly, automatically, and thor- oughly from the premises, as soon as they are generated ; and are either applied directly to the soil as fertilizers, or are transported to some place where they may be safely discharged, directly or after infiltration through the earth, into a water-course, or where they may be chemically treated for conversion into a useful manure. Each year adds new means of treating the sewage eco- nomically, and this improvement has already been carried so far that a general return to the clumsy system of earth- carriage, even in small villages, or in isolated dwellings, is no longer to be anticipated. Sanitary engineers are now, therefore, concentrating their energies upon the entire perfection of the water-car- riage system, and the fundamental principles which guide them in this work in the department of house plumbing are as follows : 1. A sound water-seal alone should be used for trap- ping. All mechanical devices for this purpose, such as valves, balls, and plungers, should be avoided. 2. The waste matters should be completely removed from the dwelling automatically, the instant they are formed. 3. The main drain and soil-pipe should be thoroughly ventilated from end to end. 4. The entire system of waste-pipes and receptacles should be thoroughly flushed from end to end. 5. The entire system of plumbing-work of all kinds should be directly risible and accessible from end to end. 6. All materials used should be sound and durable, and they should be jointed in such a manner as to render the whole work permanently air- and water-tight. 1. Of two methods or devices otherwise equally good, preference should always be given to the simplest. 8. Of two methods or devices otherwise equally good, preference should always be given to the most economical in construction and in operation. 9. All working parts of the system should be, as far as possible, automatic. 10. The operation of all parts of the work should be, as far as possible, noiseless. These ten broad principles are now accepted as plumb- HABITATIONS; GENERAL PRINCIPLES OF HOUSE PLUMBING. In the preparation of the following article the aim has been to explain principles rather than spe- cial appliances, and this has been carried out as far as it was possible under the conditions of the problem in hand. This problem was to furnish the reader, who might not be in a position to secure suitable expert aid, with such information as would enable him to safely plan and su- pervise the execution of the entire plumbing work of his house. Hence a consideration of many special appliances is necessitated; and here the author has encountered a 426 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. ing axioms by all leading sanitarians. Without comply- ing with them all, no house can be properly plumbecl. On the other hand, no other observance is necessary to render the work perfect; and by their aid the best meth- ods and appliances now in use may be easily selected. Their full force will be understood from what follows. 1. Efficiency of the Water-Seal.-A perfect interception of sewer-gas may be accomplished by a simple ■water-trap, or deep bend in a pipe filled with water, acting in com- bination with a thorough system of sewer- and soil-pipe ventilation. Without the assistance of this ventilation, to relieve the water in the trap from undue pressure from wind or pent-up gases in the pipes, the water-seal would be insufficient. Of late years sewer- and soil-pipe ventila- tion has become universal in good plumbing, and the use- fulness of metallic valves or other mechanical closures to assist the water-seal has disappeared. It has been shown by Dr. Carmichael1 and others that, if a water-seal be properly maintained against evaporation and siphonage, or destruction from any cause, the amount of sewer-gas that can pass through in twenty-four hours, even under the worst condition, but with a ventilated soil-pipe, is infinitesimal and absolutely harmless, and that disease germs cannot pass at all through water at rest at normal temperatures. Dr. Carmichael also experimented with an unventilated soil-pipe, and found here that the quantity of carbonic- Mechanical closures in our traps are not simply super- fluous. They are a source of positive danger. The ball or valve cannot be made to fit its seat with such accuracy as to exclude those microscopic substances which consti- tute the most dangerous element of sewer-gas. The valve and its seat become, moreover, in time corroded and coated with sediment, which opens a still wider avenue for the escape of any substances which might pass through the water alone. A false sense of security is engendered, and less care is taken to insure the soundness of the water- seal than would be the case were it assumed, at the outset, that up- on it alone safety de- pended. Our undivided atten- tion should be devoted to rendering the water- seal of the trap perfect- ly secure. A second objection is the obstruction the me- chanical closure causes to the rapid outflow of the water ; a third is the increased complication and expense it occasions ; and, finally, a fourth is the necessity of constructing a chamber or con- tainer for the movement or play of the valve, plunger, or ball, 'which thus forms a species of small cesspool or filth collector in violation of our second law. As illustrations of this we have the foul receiver of the pan-closet (Fig. 1454), which must be constructed large enough to allow for the play of the pan ; the valve and plunger chambers of the closets which derive from them their typical names ; and the valve, ball, and mercury chambers of mechanical seal-traps. It is sometimes urged by the manufacturers of these ap- pliances that they afford better protection against back pressure of sewer air. Back pressure, however, is rarely encountered now with our ventilated drains and soil- pipes, and, moreover, this pressure can be effectually guarded against by simpler means, which will be described hereafter. 2. Instant and Complete Removal of the Wastes.-All refuse matter should be removed instantly from the prem- ises as soon as it is generated, allowing no time for dan- gerous putrefaction to set in. The waste-pipe system should contain no chamber or pocket for the accumula- tion and retention of matters which generate foul and corrosive gases tending to impregnate the water-seals of the traps, corrode the metal work, and lie in wait to press into the house at the first unguard- ed entrance. The waste-pass- ages should be as smooth, compact, and direct as pos- sible, so that their contents may be expelled easily and completely. The soil-pipe should nowhere exceed four inches in di- ameter, and the smaller waste- pipes should not be more than an inch and a half in diameter for a single fixture, since this size is ample to carry off the largest quantity of waste or overflow-water that can ever enter them, and will carry it off more rapidly than larger pipes. The outlets of all fixtures should be at least as large as the waste-pipes they serve, and their traps should offer as little friction to the outflowing water as possible, so that the waste-pipes may be filled "full-bore" by their discharge, since the flow of the water is thereby im- mensely accelerated. As illustrations of the evils arising from a neglect of this rule, we may cite, besides the containers of the water- Fig. 1455. -Old-fashioned D Trap. Fig. 1454.-Section of the Ordinary Pan-closet, showing Accumulations of Foul Matter in its Receiver. acic gas, the largest component of sewer-gas, given off from the trap in twenty-four hours was less than that obtained " when a bottle of lemonade was opened," and less than that which is exhaled by a man in five minutes. As for the ammonia, sulphuretted hydrogen, and other gases of sewage decomposition, the quantity which could pass through the water-seal was found to be many times less, or utterly insignificant and harmless. In short, it has been sufficiently proved that sound water-seals in traps are perfectly trustworthy. "They exclude," says Car- michael, "the soil-pipe atmosphere to such an extent that what escapes through the water is so little in amount, and so purified by infiltration, as to be perfectly harmless ; and they exclude entirely all germs and particles, includ- ing, without doubt, the specific germs or contagia of dis- ease, which we have already seen are, so far as known, distinctly particulate." It must be borne in mind, moreover, that in a system of water-carriage we are obliged to rely upon a simple water-seal, whether we desire to or not, because our water- closet traps or their overflow's are, and must be. con- structed without mechanical obstructions, and it is evi- dently useless to apply such closures to our smaller traps if we leave the larger ones without them. Fig. 1456.-Round or Pot Trap, showing its Con- dition after short Usage under a Sink. 427 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. closets already referred to, that of the old-fashioned D trap (Fig. 1455), and of the modern pot or round trap (Fig. 1456), all of which, though condemned by sanitari- ans, are still largely used on account of the ignorance of the public in these matters. These appliances are nothing more than small cesspools-retorts for the generation of foul and dangerous gases. There is no longer any ex- cuse for their use, because appliances both simpler and better can now be obtained to do their work. Fig. 1457 represents a wash-basin constructed on the cesspool principle. Filth gradually accumulates above and around the waste-plug, as shown in our drawing. Decomposition goes on and foul gases are freely liberated into the house, not only w hen the basin is empty, but at all times, through the joints around the handle of the stand-pipe. Whenever the fixture is used the foul sedi- ment contaminates the pure water, and the bather applies to his hands and face as much of the refuse of preceding bathers as the water happens to take up from the extended waste-pipe surface between the strainer and the outlet- plug. Strange to say, basins constructed on this princi- ple are among the most popular now in use, even in houses otherwise most luxuriously appointed. 3. Thorough Ventilation.-However carefully the waste- pipe system is constructed, with a view to a rapid and complete removal of the waste matters, the main soil-pipes will, on account of their size, their form, and the nature of their service, become more or less fouled. This will occasion a certain amount of decomposition, and the gases generated wull rise in the pipes to their highest points. In order to liberate The first four are due to the action of the surrounding atmosphere, and are properly treated under the present heading of Ventilation. The last three are dependent upon the form of the trap and the nature of the substances which enter it. Siphonage. Trap siphonage is the displacement of the water-seal by atmospheric pressure. In its normal con- dition the water in the trap is maintained by an equi- librium of atmospheric pressure on its two exposed sur- faces, one on the house and the other on the drain side of the trap. Thus Fig. 1458 represents the ordinary S trap fixed under an ordinary wash-basin, and connected in the usual manner with the house-drain. There is normally an equal pressure on the two surfaces of the water-seal. But this equilibrium is constantly disturbed by the move- ment of air and water in the waste-pipe system. When, for instance, a water-closet in the story above is discharged into the main waste or _ soil-pipe with which our trap is connected, as shown in the figure, a body of water descends within the soil-pipe, like a plug or piston, more rapidly than the air in front can escape or the air be- hind can follow it. The air in front of the piston is, therefore, compressed, and the air be- hind rarefied, and the pressure on the drain side of the trap is consequently greater than that on the house side when the falling column is approach- ing the branch waste-pipe, but less after it has passed it. Hence the water-seal is suddenly vibrated with greater or less violence, according to the intensity of the atmospheric dis- turbance. When the excess of press- ure is on the drain side of the trap- seal the water is forced back toward the lavatory, and the action is called back pressure ; but when the reverse is the case the water is forced for- ward into the drain-pipe, and the action is called siphon- age. These two forces, "back pressure" and "siphonage," are supplementary to each other. If one is strong at any place the other is correspondingly weak. They mutually destroy each other, and they cannot coexist in any one place to any very serious extent. Thus the air in front of a descending water column cannot be seriously com- pressed unless a sudden bend or some unusual obstruction stands in the way of its escape below. To produce a serious back pressure the descending water-plug must have acquired considerable velocity of movement, and the bend or impediment must be close to the mouth of the waste-pipe on which is placed the trap to be tested. This might occur, for instance, at the foot of a tall, straight soil-pipe where it enters the horizontal drain, and down which the water discharged from an upper story water- these gases, all the main stacks of pipe should be carried up, through, and above the roof of the house, and left open. The chemical action of decomposition produces warmth enough to create a certain amount of circulation in the pipes, but in order to produce a free and reliable current the soil-pipes should be opened to the outer air both at the top and at the bot- tom. The warmth of the house, together with the chem- ical action, will then set up a constant and abundant cir- culation of fresh air through the whole pipe system, and this will also occasion, by the law of the diffusion of gases, a sufficient aeration of the smaller branch waste- pipes. The ventilation of the branch wastes, furthermore, will be assisted by the flushing of the various lavatories which they serve. Air always follows the discharge of waste water, and when this discharge takes place rapidly, filling the pipes full bore, a large volume of pure air rushes through the pipes behind the water column and thoroughly aerates them, completely replacing any slight amount of impure air that may have collected in them with fresh air from the room. It is, therefore, only necessary to ventilate the main stacks of pipe. The smaller branch wastes are better without it, as will be understood after a brief considera- tion of the various agencies which tend in practice to de- prive traps of their water-seals, and of the best methods of overcoming them. These adverse influences are : Siphon- age, Evaporation, Back Pressure, Self-siphonage, Capillary Attraction, the Accumulation of Sediment, and Leakage. Fig. 1457.-Wash-basin having its Outlet-plug at the End of a Concealed Outlet-passage, forming a Cesspool. Fig. 1158.-Movement of Fluids in Traps and Waste-pipes. 428 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. closet could descend with unbroken force. An ordinary S trap placed close under a lavatory just above this bend might, under such circumstances, lose its entire seal upon the discharge of a water-closet above by back pressure. But the action of siphonage would be very feeble at this point, partly because the compressed air would here par- tially force its way up through the descending water column, dividing it up into a comparatively feeble spray, and partly because its subsequent power of suction would be reduced by the bend in the same proportion as the back pressure has been increased. In short, its full energy cannot be spent in each of two opposite directions. On the other hand, a trap which, near the top of the stack, would lose its seal by siphonage, would scarcely feel the influence of back pressure, and at a point inter- mediate between these two, where the two forces would be equal, their effect would be so diminished as to require but a comparatively slight power of resistance on the part of the trap-seal to withstand them.2 Although the two forces are supplementary, they are by no means equally dangerous elements in plumbing. It should be observed that the strength of siphoning action is in proportion to the velocity and volume of the descending water column. Hence it may take place as well in the smaller pipes as in the main soil-pipe, and the seals of traps which connect with small lavatory and sink wastes may be destroyed as readily as those which connect with the main soil-pipe. The destruction of trap-seals by siphonage may take place anywhere on the line of the waste piping, and be caused by the discharge of any fixture in the house, whether it be its own or any other fixture. Severe back pressure, on the contrary, can, in properly plumbed houses, only take place in the manner above described, i.e., at the foot of an uninterrupted fall of vertical piping, where it turns abruptly to the horizontal, and this condition of things rarely is, and never need be, met with. A few years ago, before it became customary to venti- late the main drains and sewers, back pressure was also occasioned to a certain extent by wind or the tides in the drains. But as no properly informed person now would ever think of plumbing a house without some form of vent in the main pipes, this source of evil is no longer to be counted upon. Let us see how the destruction of the seal by these t.wo agencies may be prevented. Considering first siphonage, we find three methods em- ployed : One is to attach a special air-pipe to the waste-pipe just below the trap, for the purpose of supplying the necessary amount of air at the crown of the trap to re- store the atmospheric equilibrium without obliging it to pass through the water-seal. A second is to enlarge the upcast limb of the trap until it becomes a large pot, or reservoir, which permits the air to pass through the water-seal without removing all of the water in its passage. A third is to give the trap such a form that it becomes itself an air-supply passage, without danger to the integrity of its water-seal, or materially increasing at any point the size of its water-way. The first method adds greatly to the cost and complica- tion of the work. It has lately given rise, in a few cities, to the so-called ' ' trap-vent " law, which rigidly requires every trap, under all circumstances, to be vented. In regard to the practical working of this law, which has been on trial for a very short time, two things have been learned : First, that the trap-vent is not always efficient in preventing the destruction of the seal by siphonage ; second, that it is always active in destroying the seal through evaporation. Nevertheless, this method appears to have still a few advocates of recognized ability. But they now adhere to it chiefly, if not entirely, on account of an alleged indi- rect advantage produced by the air-current in partially ox- idizing foulness in the waste-pipes. The very careful and satisfactory experiments which have been made within the last few years to test the efficiency of this method, have shown conclusively that the same agent, friction, which produces the action of siphonage by retarding the air in the water-pipes behind the descending water column, will often likewise retard the supply in the vent-pipe and defeat its purpose. The partial vacuum created in the waste-pipe calls for in- stant tilling. As the falling water suddenly passes the mouth of the branch waste, the vacuum created instantly within it must as instantly be supplied if the water-seal of the trap is to be preserved. The friction caused by the walls of the long, narrow trap vent-pipe forms a greater obstruction than the inertia of the light body of water in the trap. The result is that this water is blown out be- fore the air in the trap vent-pipe has had time to force its way down to the rescue, and the value of the trap-vent is destroyed. In fact, it is very evident, upon reflection, that if the large four-inch soil-pipe is unable to admit air behind the water column fast enough to fill the partial vacuum created, the smaller vent-pipe of equal length cannot always be expected to do its work. The second method is both inexpensive and simple, and is much more efficient in resisting siphonic action than the first. It has, however, the serious disadvantage of involving the use of cesspools, or filth retainers, in the house, and such retention is in violation of the important principle of sanitary drainage which calls for complete removal of foul matters from the premises the instant they are generated. This method has, however, at present a very large num- ber of advocates, who consider the retention of a limited quantity of filth in a trap less of an evil than the dangers and difficulties coming from trap-venting. They claim that a guard which is only sometimes reliable is worse than none at all, as giving a false sense of security, and that the purification of the branch waste-pipes can be effectually accomplished by powerful water flushing, making the induction of the air-current from the soil- pipe for this purpose quite superfluous. They find, moreover, that abundant aeration goes on, as already explained, without the aid of the special vent- pipe, both from diffusion of the air in the ventilated soil- pipe, and from the powerful influx of pure air from the room induced with and after the water flushing at each usage of the fixture ; and that a waste-pipe of mod- erate length, branching from a well-ventilated soil-pipe, and terminating in a properly constructed lavatory, forms no dead end requiring ventilation, since the movement of air and water within it, in its normal usage, creates ample circulation in the pipe, and completely replaces whatever foul air might be in it with a volume of pure air from the room every time the fixture is used. The third method is the simplest and least expensive of all. It is more reliable than either of the others in resisting siphonage action, and it does away with the serious objection of the second method, that of filth reten- tion. It is the method now advocated by the leading san- itarians of the country, and is rapidly extending toward universal adoption. Let us now examine briefly these three methods, since the question is not only one of the most important and interesting in the whole domain of sanitary plumbing, but its investigation will throw light on every other part of the subject. The Trap Vent-pipe. Until very lately it was supposed that trap-venting afforded a reliable cure for siphonage, and under that supposition the trap-vent law was made. This law has now been on trial long enough to show that the trap-vent is by no means able to do what it pretends to. and thereby affords a false sense of security ; but that it gives rise to new evils considerably more important than the good it could do even if it accomplished all that it claimed.3 1. It tends to destroy the seal of the trap by evaporation. In some cases it has been found to lick up the seal of an ordinary lavatory S-trap in less than a week. .2. It increases the unscoured area of the trap, making it a cesspool (the mouth of the vent-pipe forming this unscoured area), and thereby thwarting one of the chief objects for which it was devised.4 3. It retards the outflow of the water about thirty-three per cent, when properly constructed lavatories are used. 4. It compli cates the plumbing and adds to the danger of leakage 429 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. through bad jointing. Fig. 1459* represents three fixt- ures plumbed with the trap vent-pipes and separate overflows, and Fig. 1460 the same fixtures plumbed on the total cost in new work, and indefinitely in old work, in which the trap ventilation sometimes becomes by far the greatest part of the work to be done. Of late very thorough tests have been made in this country to ascertain how much reliance can be placed on the vent-pipe. My own experiments6 in this field show conclusively that it is totally unreliable, I having found repeatedly that the dis- charge of a single water-closet may, under certain ordinary conditions, destroy the seal of a trap, fully and newly ventilated in accordance with the law. Other experiments made by those who were formerly among the strongest advocates of trap- venting have given the same results. Thus we find that in this case practice fully bears out the theory, and that where the large soil-pipe is unable to supply air fast enough to pre- vent siphonage, the small and usually tortuous vent-pipe can- not be relied upon to afford se- curity. Ventilation increases 'the danger arising from capillary attraction. This is a subtle enemy of the water-seal of traps. It works like the vampire, silently and stealthily drawing out its life without warning of any kind. It is caused by the lodgment of any porous substance lying along the outflow of the trap, one end dipping into the water, and the other descending into the waste- pipe. It slowly soaks up and drains off the water-seal until it is destroyed. Fig. 1461 shows an S-'trap losing its seal by capillary attraction. Care- ful experiments on the working of this agency on traps have shown three things: First, that the substances exerting the capillary action can conduct the water only to a certain limited distance above and beyond its surface ; and that the rapidity of the removal of the water in a closed vessel will be in proportion to the short- ness of the distance required to be raised. Second, that substances likely to col- lect in traps will not carry water over four inches above the water-seal in per- pendicular direction, or three if sufficient horizontal be added to it. Hence a trap should be constructed in such a manner that the distance from the surface of its water-seal, before it is lowered to the point of breaking, to the mouth of the overflow, shall be greater than the capillarity of any sub- stance liable to collect in it. Third, that capillary attraction in an open vessel greatly increases the loss by evaporation, and that the rapidity of the removal of the water in vessels of similar form, but exposed to different degrees of change of air, will be in proportion to the velocity and hygrometric condition of the air-current. Hence trap ventilation aggravates the danger arising from capillary attraction. The second method of obtaining security against siphon- age consists in the use of a large unventilated pot or re- servoir-trap. A small pot-trap will not resist siphonage. Fig. 1459.-Complication arising from Trap Venting. Piping of three fixtures. without vent-pipes, but rendered safe by the use of anti- siphon traps and large waste outlets. 5. It aggravates the danger arising from capillary attraction ; and finally, Fig. 1461.-Capii- Idry Attraction s-trap" Fig. 1460.-Simple Method of Piping the same Three Fixtures, with Anti-siphon Traps and Stand-pipe Overflows. 6. It seriously increases the cost of plumbing, an increase which amounts to as much as from five to ten per cent. * Taken from a piece of plumbing actually executed (except that the relative positions and kinds of fixtures were changed) in New York, and exhibited as a " model job" by the advocates of trap-venting. 430 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. None which is less than eight inches in diameter can be relied upon in all cases. A six-inch pot-trap might some- times be siphoned out by discharges from fixtures occur- ring in common practice. A five-inch pot-trap siphons out much easier. An ordinary four-inch trap has very little resisting power, unless its seal be unusually deep. Three-inch and two-inch traps are altogether useless, and but little more than S traps. The larger pot-traps are, however, veritable cesspools, and as such are to be avoided. When used under sinks they quickly collect grease, which in time converts them practically into S-traps, and deprives them of their origi- nal power of resisting siphonage. They are, moreover, expensive. A plumber's scale of charges for these traps is at the rate of $1 for every inch in the diameter of the trap. Thus, if the standard rates are asked, a five-inch, six-inch, and eight-inch pot-trap cost, respectively, $5, $6, and $8. The pot-trap is, moreover, bulky and unscientific in construction. Its clean-out cap is faultily arranged at the top, where, if improperly ad- justed, it will allow the escape of sewage gas without warning. The clean-out cap of a trap should always be, wholly or in part, below the normal level of the standing water, in order that, if an unsound joint occur, it will at once be detected by an escape of water, and the defect reme- surface should be used to throw the water back into the trap and let the lighter air escape to supply the vacuum in .the soil-pipe. Such a reflecting surface is found in the flat top of the pot-trap above the outlet mouth. We will, therefore, retain this useful feature, but reject the objec- tionable one of the excess of sectional area in the body over that of the inlet and outlet arms, and we have a trap like that shown in Fig. 1463. The reflecting surface, however, should not be arranged as here shown. The pocket increases the unscoured area of the trap. It is true it is no worse than the mouth of a venti- lating pipe, which, under the present law, it is cus- tomary to put at this place. But it is just as certain that such a pocket will become clogged in time, as it is that grease and filth will deposit a sediment on everything with which they come in contact. The higher or deeper the pock- et, the more readily will the deposit be formed. A shallow pocket might be partially scoured by the force of the water pro- jected upward against it by momentum. In this case a certain portion of each deposit of filth would be washed off by friction, and the process of clogging would be somewhat retarded. But let the pocket be deep enough, and there will then be parts which will be within the reach of the waste- water, but beyond its scouring effect. The spray thrown up by momentum will at this height have lost its power. The drops of dirty water will simply rise to their turning- point, deposit their filth, and trickle back again into the trap. The ventilating outlet forms exactly such a pocket. At a certain height above the crown of the trap the inner surface of this flue will receive the sputterings of the filth- laden waste-water, but never receive the scour. Hence the area of the vent-opening must infallibly continue to decrease in size more or less quickly, according to the usage of the fixture, until the opening is too contracted to be of any value in resisting the action of siphonage on the water-seal. Moreover, the cool ventilating draught helps to congeal the fatty vapors aris- ing from hot waste-water in the trap and hastens clogging. We will, there- fore, simply retain the reflecting sur- face, but reject the pocket. Further- more, we will slightly contract the inlet and outlet mouths at their junc- tion with the body. This allows the air rushing through the body of the trap to pass through the water instead of driving it out before it. A very slight contraction is sufficient. These two modifications make the second step in our improvement, and are shown in Fig. 1464. A trap was con- structed in this manner, and proved to be very much stronger in resisting siphonic action than an S trap of equal depth of seal. Still our trap is very far from anti- siphonic. Referring to our glass pot- trap, we shall see that the water pro- jected violently upward from the sur- face, by the air-bubbles rushing through the standing water under the influence of siphon- age, is obliged to pass twice by the mouth of the outlet- pipe, once before and once after reflection against the top, and that it is at these moments that it is sucked out and lost. That part of the spray which happens to Fig. 1463.-First Modification. Fig. 1462.-Movement of Fluids in a Pot-trap. died. It is better to endanger the floors or plastering than the life or health of the owner. It is found to be exceedingly difficult to make a threaded joint, like the one here used, water- and gas-tight by simply screwing on the cap over a rubber or leather washer, such as is used on pot-traps. In the effort to secure tightness the plumber screws the cap on so hard that the house owner is rarely able to unscrew it and properly replace it with the ordi- nary tools at hand for examination, or to carry out the cleansing which is so frequently necessary. A Hat washer compressed by a threaded cap, in the manner customary with pot-traps, cannot readily be made tight. The third method of obtaining the security desired is to make use of some form of trap which is both antisiphonic and self-scouring at the same time.* "If we examine the action of the fluids in a pot-trap when it is subjected to siphoning, we shall find the air is driven through the water in the manner shown in Fig. 1462. Part of the water is carried directly out of the trap, and part is forcibly thrown up against the top of the body of the trap, whence it is deflected back in the form of spray in all directions. Part falls across the outlet and escapes. One of the principal reasons why the S trap is so easily siphoned out, is that the curve at the top conducts the water directly into the outlet. Some form of reflecting Fig. 1464.- Second Step. Partial con- traction of the inlet and outlet mouths, and reduction of the pocket. * The following description is taken from The Principles of House Drainage, above referred to. 431 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. be thrown farthest from the mouth of the outlet-pipe, will be seen to fall back safely into the trap; but that which passes near this outlet, either in rising or after re- flection, is drawn out by the concentrated and powerful suction at this point and wasted. And we find that one of the principal reasons why a large pot-trap resists siphonage longer than a small one is, that in the large trap the spray has more space above the surface of the standing water than in the small one, so that a smaller proportion of the water thrown up by the rushing air- bubbles passes within the influence of the suction at the outlet-pipe. If our re- flecting surface could be placed below instead of beyond the mouth of the outlet, this loss could be avoided. Our next step must, therefore, consist in so placing the reflecting surface. In Fig. 1465, this has been accomplished, but in an awkward man- ner. Before this surface can come into service, the level of the water must evidently be reduced to the level shown by the shading in the figure. Hence, the perpendicular part of the body of the trap above the lower re- flecting surface is not placed to advantage. Nevertheless, this trap will resist a very powerful siphonic action, even as it is. The two reflecting surfaces, the lower and the upper, are so effective, that this form of the trap has proved more tena- cious of its last inch or two of seal than a four-inch pot- trap, although its diameter is nowhere greater than that of the outlet and inlet pipes. In this, and in the preceding forms, the depth of seal is too great to allow of a free and rapid discharge of the wastes. The air, in passing through the trap, disturbs nearly all the water in it. Our next step will therefore be to diminish the height of the water-column through which the air has to pass, and thus reduce the disturb- ance of the water without lessening its volume. It may be done by laying the body of the trap horizontal instead of perpendicular, as shown in Fig. 1466. This immedi- ately gives us a very important improvement in resisting power. The area of the trap is no greater than that in Fig. 1464, but it is found to offer double the resistance to siphonage. More- over, while the volume of water is the same as in Fig. 1464, the seal is not so deep. Hence, the flow of water through this trap is more rapid than in the former, and its scouring effect is correspondingly increased. As soon as the water in this trap has been lowered to the point indicated in the draw- ing, ample space is left above it for the passage of the air. It is evident that a much smaller body of water is dis- turbed by the passage of the air than is the case with the trap shown in Fig. 1464. Nevertheless, the trap thus made is not yet sufficiently antisiphonic. It is, moreover, awkward in form and difficult to set in such a manner that it shall remain firm in place." The long horizontal body is liable to sag and lose its form. Moreover, a single reflecting surface is insufficient to separate the water entirely from the air, and a strong and long-continued siphonic action destroys its seal. Other improvements are evidently necessary. A fifth step consists in increasing the number of reflect- ing surfaces, and in breaking up the long horizontal body by making it return upon itself in a quadrangle, as shown in perspective in Fig. 1467. In this form of the trap we have still further greatly increased the reflecting surfaces and the power of resisting siphonic action, and we are now able to dispense with re- flecting pockets ; but we have obtained a trap exceedingly difficult to manufacture, awk- ward in appearance, and troublesome to clean out in case of accident, as when a match or any such foreign substance is dropped into the waste-pipe and becomes lodged in a bend of the trap. This form of trap must be simpli- fied so as to render it practi- cal, without losing any of the advantages we have thus far arrived at. Figs. 1468 to 1474 show the manner in -which this may be done, and the arrangement forms the final step of our improvement. We have here retained all the reflecting surfaces; the horizontal body, which allows the air to pass above the water after a small quantity has been driven out, without disturbing the rest; and the slight contraction of the in- let and outlet pipes at their junction with the body of the trap. We have added a cylindrical movable clean- out cap of glass, and obtained an ap- paratus which can be readily cast in lead in moulds of iron. The quad- rangular shape of the horizontal body is retained, but the two parallel cylinders are brought together and merged into a single cylinder having a central partition about two-thirds of its length, or extending from one end to the edge of the clean-out cap, which at the other end forms about one-third of the total length of the cylinder. In ordinary use the waste-water passes through this trap in such a manner as to act to the best advan- tage in scouring it. The partition wall in the centre of the body causes the water to scour each side in succession. Thus, while in outward appearance the body resembles a small pot-trap placed horizontally, it has in principle the self-scouring form of the S-trap. It must be understood, however, that, like the S-trap, it is only self-scouring when properly set, namely, with a free out- let from the bowl somewhat larger than the inlet-arm of the trap at its largest part, or at its point of junction with the fixture. If set under a fixt- ure giving a clear water- way of only an inch or of half an inch, this trap will not scour it- self, nor will the waste-pipes with which the trap is connected. A good-sized wash-basin holds, up to its overflow, about two gallons of water. This will escape through an average length of one and one-half inch waste-pipe, running full-bore and having a good fall, in about three seconds. Hence, through such a pipe the water rushes out at a rate of more than half a gallon a second and fully scours the pipes. With lavatories constructed on this principle, the Fig. 1467.-Fifth Step. Fig. 1465.-Third Step. Fig. 1468.-Sixth Step. Fig. 1466.-Fourth Step. Fig. 1469.-Perfected Trap. 432 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitation*. Habitation*. required in the regular use of the fixture, is all that is necessary, provided the arrangements for its discharge be suitable. If every lavatory be constructed with an out- let large enough to fill the waste-pipes as nearly "full bore " as possible, there will be no occasion for the erec tion of special flush-tanks at the highest point of the pipe system. Each fixture will then serve itself as a flush- tank. A few years ago, before it became customary to venti- late all the main pipes thoroughly, dangerous gases might argument for trap ventilation, based on the supposition that it is necessary to keep the branch wastes clean, no longer holds good. Although the seal is not excessively deep, yet the trap, owing {o the considerable horizontal extension of its pas- sages, contains a large enough body of water to protect it from the dangers of evaporation and back pressure. The contraction of the inlet and outlet arms at their junction with the body of the trap ren- ders it secure against self-siphonage. The form renders loss of seal through capillary attraction impossible, as will be hereafter shown. When used where trap- venting is pre- scribed b y law, this trap can, of course, be vented like any other. The vent may be applied at any part of the outgo, either at or below the crown. But since, unlike S-traps, its seal cannot be destroyed by self-siphonage or momentum, the vent need not be applied at the crown. It may be applied anywhere below the crown, far enough away to quite avoid the injurious effects of evaporation. Hence, ventilation does not produce the destruction to the seal that it does with other self-cleansing traps, and may be used, so far as this is concerned, with impunity. Trap ventilation is nevertheless, in this case as in most others, absolutely useless, and its installation is a total loss to the houseowner. The strongest siphoning action that can be brought to bear upon this trap in practice fails to break its seal, and it is found to have a power of resistance very consider- ably greater than an ordinary six-inch pot-trap, or even than an S-trap fully and newly ventilated. The trap may be placed close to the fixture it serves, and on this account as well as on account of the small body of water it con- collect in the ends of pipes which were sealed up, and " dead ends " were things to be guarded against with far greater solicitude than now, when sewer and soil-pipe ventilation is so general. " Dead ends" are parts of a pipe system where there is no life or movement. There can be no "dead end" in pipes terminating in properly constructed plumbing fixt- ures. Not only does the discharging water rush from these with great force, but pure air from the room is drawn through afterward by suction, so that water and pure air are both brought into service for cleansing every time such fixtures are used. It is very rare that we find lavatories constructed on this principle, even in the best and most costly buildings. We find that wash-basins and bath-tubs have been selected for their convenience, appearance, and economy, while sanitary considerations have been quite overlooked, in the Fig. 1470. belief that they have little or nothing to do with the form of these particular fixtures, so long as their traps and waste-pipes are properly made and con- structed. Fig. 1475 shows actual dimensionsof the ordinary basin-strainer. They dis- charge a stream scarcely three-fourths of an inch in diameter, even when new. A very short usage reduces these meagre openings, through the collection of sediment, to a stream varying from a fourth to a half inch in diameter. This amount, trickling through waste-pipes which are capable of carrying off ten times as much, fouls but does not scour them. I have taken out such pipes and found them half filled with slime and filth. No amount of ventilation Figs. 1471 to 1474.-Body of the Trap (shown in Fig. 1470) with Mov- able Metal Cap removed to show the Interior; Reflecting Partition, and Glass Movable Cap with its Metallic Clamping Ring. tains, it does not, like the large pot-trap, clog with grease under sinks. The grease passes through the trap in a liquid state, and escapes into the proper grease receptacles beyond. 4. Thorough Flushing.-The great importance of thor- ough flushing, as a means of cleansing the waste-pipe system, is now beginning to be understood. It is by no means necessary that this should involve a waste of water. A small body of water, no more than is Fig. 1476.-Ordinary Plug and Chain Wash-basin. 433 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. could cleanse them. But the sediment was soft and gelat- inous, and could easily have been swept away by the all work should be placed in full view on ceilings and walls. Bath-tub traps should be placed directly under the plaster of the ceiling below the fixtures, not between joists. Bath-rooms are generally arranged over each other, or over china closets, or back halls, which enables this to be done. But if it is impossible, a small hinged trap-door should be cut in the floor at the foot of the bath tub to gain access to the trap. Wash-basinsand pantry-sinks may have the little stack of side drawers if desired for convenience. These do not in any way confine the plumbing work. There is no rea- son why the central space in which the pipes and trap stand exposed should not be protected from dust by a cupboard door. But all within should be neatly and tightly sheathed or tiled. Some writers insist upon hav- ing lavatories set entirely open. This is to be recom- mended in the case of sinks which otherwise would be quickly appropriated by old pans, cloths, and other rub- bish and vermin, but I see no necessity for it in the case of wash-basins, or American copper bath-tubs, since all the plumbing may be equally well inspected and approached without going to the extreme of omitting the convenient and customary side drawers; and a narrow space between the bottom oi a bath-tub and the floor would only form a lodgment for dust without increasing in any way the con venience of access to the working parts. Water-closets should never be encased. Those kinds which have much machinery about them to collect dust, such as the pan, valve and plunger closets, are not to be recommended. The best kinds are smooth and simple in their forms and require no cover. They should be sur- rounded with tiles, marble, or hard wood on the floors and walls, and no casing except the seat and a light frame to sup- port it should be erected about them, so that all parts can be Fig. 1477.-Wash-basin with Waste-cock Outlet. powerful discharge of a basin tilling the pipes "full bore." Fig. 1476 represents the ordinary plug-and-chain basin with the contracted outlet and strainer. Fig. 1477 represents a basin with the so-called "Boston waste" attachment. This popular device is probably the very worst kind of lavatory that could be devised. The waste-cock discharges a stream even smaller than the ordinary basin outlet and strainer, the waste opening through the ground cock being scarcely one- fourth of an inch in diameter in the average, even when new. It has the cesspool chamber already re- ferred to as so objectionable from a sanitary point of view, and so disgusting in polluting the clean water in usage. It is, moreover, ex- ceedingly complicated and liable to get out of order, and very expensive. The great extent of the use of such a barbar- ous device illustrates sharply the lamentable ignorance of the public in these matters, and shows how important it is that their attention should be called to them. 5. Accessibility and Visibility.-Until within a few years it was considered necessary to conceal all parts of the plumbing work from sight by enclosing it be- tween the floors and ceilings, or behind casings. We are now beginning to understand that there is nothing really objectionable in the sight of bright and polished metal pipes and well-designed fixtures set in a workmanlike manner. On the contrary, they may be made highly ornamental, and, as the chimney-flues which carry off the foul air and products of combus- tion, once despised, have now become the crowning ornamental features in the design of a house, so there is no reason why the waste- pipes, which carry off the foul water and products of decomposition, should not be made to contribute in like manner in a high de- gree to the architectural ef • feet. If plumbing work be con- cealed, leakages are liable to take place and cause irreparable damage before they are dis- covered, and the cost of hunt- ing for and repairing a leak is often immeasurably increased. There is no reason why every inch of plumbing in a house should not be immediately accessible and visible, except possibly where pipes pass through parlors or important reception rooms, in which case they should be covered by movable panels, preferably hinged like a door. In the bed-rooms, closets, bath-rooms, and servants' departments kept clean and sweet by periodical washing and con- stant ventilation. The casing around a water-closet is a constant source of trouble. Dust and dirt collect in the corners. Drippings from careless usage of the closet, especially by children, servants, and invalids, fall in the woodwork and develop foul odors. The free cir culation of the great purifiers, light and air, is prevented, and the dis- agreeable smells increase with age. The interior of the hidden over flow passage of the ordinary plug- and-chain basin can never be reached for cleansing. It becomes foul after a while, and delivers into the chamber a nauseating odor. A defective joint in it, or a wrongly connected overflow-pipe, may be the source of serious danger. These lead overflow-pipes have sometimes been found connected with the sewer side instead of the house side of the trap. Fig. 1479.-Ordinary Pipe with a " Paper and Put- ty" Joint on the Main Pipe, and with Uncalked Lead-joint on the Smaller Branch. Fig. 1478.-Section of Poorly- cast Iron Pipe. 434 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. 6. Sound Materials and Jointing.-In plumbing, more than in any other department of building, it is essential that sound and durable materials only should be used. It might seem superfluous to call attention to this. Yet the frequent use of the flimsily constructed pan-closet, and thin and defective waste-pipes in the most elaborate and a tool after the lengths are set up. The gasket is used to prevent the lead from running out of the joint and ob- structing the bore of the pipe at some point below, besides wasting the lead. The lead is now poured upon the gasket from a ladle, and shrinks as it cools. The calking tool must then be used to expand it again and drive it into the cavi- ties and pores of the iron. This is a difficult operation, and re- quires considerable skill on the part of the workman to calk the joint in the contracted spaces constantly occurring in house plumbing. The result is that the ordinary hand-calked joint is rarely left perfectly tight. Of late years it has become custom- ary in the best work to require the tightness of the joints, and the strength and soundness of tile pipe, to be tested under hydraulic pressure. This test is applied by stopping up the outlets of the pipe system, after it has been set up in the house, Fig. 1480.-Perspective View of Lead Ring. expensive buildings, shows that the reverse is the case. The cost of manufacture of any article evidently depends upon the number, material, and complexity of the parts, and the manner of putting them together. The pan-closet consists of nineteen different pieces, not including nuts and bolts, or of fifty-one pieces including them. A perfect closet can be made in a single piece, with two couplings and four bolts to connect it with supply- and waste-pipes. To make these complicated fixtures so that they shall yield a reasonable profit to the manufacturer, to the dealer, and to the plumb- er, is only possible when they are sold at the low price to which competition has reduced them, by re- ducing the weight and the quality of the materials and workman- ship to the min- imum. They are usually of the flimsiest and most unreliable character. Great caution should be ob- served in selecting the iron pipe for the main waste- pipes. The castings are more likely to be uneven than even in thickness, and we sometimes find, on breaking them, that they scarcely measure a sixteenth of an inch on one side, while the other contains the balance of the metal (Fig. 1478). It is the same with a stack of iron piping as it is with a rope. The measure of its strength is its weakest part. Of what use is it to pay for pipes a fourth of an inch thick, when many pieces in the stack are in places thinner than a piece of pasteboard ? All pipes should be tested for thickness before use, or as they are put up, and only those kinds should be accepted which are found carefully cast, so as to be gen- erally uniform in this respect. Here again, compe- tition has reduced the price of iron piping to so low a figure that the castings of the or- dinary kind are usu- ally very defective, and it is no uncommon thing to find castings as defective as that shown in Fig. 1478. The usual method of jointing pipes is by hand calking. This is accomplished as follows: A gasket of jute or other similar fibre is inserted into the cavity of the bell or hub, and the spigot end of the length next above it is set firmly down upon it, or the gasket is rammed in with Fig. 1483.-Perspective View of Joint between Lead and Iron Pipes. Fig. 1481.- Section of Lead Ring. Fig. 1484.-Diagram Showing Use of the Wrenches in Contracted Spaces. with caps or plugs, and filling the whole with water up to the roof. If the joints are leaky or only made tempor- arily air-tight by a coat of paint or putty over a careless lead calking, or if the pipe is defective in any way, whether through inequality of thickness or porousness of metal, the effect will at once be revealed by a leakage of the water. A simple smoke or peppermint test fails to expose these defects, on account of the thin film of paint with which the pipes are coated inside and out before they leave the foundry. Even if a hand- calked joint has been made to stand the test when new, its tight- ness is very soon destroyed by expansion and contraction. The lateral expansion of the spigot is greater than that of the hub when hot water or steam passes through the pipes, because it is on the in- side, nearer the heat. Hence the lead is temporarily compressed between the two, and being inelastic, does not resume its original bulk when the pipes cool again. This leaves a minute opening for the escape of soil-pipe air all around the spigot (Fig. 1479). The ordi- nary flow of water down the pipe will not reveal the leak because the spigot sets within the bell, and sewer-gas or soil-pipe air enters the house unannounced. Fig. 1485.-Half Ring. Fig. 1482.-Section of Joint between Lead and Iron Pipes. 435 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. On account of these defects, as well as of the difficulty of disjointing the pipes in case of repairs or alterations, and of the great amount of lead consumed in the work, the ordinary system of pipe- jointing must be considered very unsatisfactory. The effort to provide a better method of jointing has given rise to several im provements, among which may be mentioned the Dur- ham system of wrought iron threaded piping. In this, heavy seamless wrought iron tubing of uniform thickness is substituted for cast iron, and the lengths and fittings are screwed into each other somewhat in the same man- ner as gas-piping. This has been tried for several years in house-plumbing, and with success. The joints are perfectly and permanently tight, and the material is tough and homogeneous in texture. The pipes are now coated by the Bower-Barff rustless pro- cess, and it is believed that the chief objection to the use of wrought iron pipe for water service is thereby avoided. This pipe is very much to be preferred to the ordinary hand-calked bell and spigot pipe. To avoid the difficulties, how- ever, connected with thread- ing and screwing together of wrought iron pipe, and to per- mit of the use of cast iron with- out the defects involved in or- dinary hand-calking, the writer has devised and put into use a very simple and economical form of Hanged cast-iron pipes, which may be connected by means of bolts after the man- ner of cast-iron steam-pipes, and rendered permanently tight without the employment of skilled labor. It may be de- scribed as an adjustable hanged joint, and is shown in Figs. 1480 to 1491, inclusive. The packing consists of a cold lead ling (Figs. 1480 and 1481), which is crushed between flush hanges, or, if lead and iron pipes are to be connected, a lead pipe hanged over a ring on one side, and a hush flange on the other, are used, as shown in Figs. 1482 and 1483. The pressure is applied by two ratchet wrenches constructed for the purpose, and used simultane- ously, one working left- and the other right-handed, as shown in Fig. 1484. The half-ring casting shown in Figs. 1485 and 1486, has for its ob- ject to enable a pipe to be revolved on its axis, to enable, say a branch pipe, to turn to any required angle before the bolts are tightened up. Fig. 1487 represents a number of lengths of this piping put to- gether. The amount of lead used in each joint is only a fourth or an eighth as much as is required by the ordinary bell and spigot joint, and it may be read- ily compressed so as to make a steam-tight joint in a couple of minutes by an ordinary workman once ascus- tomed to the new system. The expansion of the two flanges being exactly even, no injury can be done to the joint by hot water or steam. The strong bolts prevent a leakage being made by sag- ging or longitudinal tension of the pipes, while the ordi nary cup-joint depends for its resistance to such a strain only on the friction of the lead calking against the sides of the iron. The flush flanges enable any piece of the piping to be taken out for alteration without breaking it, and the opportunity for the use of sand, paper, putty, or other fraudulent packing is pre vented, since all the pack ing used is directly visible when set in place from the outside. Branches and fit- tings of various kinds, similar to those used in wrought-iron screwed pip- ing, enable any change of direction to be given with entire facility, by a work man accustomed to the new system. Lead melting on the premises, and all pipe cutting, which is both diffi- cult and dangerous to the pipe, is avoided. Fig. 1488 represents the pipe ends capped for testing the joints. Fig. 1489 shows the manner in which this pipe may be connected with ordinary pipes, and Figs. 1490 and 1491 give two methods of inserting a new pfece of pipe in an old stack for alterations or repairs. The pipes are cast in short lengths, and in such a man- ner that they are of uniform thickness throughout, and Fig. 1486.-Half Ring in Position. Frte. 1489.-Connection with Ordi- nary Bell and Spigot Pipe. Fig. 1487.-Straight Pipes and Bend Connected. Fig. 1490.-Method of Inserting a New Piece of Pipe into an Old Stack, Using Brass Castings and Soldering them together with Slip-joints. Fig. 1491.-Second Method, Using Iron Castings and Brass Tubes threaded upon them. The Brass- es to be soldered together. as the calking requires no hammering, porcelain enam- elled pipe may be used with safety if desired. 7. Simplicity.-The present tendency in plumbing work is toward too great complication. Pipe ventilation is car- ried to an excess. Balls, and valves, and other machin- ery are used where the work could have been better constructed without them. Germicides and disinfecting Fig. 1488. - Pipe Capped ready for the Application of the Hydraulic Test. 436 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. apparatus have been resorted to for removing evils which have no excuse for originally existing, ami the most in- tricate and curious machinery is often employed to ac- complish the simplest results. The pan-closet, made up of sixty different pieces, may here again be pointed to as an example of this. In short, the pan-closet has one show how the element of simplicity may be lost sight of. The dewice contains every variety of waste-cock, valve, crank, and lever, designed to afford certain security against the. entrance of sewer-gas ; and yet, the only cer- tainty attained is, that the waste passages will surely become soon clogged with filth, and the only security is that their clogging will permanently shut off connection with the sewer alto- gether. 8. Economy i n Construction and Operation. - Other things being equal, the less expensive in construction an appliance may be, the better, in order that the money used may be put into extra strength and quality of material. Moreover, the world must be taken as it is, and we know that, until the mil- lenium arrives, we shall continue to find cost an item of considerable importance, even in the choice of plumbing goods, and that many will value economy even before sanitary considerations. Therefore it is important that economy of construction should be carefully considered in the design of plumbing fixtures, and in the general arrangement of the work. It is one of the objections to the common pan-closet, and to the patent English basin last illustrated, that the principle of their construction is so complicated and costly. There is a ten- dency on the part of the manufacturers to reduce the strength and quality of the goods, in order to enable them to sell in competition with simpler devices. For the same reason, among others, the expensive sys- tem of trap-ventilation is to be condemned, now that a simpler and more economical means of attaining secur- ity is at hand. Economy in op- eration is equally important with economy of con- struction. Water- closets and other fixtures which cannot be Hushed with- out an extravagant consump- tion of water are to be avoided, since closets can be made with an equally effective flush, with- out waste of water. So, also, complicated devices which require constant care, cleansing, and repair, and traps which have to be period- ically filled with water by hand to replenish their seals, or which require constant atten- tion to clean out accumula- tions of filth within them, are to be avoided. 9. Automatic Operation.-. This desideratum is closely allied to the last. The work should be of such a nat- ure as to keep itself in working order as far as possi- ble, and be independent of human intervention. In those places where it has been customary to require the venting of traps, it has been found necessary to issue printed cautions, warning house-owners against leaving their traps unused, on account of the evaporation of the water-seals induced by the air-current, and advising them Fig. 1494.-Valve-trap. Showing where de- posits may collect. Fig. 1492.-Plunger-closet. Showing where foul deposits may collect. merit, namely, that it never fails to provide a forcible illustration of every evil we should strive to avoid in plumbing. Figs. 1492 and 1493 represent ordinary valve and plunger closets of the types which have been much used and have become familiar to us. These closets are no better in principle than the pan-closet, and the only rea- son why they have longer remained popular than the latter is, because they have been constructed of better and stronger materials, generally under the protection of patent rights. The re- ceiver is smaller than in the pan-closet, but, on the other hand, to offset this advantage, the closet has the disadvantage of requiring a special over- flow passage which is eas- ily siphoned out by its own discharge. This of- ten happens. Fig. 1494 represents a valve-trap, and Fig. 1495 an English valve-basin, which may be taken as types to illustrate their class. We see how sediment is liable to collect in them. After what has already been said, no further explanation of the evil of these devices will be needed. Fig. 1496 gives a very complicated form of lavatory invented and patented in England. It is introduced to Fig. 1493.-Valve-closet. Showing where deposits may collect. Fig. 1495.-Valve Outlet Wash- basin. 437 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to have some competent and trustworthy plumber employed to refill the traps with water at least every two weeks, and, if possible, to have all the windows of the house open for twenty-four hours before its re-occupation after tempo- rary absence.6 There is no occasion for using a sys- tem requiring such constant supervision to provide against evaporation, and, moreover, the competent and trustworthy individual who is to be responsible for the security of the premises is not always so easily found as could be wished. Traps should be constructed so as to keep them- selves always sealed, and pipes and lavatories ar- ranged to keep themselves always well flushed and clean. 10. Noiselessness.-Most of the modern water-clos- ets, which are designed to give a quick and powerful flush of water, are open to the serious objection of excessive noisiness in operation. Every precaution to secure the privacy in usage which civilization de- mands is thwarted by the boisterous flourish of rushing water with which most water-clos- ets invariably herald throughout the house, any such absurd at- tempt. This is par- ticularly mortifying in cases where the toilet- room leads off the main hall. The flushing of a water-closet should be so arranged that when the toilet-room door is closed it will be inaudible from the outside. Having established the principles which should guide us in at- taining a perfect sys- tem of plumbing work, it remains now to select the appliances which conform to them. The question of the special form most de- a stand-pipe, and to be completely out of the way of the user it must set in a recess under the slab at the back of the lavatory, which must be perpendicular at this point to meet it. To be simple, the stand-pipe and outlet-plug must be one and the same thing, and to be easy to oper- ate it must be raised and lowered by some simple lifting device above the slab, within easy access. Being unable to find any existing apparatus conforming to these requirements, the writer was obliged to construct a lavatory of his own design. The device, as applied to a wash- basin, is shown in Fig. 1497. The other forms of lavatories, as bath-tubs, pantry-sinks, and wash-trays, are constructed on the same prin- ciple, so that a description of the first will suffice for the rest. The description of this basin may be appro- priately left to another writer. William Paul Gerhard, C.E., the well-known authority on Sanitary Engineering, writes of it as follows : * " Fig. 1497 shows a perspective view, Fig. 1498 a plan, and Fig. 1499 a section of the basin. The basin is made in the best earthen- ware, either of the usual round or else of an elliptical form. Every part of the basin, of its fittings and passages, is visible and kept easily accessible, and is entirely free from fouling chambers or easily befouled corners, and basin Fig. 1497.-Perspective View of Wash-basin with Stand- pipe Overflow. and all may be kept clean from top to bottom, even as far down as the waste-pipe and trap, without removing the basin or any part of it. As will appear further, it is of the utmost sim- plicity and of great convenience in use, while its appearance is, if anything, even more pleas- ing than that of the usual form of bowl. It differs from the latter in having its outlet at the rear, thus presenting a bottom of the bowl entirely unencumbered or roughened by any brass grating or socket and plug. The diameter of the brass outlet at the bottom of the basin is two inches, inside diameter, and, allowing for the obstruction caused by the strainer, it has a clear water-way of about one and a half inch, the size of the waste-pipe attached to it, and hence a very rapid flushing discharge is secured. In fact, the rush of water from this basin through the waste-pipe and trap is so great that the seal of even a ventilated S trap is de- stroyed by it. In order to restore the seal, the bottom of the basin has only a slight inclination toward the outlet, so that the last flow of water from it is sufficiently re- tarded to restore the seal of the trap. It is thus seen that the great desideratum, that the fixture should act as a flush-tank for its waste-pipe and trap, is here accomplished. The basin is shaped, as seen on the plan, with a per- pendicular recess at the back, and in this recess, com- pletely out of the way of the user, is placed the stand Fig. 1496.-Complicated Form of Wash-basin Apparatus. sirable for traps and soil-pipes lias already been consid- ered. We have next to take up lavatories, water-closets, sinks, and other plumbing fixtures. Lavatories.-In order to conform to our ten require- ments, our lavatories must be quick-emptying,without con- cealed parts, and simple in form and in operation. This obliges us at once to discard the ordinary plug and chain lavatories, all those which have small or elongated outlets, or concealed waste-passages anywhere ; and finally the double, or tilting, class of basins. To be quick-emptying, the lavatory must have an outlet large enough to more than fill the water-pipe which serves it "full bore." Hence the outlet should not be less than two inches in diameter to allow something for the obstruction caused by the strainer. To avoid concealed parts the overflow passage must be in full sight, and as its outlet must be near the top of the fixture, some form of passageway which shall ex- tend from the top to the bottom of the fixture must be provided; and since this cannot be on the outside with- out being concealed by the slab or frame, it must be on the inside. Hence it must have the general form of * The numbers of the Figures in Mr. Gerhard's series have been changed to conform with the rest of this article. Also a lever of im- proved form for the lifting device has been substituted for that made at the time Mr. Gerhard's description was written. 438 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. pipe over-flow-a tube, one and one-fourth inch, in- side diameter, and about four inches high-which serves to close the outlet of the basin if it is desired to fill the latter. This overflow pipe has a smooth surface, and enough space is provided between the stand-pipe and the walls of the recess to allow of the convenient use of a scrubbing cloth, so that both the basin and the stand-pipe may be cleansed without the necessity of removing the latter. But it is not even difficult to remove the stand- pipe, should this be desired, as the stand-pipe is lowered or raised by a very simple and convenient lever move- ment. The lever is located on top of the marble slab and lifts the rod which passes through the slab, and is guided by a short tube secured to the slab, and to which the stand-pipe is suitably hooked. The lever movement is so arranged that the stand-pipe may be lifted without much Through it waste water is completely and rapidly re- moved, a quick discharge, as from a small flush-tank, ef- fected, filling the pipes full bore, and the trap and waste- pipes are thoroughly scoured. It provides for an overflow without requiring a special pipe or valve for this purpose; it has no brass-work in the bottom of the bowl in the way of hands when washing, and no chain and plug. The pernicious habit of washing in running water is rendered unnecessary, and hence an important aid is established to- ward the prevention of water waste. The whole of the fixture, and all its parts and appendages, are visible and readily accessible ; its outlet is controlled by a very sim- ple single movement, which mechanism requires only very little strength to operate. It is easily attached to the slab, readily fitted up by the plumber, and has no concealed parts liable to clog or become obstructed. In Fig. 1498. -Plan of Basin. Fig. 1499.-Section of Basin with an Antisiphon Trap Attached. friction. To the lever is attached a plated handle, and by turning the latter the stand-pipe is easily lowered and the outlet closed. " The stand-pipe outlet basin is superior to ordinary forms with overflow pipe in other minor respects, one of them being that it requires fewer joints for the plum- ber to make, and that it does not offer any temptation to unskilful and ignorant mechanics to connect the over- flow pipe, as required in the ordinary form of bowl, to the wrong side of the trap attached to the waste-pipe. It is evident that the opening in the marble slab may be of the same shape, for this as it is for other basins, i.e., either plain circular or elliptical. " To sum up. the wash-basin under consideration offers the following advantages : It is a quick-emptying, self- cleansing, back-outlet basin, without concealed overflow. short, it is a durable, simple, and well-constructed sani- tary plumbing fixture." Fig. 1500 shows a wash-basin set open. Its waste-pipe is trapped by an antisiphon trap. By doing away entirely with the usual cabinet-work surrounding these fixtures, light and air are admitted into spaces which are generally damp and musty. Better workmanship is obtained from the plumber, and greater cleanliness from the housemaid. Fig. 1501 shows the same principle applied to a bath- tub. The trap is here placed between the floor-joists, and in order to gain access to it, a small trap-door is used. Fig. 1502 represents a copper pantry sink treated in the same way. The same principle should be applied to wash-trays and kitchen sinks. The kitchen sink receives a large amount of grease and refuse. The grease passes through the strainer in a fluid state, and this gives rise to 439 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the principal difficulty in dealing with the fixture. The grease adheres to the trap, if it be one of the pot or reser- congeal in its passage through it, because the small body of water in it is insufficient to cool the liquid grease. But to prevent clogging in the pipe beyond the trap, special precautions must be taken. In small houses, and wherever care is taken to save the grease, a common kitchen sink may answer all purposes. But where grease is allowed to run through the sink, unusual precautions must be taken. An excellent device designed by Mr. Gerhard, and based on the quick flush- ing principle of Col. Waring's Flush Pot, and on the form of outlet just de- scribed, is shown in Figs. 1503 and 1504. The sink is divided into a shallow and a deep part, with an upright strainer intervening. The shallow part is used like an ordinary kitchen sink. From it the waste water passes through the upright strainer into the deep part until the latter is tilled. The top of the overflow pipe is placed slightly above the bottom of the shallow sink, so that the cook will be obliged to lift the overflow pipe to clear it. The opening of the plug allows all the water to rush out with great speed and force, scouring the pipes and driving grease and everything else headlong through the outlet strainer into the proper grease receptacle immediately outside of the house walls. A perforated dish-strainer may be employed over a portion of the dee' ■ part, which latter serves as a most con- venient vessel for washing pots and other utensils requiring a deep body of waiter. Grease-traps. -Another precau- tion to prevent clogging of pipes, as well as to save the grease, which has considerable commercial value, is the use of the regular grease-trap already referred to. These receptacles should never be placed in- side of the house, but just without the walls, as near the sink as possible, and they should be large enough to re- tain all the grease likely to pass into them for at least a month. It would probably be better to have them large Fig. 1500.-Wash-basin Set " Open," withan Antisiphon Trap under it. voir class, and to the waste-pipes as soon as it chills, es- pecially in pipes too large to receive a good flush, and causes clogging and considerable inconvenience. Fig. 1501.-Bath-tub. enough to require emptying only two or three times a year, say, of a capacity of two or three cubic feet. The grease floats on the top, and the heavy refuse sinks to the bottom of the trap. The inlet pipe opens several Fig. 1502.-Pantry Sink. Clogging of the trap may be prevented by the use of the "Sanitas" trap, which does not allow the grease to 440 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. ize the soil, so that they are constantly fouled. A pre- liminary Hush is sometimes arranged to partially obviate this trouble, but this contrivance is not to be relied upon. The method of connecting the common hopper with the soil-pipe is usually defective, the seal is too shallow to withstand even a slight evaporation and siphonage, and they are exceedingly noisy in operation. All closets which depend upon a double trap violate rules 1, 4, 7, 11, and 13. The side-outlet, or so-called wash-out type of closets, have a shallow bowl flushed by a strong stream of water, which drives the waste matters out of the bowl into a shallow trap underneath ; they are quite popular at present, but they violate rules 1, 2, 3, 4, 7, 11, 12, and 13. The Hushing of this kind of closet is usu- ally attended with spattering. The standing water in the bowl is not sufficiently deep, and the manner of Hushing is noisy and ineffec- tive, the lighter wastes frequently whirling round and round for some time before being driven out. The trap is inconvenient of access, and its seal is very shallow, and easily broken by siphonage, evaporation, or incorrect setting, and being out of sight, the evil may not be discovered until the damage is done. The pipe sur- face between the basin and the pipe is easily fouled and difficult to clean. The water-closet shown in Figs. 1505, 1506, and 1507 inches above the normal level of the water, and the out- let pipe descends as many inches below, in order to pre- vent choking up. The interior surfaces are smooth and rounded. The whole is made preferably of salt-glazed earthenware an inch thick, and should be well ventilated. Some persons thoughtlessly use a common round or Fig. 1503.-Section of Kitchen Sink. pot-trap, directly under the sink, fora grease- trap, and imagine that because they find it nearly filled with putrefying grease when- ever they chance to open it, it serves its pur- pose excellently. The fact is, as any one can understand upon a little reflection, that such a trap is worse than useless for grease retention. The trap is too small to retain more than a very small fraction of the grease escaping from the sink, and yet is large enough to cool enough of it to fill up the trap until the water-way is diminished to the size of the pipe, and the trap is converted into an ordinary S-trap, having its walls constructed of putrefying grease instead of lead. If the trap be placed near the sink, the hot water will keep this amount of passage-way always open. If it be distant from it, the trap becomes sometimes entirely clogged up. Now, a pot-trap, on account of its great weight, cannot be placed close up to the bottom of the sink. It must rest on the floor, and at this distance the grease sometimes has time to cool and entirely close up the water-way through the trap. It is for this reason that I consider the pot-trap par- ticularly unsuitable for sinks, and it at the same time ex- plains why the trap shown in Fig. 1469 has proved it- self so successful here. Being light and small, this trap can be set close to the sink, where grease never can cool or congeal in it. All passes through and goes to the regular grease-trap beyond. Water-closets.-The requisites for a water-closet are, (1) simplicity, (2) quickness and thoroughness of flushing, (3) freedom from all unscoured parts, (4) economy in con- struction and water consumption, (5) compactness and con- venience of form, (6) amplitude of standing water in the bowl, (7) accessibility and risibility of all parts, including trap, (8) smoothness of material, (9) strength and durability of construction, (10) facility and reliability in jointing, (11) security against evaporation and siphonage, (12) ease and convenience of flushing, (13) noiselessness in operation, and (14) neatness of appearance. The pan-closet must be discarded, because it violates every one of the above requirements. The valve and plunger closets must be discarded, be- has been designed to conform to all the requirements we have enumerated. Mr. Gerhard describes it in " Good Housekeeping " as follows : " The closet is manufactured in white earthenware, and resembles somewhat in shape the short hop- per, having only a bowl and a trap combined in one piece, and no superfluous interior sur- faces, angles, or corners to which soil may ad- here. The area of the bottom of the bowl has been so shaped as to present a large surface of standing water to receive and deodorize waste matters, and the overflow point is raised much higher than usual, in order to retain a deep body of water, and hence a deep water-seal in the bowl. It should be noted that the water is deepest at the rear of the closet, at the point where soil would be most liable to strike the sides. " The top of the bowl is provided with a flush- ing rim into which the flushing water enters in a novel manner. To avoid the usual noisy operation of the flush, and also the frequent spattering, the flushing water is conducted into a large body of water below the normal water-level, as shown, from where it overflows into the flushing rim and thence down the sides of the bowl. A part of the flushing water is directed, indepen- dently of the stream which feeds the flushing-rim, to the Fig. 1505.-Transverse Section of Water-closet. Fig. 1504.-Plan of Sink. cause they violate all but the sixth and twelfth require- ments. The ordinary so-called long and short hoppers are to be rejected because they violate the second, third, fourth, sixth, tenth, eleventh, and thirteenth requirements. There is no standing water in their bowls to receive and deodor- 441 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bottom of the bowl, where it enters through a jet or noz- zle arrangement, discharging with great force into the as- cending leg of the closet trap. This removes part of the water from the trap, and causes that which is in the bowl to sink into its neck, where it is more easily acted upon by the upper flush. Meanwhile the upper jet tills the passage leading to the flushing-rim, and, overflowing, descends upon and drives out the waste matters which have descend- ed into the neck. The lower jet is al- ways covered by water from the upper flush, the con- struction and proportions being such as to insure this result. Hence both jets are noiseless. ' ' In ordinary trap-jet clos- ets no provision is made to insure the covering of the jets, and a loud roar is occasioned. These closets, moreover, are emptied by siphonic action produced in- tentionally in the trap, and this emptying by siphonage adds to the jet roar a dis- agreeable ' gulping ' sound caused by the sudden inrush of air under the dip as the water escapes. Both of these causes of noise are avoided by the flushing principle adopted in the present type of closet. "The action of this closet is almost instantaneous, it being possible to flush it easily in one second and with less than a gallon and a half of water. " Another peculiar feature of the flushing of this closet is the supply-pipe with which it is provided, and in which all delay and noise occasioned by the water passing from the cistern down the service-pipe, when the pull is oper- ated and the cistern-valve is lifted, is avoided by con- structing the supply-pipe on the principle of an inverted from the upright supply-pipe until the trap is refilled up to the overflow' line. There is, thus, provision made for the re-establishing a perfect deep water-seal, if the latter should be lost by evaporation or even by siphonage. The latter case W'ill but rarely occur, as the trap has more than the ordinary depth of seal. Evaporation, on the con- trary, is constantly going on in houses closed during the summer months, and it is here that the advantage of the self-sealing closet and the peculiar mode of supply, de- scribed above, become most apparent. Finally, as every part of the closet-bowd and trap is readily accessible, and at all times open to inspection, it is easy to remove, by a sponge or otherwise, all water from the closet in houses to be left unoccupied during the winter, in which plumb- ing w'ork is most exposed to freezing." Slop Hoppers and Urinals are never to be recom- mended in private houses. A good water-closet, properly set up and protected, will serve their purpose much bet- ter and quite as economically. The appliances always become nuisances in the house by emitting disgusting odors. They are never properly flushed, and it might al- most be said they never can be. Fig. 1508 shows the manner in wdiich a W'ater-closet should be set to permit of its convenient use as aurinal as Fig. 1506. -Longitudinal Section of Water-closet. Fig. 1508.-Water-closet set for Use either as a Urinal or as a Water- closet. well as a water-closet. This is often particularly desir- able in offices and on the first floor of private houses. I have used this form of urinal in both public and private houses, and have found the arrangement in every respect perfectly successful. The large body of standing water in the bowl immediately dilutes the urine and prevents its fouling the sides, and habit with water-closets leads to its flushing after its use as a urinal, at times when the ordi- nary form of urinal would have been left unflushed. But should, by any chance, the flushing be neglected, the next use of the fixture as a water-closet would insure its clean- sing. Water-supply.-An ample water-supply, either from the public mains, or separately pumped in each house from wells or cisterns, is as necessary a part of a system of sanitary plumbing as a proper treatment of the waste matters. Without a sufficient and reliable supply the fixture and drains cannot be properly flushed, and are liable to be- Fig. 1507.-Plan of Water-closet. bottle, so that the water shall be hung in it below the cistern-valve as far down as the standing water in the bowl, simply by the pressure of the atmosphere. This pipe is, therefore, always full of water, the pipe being closed at the top by a cistern-valve, and at the bottom sealed by the water in the closet bowl. The flush is thus made to act instantaneously. The closet is self-sealing, for the moment the water in the trap is lowered to a cer- tain point just above the dip of the trap, water follows 442 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. come foul and even totally inoperative through clog- ging. Whatever be the source of the supply, a part should al- ways be conveyed into a suitable tank at the top of the house, and from this tank nearly all the plumbing fixtures in the house should be supplied. In a few places, such as at the kitchen and pantry sink, a direct supply from the rising main is to be preferred in order to obtain pure water for drinking purposes. The advantage of the tank-supply over a supply direct from the main, when town or city pressure is available, is that it secures an unvarying pressure at each fixt- ure, and avoids the severe strain and shocks on the pipes, faucets, and kitchen boiler which a direct supply produces. A further advantage of the tank-supply is that it furnishes a reserve of water to be drawn upon for the supply of water-closets, etc., in case of the public supply being cut off for por- tions of the day for repairs, or on account of freez- ing or other accident. A tank five or six feet long, by from three to four feet wide and three feet deep, will be sufficiently large for an ordinary house. It should be placed in the attic, and made of strong boards or plank lined with sixteen-ounce copper. Lead and zinc are not to be recommended, on account of the chemical effect some kinds of water have on them. The tank should be supplied with water from the rising main by means of a ball-cock, and should have an overflow-pipe discharging into the nearest suitable fixture, where its escape would be in sight. The falling main from the tank should be controlled by a valve or stop-cock, having an air-pipe just below it extending to the top of the tank, to shut off the water in case of repairs ; but this is not absolutely necessary, as the tank itself could be emp- tied for this purpose as well as the falling main, only that this would involve a considerable waste of water. For hot water supply, a copper boiler and a small iron water-back, connected with the kitchen range, are used. The boiler is supplied with cold water by a pipe from the tank entering the top of the boiler, and descending nearly to the bottom. A brass pipe from the bottom of the boiler supplies the water-back. The heat of the range warms this, and causes it to circulate and pass out at the top into a second brass pipe, leading back into the boiler higher up. The hot water is then drawn from the top of the boiler through a third brass pipe to supply the house. A sediment cock is placed on the lowest brass pipe to draw off sediment from the boiler and water-back. To obtain a circulation throughout the hot water pipes, so that hot water may be obtained immediately at any point on their line, the hot water pipe should return to the boiler after supplying all the fixtures in succession. Two or more hot water pipes from the top of the boiler may sometimes be required to carry water to points which cannot be conveniently connected in a single circulation. From the highest point, moreover, of the hot water cir- culation pipe, a steam escape, or relief pipe, should rise to the tank and bend over its top, so as to allow of the escape of hot water or steam. This renders the boiler safe against both explosion through a surplus generation of steam in the water-back, and against collapse. Precautions should be taken to prevent the burstipg of the water-back in winter time. If the range fire is al- lowed to go out on very cold nights, and the pipes and kitchen itself are much exposed, the water in the water- back and connecting pipes may freeze, and when the fire is again lighted in the morning, the circulation being stopped, steam may be generated and cause a violent and dangerous explosion, often destroying the range or caus- ing more serious damage. The best precaution is to al- ways keep a fire in the range at night, in kitchens which are exposed. Or if, by any chance, the fire goes out before morning, to thaw out the pipes, or make sure that the pipes are not frozen by opening the sediment cock and seeing if the water runs freely before relighting the range fire. Brass pipes for hot water are to be preferred to lead, because repeated alternations of hot and cold do less in- jury to them than to the soft and inelastic lead. The ef- fect of these alternations on lead pipe is to make it sag be- tween its supports. It is lengthened by the heat, but does not contract again on cooling. Hot water pipes should be kept at least an inch away from lead pipes for the same reason, and the brass should be shellacked when finished to protect it from corrosion. No paint should ever be applied to brass or lead. Where cold water is of such a kind that it is like- ly to corrode lead, brass, tin-lined iron, or enamelled iron pipe should be used. Supply-pipes should not run near costly decorated work. But if it becomes at any time impossible to avoid this, it is best to enclose them in zinc tubes ar- Fig. 1509.-Plan of the House Drains ranged to carry off safely a possible leak, or a dripping from condensation. The lines of all the pipes should be perfectly straight, the supports neatly put up at small intervals, so that no sagging will be possible, and all should be laid with a continuous fall toward some draw-off faucet. Neat strips of boards should be nailed to the walls and ceilings to carry the pipes, and the horizontal pipes should be secured by brass bands about two feet apart when hung below, and six feet when they lie upon the board. The vertical pipes should be secured by hard metal 443 Habitations. Habitations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. "tacks" soldered to the pipe, and screwed to the boards at distances of about four feet, to prevent them from ' ' creeping. " Plumbing Specifications.-Having explained the general principles governing sani- tary plumbing, it only remains, in conclusion, to show their applica- tion to actual practice by means of them. The bath-room is fitted up with towel-racks,' sponge and soap brackets, and all the minor convenien- ces as shown in the cuts. Wherever a choice may be made between different pat- terns or devices a blank space is left in the specifications. General Conditions.-The contractor shall give his personal superintendence to the work, and shall furnish all materials, labor, etc., necessary to com- plete the work according to the true intent and meaning of the drawings and these specifications. No portion of the work or contract shall be sublet or assigned by the contrac- tor, except by the permis- sion of the architect or sani- tary engineer in writing. All materials to be of the best quality of their respec- tive kinds, and all labor to be done in the most thorough and workmanlike manner, to the full satisfaction of the architect. Where no figures or mem- oranda are given, the draw- ings shall be accurately fol- lowed according to their scale ; but figures or mem- oranda are to be preferred to the scale in all cases of difference. The drawings and these specifications shall be con- sidered as co-operative, and work or material called for by the one and not men- tioned in the other, or vice versa, is to be done as though fully treated of by both. The work is to be commenced at once on notice from the architect, prosecuted without delay or unnecessary intermission; without obstruction to other works, in co- operation with them, and to be completed in full so as not to prevent the occupancy of any suite of apartments or adjuncts thereto. The owner will pay on account, from time to time, at Fig. 1510.-Plan of the Bath-room and adjoining Chambers. a plumbing specification laid out in accordance with them for a special building selected as a type. The following form of specification is one that is adapted to the requirements of a country residence (for both summer and winter), costing in the neighborhood of $10,000. The distri- bution and arrangement of the plumbing may be learned from the accompanying sketches. Fig. 1509 shows the plan of the drain-pipes in the basement; Fig. 1510 a partial plan of the second story, giving the details of the principal bath- room, and Fig. 1511, the interior of the bath-room in perspective. It will be seen that the bath-room communicates directly with the dressing-rooms of the three prin- cipal bed-chambers, and also indirectly with other chambers through the hall. It is fully lighted and ventilated. The gas- burner is arranged in an ornamental glass lantern set in tlie wall over the bath-tub and connecting with a ventilating fine. The heat of the gas creates an excellent current of air in the flue and draws out the foul air both from the bath-room and from the adjoining bed-rooms. The light is prevented from flickering by a special arrangement of tin screens in the lantern. The foul-air registers are in the lower part of the walls of the rooms. That in the bath-room is just under the lan- tern. The fresh air registers from the furnace are all wall registers, so that dust and dirt shall not fall into the rate of seventy-five per centum of the work actu- ally done and materials legally delivered, on the writ- ten certificate of the architect. Payments on account are not to operate as acceptance of the work. Any balance Fig. 1511.-Perspective View of Bath-room. 444 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Habitations. that may be found due on the completion of the work will be paid thirty-five days thereafter on written cer- tificate as above. Any damage done to any part of the work covered by this contract, whether occasioned by the contractor's men or by anyone else, shall be made good by the con- tractor, unless the same shall have been occasioned after the entire work is completed and delivered over to the owner, ready for use, and satisfactory to the architect. The contractor is to clear away from the premises, from time to time, as the good of the work may require or the architect direct, all rubbish caused by his opera- tions, and at the completion of his work to leave every- thing clean and whole. No cutting of timbers or studs to be done without the permission of the architect. All pipes to have proper fall, so that they shall prop- erly drain themselves when the water is turned off. No pipe to be put in such a position that it shall be liable to freeze. All pipes to be in full view throughout, except where particularly specified to the contrary. The horizontal runs are to be secured to neat strips of wood on the ceil- ings of the room below, and never to be laid between the floor joists. Brass clamps are to be used on hori- zontal pipes and on brass pipes, two feet apart when pipe is below, and six feet when above the board. Lead tacks on perpendicular runs of lead pipes four feet apart. The hot- and cold-water pipes are to be kept at least one inch apart everywhere. All joints in lead pipes throughout are to be wiped joints. All brass pipes are to be put up with right-angled turns, so arranged as to allow free expansion and con- traction. All lines of piping to be straight and parallel where they run together. Schedule of Fixtures.-Basement: Three (3) wash-trays, 2 feet long each ; one (1) water-closet; one (1) wash- basin. First story; One (1) soapstone kitchen sink, 3 feet 8 inches x 1 foot 8 inches x 8 inches ; one (1) china-closet sink, 24 ounces, 14 inches x 20 inches ; one (1) bath-boiler and iron stand ; one (1) water-closet; one (1) wash-basin. Second story : One (1) water-closet; one (1) bath-tub ; three (3) wash-basins. Third story : One (1) water-closet; one (1) bath-tub ; one (1) wash-basin. Traps: One lead trap for the three laundry tubs = 1 wash-tray trap ; one lead trap for the kitchen sink = 1 sink-trap ; one lead trap for the china-closet sink = 1 china- closet trap ; one lead trap for each wash-basin = 6 wash- basin traps ; one lead trap for each bath-tub = 2 bath-tub traps; one lead trap for the refrigerator - 1 refrigerator trap ; total, 12 traps. The traps of the bath-tubs to be placed under the plaster of ceiling below, in full view. Piping.-Main Drain: Provide and lay, where shown on the basement plan, a four-inch heavy cast- or wrought- iron soil-pipe, to be laid on the concrete on supports of brick having the proper grade. It is to pass through the foundation wall of the house and extend five feet beyond. The drain-pipe to have Y- branches to take the waste- and soil-pipes, and a running trap just before passing through the foundation. The drain-pipe to be vented inside the traps for circu- lation. This vent to pass through the house wall above, and the top to stand open five feet high from the ground outside, at a distance of fifteen feet from the house. If the pipes are not already coated inside and outside with coal tar pitch, or otherwise satisfactorily protected from rust, this should be done by the contractor, and he should also be required to paint the whole work after the pipe has been put up in place and jointed. Any pipe from which the paint has been rubbed or injured to be re- painted, so that the whole shall look clean and neat at the completion of the work. All joints shall be screwed up so as to be water- and gas-tight. Testing Joints : All joints throughout the house to be tested when the drain- and soil-pipes are in, by closing up all the openings with suitable pipe caps and filling the entire system of soil- and drain-pipes with water up to the top of the roof. All joints which do not stand this test must be tightened, and the test reapplied until all are tight, in the presence, and to the satisfaction, of the architect. If any part of the piping shows defects under this test, it is to be removed and a new piece substituted for the defective one, and the whole retested. Setting the Piping : The soil-pipe shall be screwed to the building in such a manner as to allow of consider- able shrinkage or settlement on the part of the latter, with- out its dragging down or affecting in any way the soil- pipe. This is to be accomplished by leaving play-room, at all the hooks or hangers securing the pipe to the build- ing, for either perpendicular or horizontal play as may, in each case, be required, and between each fixture and the iron pipe a length of at least two feet of lead pipe is to be used, which shall give, by its elasticity, the requisite hori- zontal or perpendicular play at the fixture. The upright part of the soil-pipe is to be hung directly to the studs. The hooks or staples used are to be placed at the middle length of the pipes, not at the joints, since this will give proper play. Moreover, the pipe is not to be put up at all until after the masonry of the chimney has settled and hardened fully. These same directions apply to gas-pipe mains, or to any other kind of large pipe which may be used in the building. The soil-pipe shall run up through and extend two feet six inches above the top of the roof, and be left open. The top shall have neither ventilating cap nor return bend. Wherever pipes join each other Y- branches, and not T- branches, are to be used. Bath-boiler.-Provide and set in kitchen a heavy, fifty- gallon, first quality, warranted copper bath-boiler, of quality equal to Hicks & Sons', and locate it where shown on the plan by the side of the kitchen range. Furnish a strong cast-iron boiler stand, of quality equal to the Lockwood pattern, and set the boiler upon it. Connect the boiler with the water-back of the range with brass pipe one inch in internal diameter. A ground plug hose-cock to be placed at proper height for a pail. The boiler is to have two brass pipe-couplings at the top, one for supply from the tank and the other for three- fourth inch hot water supply. This to be carried along kitchen ceiling to kitchen sink; thence to wash-basin. It will have a branch on kitchen ceiling to laundry tubs, and another up to china-closet sink. Thence to second- story basin and bath, thence to third-story bath-tub, and thence to supply-pipe from tank to boiler for circulation. Wash-trays.-Furnish and put up in the laundry, where shown, a set of three white earthenware wash trays of the Morahan Ceramic Co. ,* one to have rubbing board formed in the porcelain. All to be set complete by the plumber, and each to be supplied with hot and cold water through a five-eighth inch pipe, and five-eighth inch finished brass compression wash tray cocks. To waste through best one and a half inch nickel-plated wash-tray strainers and couplings,with plated plugs, chain-stays, and plated safety chain No. 2, and to have one . . . antisiphon, self- cleansing water-seal (without mechanical seal) trap with spun copper cup for the set of three trays. Each of the wash-trays to waste into a main one and a half inch waste- pipe having proper pitch, and entering into the trap at the top of its inlet arm in the usual manner. Clothes-boiler.-Supply the clothes-boiler, to be fur- nished and set by the mason, with cold water only, through a five-eighth inch lead pipe, carried through the top of the boiler and neatly finished with a five-eighth inch fin- ished brass ground stop-cock on the pipe in a convenient position. There will be no waste to this boiler. Sill-cocks.-Bore through the sill of the house, where shown, and put on outside a three-fourth inch nickel- plated compression sill-cock, with screw for hose. * These tubs are somewhat expensive. A cheaper specification would be for bluestone or soapstone wash-trays. Both of these kinds are strong and serviceable. 445 Habitations. Haema temesis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Wash-basins.-Furnish and fit up, where shown, . . . wash-basins (specify the variety), oval in the second-story bath-room, and round elsewhere, all to have nickel-plated fittings. The basins, as well as the traps and other appli- ances, to be set in accordance with the printed directions on the circulars of the manufacturers. Cover each basin with first quality white Italian marble slab, dished, as clear of veins as possible, and with cham- fered edges. The basin to be secured to the marble by four brass basin clamps and bolts to each, and the joint to be made tight with plaster-of-Paris. Wall plates to be seven-eighth inch, marble ten inches high. Each basin to waste through a one and a half inch lead waste-pipe as far as to the trap, and a one and one-fourth inch lead waste-pipe beyond the trap as far as the iron soil-pipe. Each basin to be trapped by an . . . antisiphon, self- cleansing water-seal trap with spun copper cup. The trap to be set close to the basin by soldering the top of the straight barrel of the trap directly to the tail-piece of the basin. There will be no secret overflow pipe to con- nect, the overflow being in the stand-pipe plug of the ba- sin, and being furnished as part of the basin. Each basin to be supplied with hot and cold water through a one-half inch pipe and No. 4 extra nickel- plated cast tube compression-cock. Water-closets.-Furnish and put up complete, where shown on plans, and according to the printed directions of the manufacturers, . . . water-closets with twenty- gallon (thirty-gallon better) wooden cistern, lead-lined. The closets to be supplied through one and a half inch lead supply-pipes, and to have a supply-valve for each. The valve to be operated by a nickel-plated safety chain, with a light-weight, polished hard-wood handle. The cistern to be supplied with a brass compression ball-cock, and a four-inch tinned copper float. The valve to be operated by an ordinary lever, twelve inches long on long arm, and four inches on short arm. Long arm to be over-balanced by a lead or iron weight on short arm. The third-story water-closet will be supplied direct from the main cistern, which will be over it. Kitchen Sink.-Furnish and set up in the kitchen, where shown, a first quality soapstone kitchen sink, three feet eight inches x twenty inches x eight inches, with grooved soapstone draining-board, and soap dish and soapstone back, back sixteen inches high, to be supplied with hot and cold water through a five-eighth inch pipe and five- eighth inch finished brass compression-cocks, six-inch brass strainer, one and a half inch waste, and . . . antisiphon, self-cleansing water-seal trap with copper cup. Bath-tubs.-Furnish and fit up in each bath-room one . . . sixteen-ounce copper (tinned) bath-tub, six feet long. The bath-tub to be supplied with hot and cold water through a five-eighth inch pipe and five-eighth inch extra nickel-plated compression bath bibb-cocks. To waste through a one and a half inch lead waste-pipe. Bath-tub to be trapped with a . . . antisiphon, self- cleansing water-seal trap with copper cup. Both trap and waste-pipe- to go under the plaster along the ceiling of the kitchen below, where directed by the architect. The removable section of the trap in all cases to be so placed as to be easily removed if desired, and it is always to face to the front. Standpipe overflow. China-closet Sink.-Furnish and set up one . . . china-closet sink, twenty-four ounce, tinned and planished fourteen by twenty inches. To be supplied with hot and cold water through tall, nickel-plated, upright core, com- pression pantry-cocks, with screw nozzle for cold water. Waste through a one and a half inch lead pipe trapped with an . . . antisiphon, self-cleansing water-seal trap with copper cup. The top to be of cherry, to be furnished by the carpenter and set by the plumber. Standpipe overflow. Lead Pipes.-All cold-water supply and waste-pipes are to be of the best drawn lead and to weigh as follows: Rising main, three-fourth inch, weighing three pounds per foot ; other supply-pipes, five-eighth inch, weighing two and a half pounds per foot; one-half inch, weighing two pounds per foot; waste and overflow pipes, one and a half inch, weighing three pounds per foot; one and one-fourth inch, weighing two and a half pounds per foot. Brass Pipes.-Hot-water pipes throughout to be of Na- tional Tube Works best seamless drawn plumbers' brass tubing, with brass fittings, all put together with red lead in the best manner and made perfectly tight. All lead and brass pipes are to be put up in the best manner on boards set in place by the carpenter. The lead pipes are to be secured by hard metal tacks or brass bands and screws, and the brass pipes with brass bands. No hooks are to be used. The waste-pipes are to run as follows : The main 4-inch soil-pipe is to be extended through the foundation wall at the southeast corner of the building, as shown. Just inside the wall is a 4-inch running trap with two clean-out caps screwed on at an angle, so as to permit of easy access to the drains in both directions in case of acci- dental stoppage. Inside of the trap comes next a T- branch for the fresh- air supply-pipe. This is to be a 4-inch iron extra heavy . . . pipe. It is to pass through the house-wall and terminate at a height of six feet above the ground. Inside the fresh-air branch comes the 4- x 2-inch Y- branch for the laundry tubs waste. Then another 4- x 2-inch Y for lead waste from stories above. Next will be a 4- x 4-inch Y- branch, and a change of direction to the basement hall. Another Y- branch and another change of direction, and straight run. Finally, two more Ys, and then the lead pipe connection with the basement water- closet, and in the cold cellar the upright stack of soil- pipe where shown. Each Y is to serve as a clean-out opening for the straight run of pipe following it. The openings to be capped with iron caps screwed on so as to be readily opened at any time and replaced at need. The upright stack will have a 4- x 2-inch Y- branch just under the ceiling of the cold cellar to take the 2-inch iron drain from the kitchen sink. The small lead 14-inch pipe from trap of sink to the 2-inch iron pipe can readily be cleared of grease by hot water poured through sink with or without potash. The 2-inch iron branch may be cleaned out when necessary through a 2- x 2-inch Y, with clean-out caps, as shown at the connection of the lead and iron pipes. At the ceiling of the kitchen another 4- x 4-inch Y- branch will extend from the 4-inch stack of soil-pipe to about the centre of the kitchen ceiling; at this point an- other Y- branch will receive the 4-inch lead pipe from the water-closet. This lead branch is to be at least four feet long. The other outlet of the Y-branch will be capped for a clean-out hole. Into the 4-inch lead pipe will be branched the waste-pipes coming from the traps of the wash-basin and bath-tub. Just below the 4- x 4-inch Y on the upright stack there will be a 4- x 2-inch Y- branch to take the lead waste from the second story north central toilet closet basin. The wastes from the pantry sink and from second-story southeast chamber closet wash-basin will descend direct into the 4- x 2-inch Y-branch already described. The 4-inch soil-pipe of iron will continue from the ceil- ing of the first floor up to the ceiling of the second floor. A 4-inch lead branch will connect the water-closet with the end of the iron pipe, a 4- x 4-inch Y-branch being placed at the connection of the lead and iron pipes. The 4-inch soil-pipe will extend up through the roof. Supply-pipes. - The plumber is to connect with the supply service pipe, which is carried into the house through the foundation of the north central basement coal-room near staircase, as shown on plan by the owner. Carry a 4-inch, three-pound rising main up on the walls in clear sight to the tank in the attic, with a stop- and waste-cock at cellar wall and branches, as follows : 4-inch branch to sill-cocks, j-inch branch to furnace supply, f-inch branch to laundry wash-trays, f-inch branch to kitchen sink, f-inch branch to china-closet, this latter continuing to the wash-basin of the second story, and to the bath-tub, and beyond that as a f-inch pipe to the third, story toilet-closet, where it will be capped. The main branch from the rising main in the cellar is to have separate stop- and waste-cock in a convenient 446 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Habitations. Hteinatemesis. place, and so arranged that the pipes can be completely drained of water. All stop- and waste-cocks to be finished brass ground cocks of the best quality. Shut off cocks to shut water off of kitchen, china- closet, and bath-room, each independent of the others. Attic Tank.-Line with 16-ounce tinned copper, in the best manner, the tank in the attic, to be furnished ready for lining by the carpenter, 5 feet long by 3 feet wide and 2 feet deep. Supply from the rising main with f-inch finished brass compression ball-cock and 6-inch copper float, and put in a li-inch lead overflow pipe to be carried dow n beside the rising main, and to empty over the third story bath- tub. Hot Water.-Hot water will be supplied to the laundry wash-tray, kitchen and china-closet sinks, wash-basins, and bath-tubs. Refrigerator.-The refrigerator will waste through a l|-inch pipe, trapped with a . . . antisiphon, self-clean- sing, water-seal trap with lead cup. The waste to descend through basement and out into a dry cesspool of stone outside of house, all below frost. Trap Ventilating.-The -water-closet traps to be venti- lated when placed where there is danger of siphonage by a special vent-pipe two inches in diameter, extending up to, and three feet above, the roof, as shown on elevation.* All other and smaller traps will be ventilated by the construction of the trap through its own waste-pipe, and no special vent-pipes shall be provided for them. All the work is to be done in the very best, neatest, and most thorough manner, tested by turning the water on to each part. All the defects to be made good at the com- pletion of the building, and all left perfect and warranted for one year. Peppermint Test.-As soon as the pipes and traps are ready and all the work done, the traps are to be filled with water, and the whole system tested by closing all air- pipes and other outlets, and pouring five ounces of oil of peppermint into the top of the main soil-pipe, followed by two or three gallons of hot water, and immediately closing the top of the soil-pipe. This is to be done in the presence of the architect or any person appointed by him, and if any odor of the pep- permint is detected in any part of the house the plumber is, at his own expense, to search for the defect or defects and make them all good. After repairing the defects so discovered, the test is to be repeated in the same way and the defects removed, and the tests repeated until no further defect is dis- covered. The whole expense of making such repairs, or of damage or delay to other work caused by them, are to be borne by the contractor. J. Pickering Putnam. 1 An Experimental Investigation into the Trap and Water-closet Sys- tem, and the Relation of the same to Sewage Products, Gaseous and Others. By Neil Carmichael, M.D., C.M. Published in The Sanitary Journal, Glasgow, Scotland. 2 See the Report to the Boston City Board of Health of the writer's ex- periments, in 1884, on Trap Siphonage and Evaporation. Published in the American Architect and Building News for 1884, and in other scien- tific journals of the same year. 3 See Report to the Boston City Board of Health, before referred to. 4 See articles on Sanitary Plumbing in the American Architect and Building News for 1883, 1884, and 1885, heading Traps, chapter on Friction. 5 Among others see Experiments on Siphonage made at the Mass. In- stitute of Technology, before the Boston Society of Architects, and the Suffolk District Medical Society, and described in The Principles of House Drainage, published by Ticknor & Co.. Boston. 6 Caution issued in 1883 by the Brooklyn City Board of Health. through normal or pathological channels, to be subse- quently rejected by acts of emesis. A systematic inquiry regarding the etiology of haemate- mesis must, consequently, embrace a consideration of the principal sources whence vomited blood may have ema- nated in A, gastrorrhagia ; and in B, extra-gastric haem- orrhages. Since gastrorrhagia is the most important fac- tor in the production of haematemesis, our attention is naturally first directed to its causes, the following classi- fication of which the writer considers sufficiently com-' prehensive for practical purposes. A. Causes of Hoematemesis from Gastrorrhagia.-1. In- juries of Gastric Vessels. These lesions may result from perforating or non-perforating wounds of the stomach, from contusions of the abdomen, from the injudicious use of stomach-tubes, or from violent acts of emesis. Perforating ulcers produce erosion of the gastric blood- vessels in about one-third of the cases, according to L. Mul- ler's statistics, and carcinoma does so, according to Brin- ton, in nearly forty-two per cent, of all cases. The source of the haemorrhage, in gastric ulcer, may be the eroded artery of some neighboring organ, as, for instance, the liver, which constitutes the base of the perforating ulcer. UcBmatemesis neonatorum is sometimes associated with gastric or duodenal ulcer, and sometimes appears to be due to a haemorrhagic diathesis,1 or to portal obstruction. Various corrosive poisons, such as the mineral acids or the preparations of mercury, and exceedingly hot liquids may erode the gastric vessels. Pointed objects, like osse- ous spiculae,2 or foils used in the feats of sword-swallow- ing, are capable, when introduced into the stomach, of producing solution of continuity in tlie vascular walls. The so-called haemorrhagic erosion belongs in the cate- gory of organic lesions, and consists in the auto-digestion of portions of the gastric parietes, the vitality of which has been impaired by active or passive congestion leading to stasis and ecchymosis. Oser 3 attributes considerable influence in the production of stasis and of consequent haemorrhagic erosions, to the anatomical arrangement of the minute gastric veins, which, possessing, according to Rindfleisch's description, infrequent anastomoses, and be- ing protected only by connective-tissue sheaths of extreme tenuity, are exceedingly liable to compression during the gastric peristaltic movements. Tuberculous and typhoid ulcers4 and neoplasmata, other than carcinomata, are rare causes of gastrorrhagia. Finally, Luton 5 mentions two cases of gastric haemorrhage with haematemesis, occa- sioned by leeches, unintentionally swallowed. 2. Diseases of the Vascular Walls. The most impor- tant examples of these diseases are varicose gastric veins, miliary aneurisms of the arteries supplying the stomach, and degenerations of these vessels, chief among which are atheroma, fatty changes, and the obscure trophic de- generative processes resulting from protracted congestion, from primary or secondary inflammation, and probably from certain morbid blood states incident to various dys- crasiae and infectious diseases. It is uncertain whether amyloid degeneration of the vessels be a cause of gastror- rhagia. 3. Congestion of the Stomach, (g.) Passive Congestion.- Increased blood-pressure in the radicles of the vena porta?, sufficient to produce capillary gastric haemorrhage by rhexis or by diapedesis, is occasioned by many causes of obstruction to the portal circulation. The most obvious impediments to the flow of blood through the portal vein are found in the vein itself, or in the liver. They act by causing partial or complete occlusion of the portal vein, either from within the vessel, as in pylephlebitis, in py- lethrombosis, in closure of the capillaries by pigment par- ticles in melanaemia, and in destruction of the capillaries during acute yellow atrophy ; or from without, as in he- patic cirrhosis, hydatid cysts, carcinomata, or other hepatic neoplasms, and in overdistention of the biliary passages from occlusion of the cystic duct, or of the ductus communis choledochus. Jaccoud6 cites large cal- culi impacted in the extra-hepatic biliary ducts ; Bartho- low1 aneurisms of the hepatic artery ; and Eichhorst10 pregnancy and violent parturient efforts, as causes of gas- trorrhagia from portal obstruction. Another familiar H/EMATEMESIS. Definition and Etiology.-The term haematemesis is applied to the vomiting of blood, but implies nothing regarding the original seat of the haemorrhage. Haematemesis is, therefore, not synony- mous with gastrorrhagia, upon which, in the great ma- jority of cases, it is directly dependent. Blood which has been extravasated into organs more or less remote from the stomach frequently finds its way to that viscus, * This vent might, under the circumstances, safely be omitted. The water-closet seal is deep and the supply-pipe is self-sealing. 447 Haematemesis. Haematemesis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cause of impeded portal circulation is obstruction to the flow of blood from the hepatic veins into the vena cava inferior. This is often incident to uncompensated heart lesions, whether due to primary cardiac or pericardial disease, or secondary to emphysema, interstitial pneumo- nia, or compression of the lung in chronic pleuritis. Leube8 calls attention to the fact that the effects of con- gestion in the vena cava may also be directly transmitted to the gastric mucous membrane through the anastomo- sis, with the superior gastric veins, of the diaphragmatic and inferior oesophageal veins which empty into the vena cava. Niemeyer9 referred the so-called gastrorrhagia and melana neonatorum to obstruction in the pulmonary cir- culation caused by congenital atelectasis. It has, how- ever, already been stated that melcena neonatorum is sometimes associated with perforating gastric or duodenal ulcer, and is occasionally referable to haematophilia. It may also be caused by the swallowing of blood from the mother's breasts or generative passages. Pressure exerted upon the superior vena cava by intra-thoracic tumors, and displacement of the vein by excessive pleuritic effusions, may cause obstruction in the portal circulation. Preg- nancy is also supposed, by some authors, to produce gas- tric venous hyperaemia. (b.) Active Congestion. This form of congestion is in- cident to acute catarrhal and phlegmonous gastritis, and to the vicarious haemorrhages rarely observed in amenor- rhcea, in suppression of haemorrhoidal bleedings, and at the menopause. Many writers, however, regard the gas- trorrhagia occurring coincidently with the cessation of habitual haemorrhoidal haemorrhages, as dependent upon portal congestion which, for unexplained reasons, pre- dominately affects the gastric rather than the haemor- rhoidal veins. 4. Morbid Conditions of the Blood. Gastrorrhagia oc- curring in certain dyscrasiae and acute infectious diseases, is usually referred to the combined influence of this cause and to degeneration in the vascular walls, probably secondary to the morbid blood states in question. The correctness of this theory has not, how'ever, been demon- strated. Among the dyscrasiae just alluded to are in- cluded haematophilia, scorbutus, purpura haemorrhagica, chol^mia, uraemia, chlorosis, leucocythaemia and pseudo- leucocythaemia, simple and pernicious anaemia, the ma- larial dyscrasia and that of carcinoma, Bright's disease and phosphorus poisoning. The chief acute infectious diseases belonging in this etiological category are acute yellow atrophy of the liver, yellow, relapsing, typhus, typhoid and malarial fevers, variola, morbilli, scarlatina, erysipelas, diphtheria, cholera, and snake-bites. 5. Miscellaneous Causes. Gastrorrhagia occurs at all ages, and its victims are more frequently women than men, probably because women are oftener affected with gastric ulcer and with hysteria, which, as well as progres- sive paralysis of the insane, is held by Eichhorst10 to occasion haematemesis through the agency of obscure vaso-motor disturbances. The occurrence of vicarious haemorrhages in cases of amenorrheea may further ex- plain the greater frequency of haematemesis in women. Dr. A. Flint refers to cases of gastrorrhagia which he designates as idiopathic, because ' ' neither following nor preceding any appreciable morbid conditions."11 Over- distention of the stomach, excitement, and excessive ex- ertion may act as direct exciting causes of gastric haem- orrhage. B. llcematemesis from Extra-gastric Causes.-Haemate- mesis is often due to the entrance into the stomach of blood extravasated at a greater or less distance from that viscus. The usual sources of the blood are the bowel, oesophagus, pharynx, nasal and buccal cavities, bronchi and lungs, abdominal or thoracic aneurisms, abscesses from vertebral caries, and cardiac aneurisms.12 13 For the etiology of haemorrhages in these situations, the reader is referred to the articles in this Handbook treating of diseases affecting the above-mentioned organs. Pathological Anatomy.-The pathological condi- tions attending haematemesis of course vary in accordance with the causes of gastric and extra-gastric haemorrhage already enumerated, which are so numerous that their description is beyond the scope of this article, and must be sought under the proper headings in this Handbook. Symptomatology.-The clinical history embraces the vomiting of blood together with the consequent immedi- ate and remote constitutional symptoms. The gravity of these symptoms generally corresponds with the amount of vomited blood. This is, however, not necessarily the case, the greater part of the extravasated blood being oc- casionally retained in the stomach. In typical cases of concealed gastrorrhagia, for instance, death may even ensue from excessive loss of blood without haematemesis, the physical examination, meanwhile, demonstrating the presence of large quantities of fluid in the stomach. Moderate haematemesis is, however, generally preceded by a sensation of warmth and, possibly, of distention in the epigastric or infra-sternal regions, and associated with nausea, a sweetish taste, pallor, coldness of the surface, and general malaise. In severer cases there are super- added the usual symptoms of suddenly developed anaemia, viz.: restlessness, tinnitus aurium, musctB volitantes, verti- go, asthenia, thirst, impaired vision, cold and clammy extremities, sighing respiration, falling temperature, rapid, feeble, and compressible pulse, apathy or even syncope, followed, after the establishment of reaction, by all the phenomena of grave secondary anaemia. These symptoms are especially oedema, apathy, functional car- diac disturbances, haemic arterial and venous murmurs, a dicrotic pulse, somnolence or insomnia, neuralgia, dys- pepsia, alopecia, albuminuria, and amaurosis.12 Melaena is a frequent sequel, and the symptoms referable to the disease which provoked the haematemesis generally con- tinue after the haemorrhage, while the microscope shows deviation of the red blood-corpuscles from their normal number, size, and form (poikilocystosis), and a relative numerical increase of the white corpuscles. The vomit- ing is sometimes accompanied by cough from entrance of blood into the larynx, which circumstance may lead to the erroneous diagnosis of haemoptysis. In rare cases, so much blood finds entrance to the larynx as to cause dysp- noea or even death from asphyxia. In the worst type of cases syncope is accompanied by convulsions and gradually merges into fatal coma. Haematemesis either occurs but once or is recurrent. In some cases the amount of blood is so slight as to be hardly appreciable without the aid of the microscope, but in others it is so great as to be rejected in an uninterrupted current from both mouth and nostrils. If the blood be abundant, as in gastric ulcer and the rupture of aneurisms, or if its so- journ in the stomach has been short, it is fluid in consis- tency, its color is arterial or venous, and its reaction alkaline. If the blood has been subjected for some time to the action of the gastric juice, as in cancer of the stomach, it is acid in reaction, is rejected partly fluid and partly in coagula the color of which is dark, or in the form of small black granules, the resemblance between which and coffee grounds or soot has been universally observed. The vomited mass sometimes resembles choco- late or ink in color and consistence. The characteristic color of the ejecta is due to the disintegration of haemo- globin and the liberation of haematin. The ejecta are found, on microscopical examination, to consist of red blood-corpuscles more or less decolorized, distorted, and disintegrated, and of food-remnants, mucus and epithe- lium from the stomach, with an occasional admixture of bile. If the blood-corpuscles have been so thoroughly and generally disintegrated as to elude microscopical ex- amination, a spectroscopic analysis may be required to absolutely demonstrate the presence of blood in the vomited matters. Diagnosis.-The diagnosis of haematemesis involves : 1, the exclusion of pseudo-haematemesis, i.e., the estab- lishment of the fact that fluid which has escaped from the mouth and nostrils is really blood, and that it has not been ingested, and subsequently rejected by artificial eme- sis for the purpose of deceiving; 2, the discrimination between haematemesis and other haemorrhages finding an exit through the buccal and nasal cavities, particularly those incident to diseases of the mouth, pharynx, nose, oesophagus, trachea and lungs; and 3, the discovery of 448 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hsetnatemesis. Haematemesis. the causative conditions producing the haematemesis and of the site of the original haemorrhage. 1. The Exclusion of Pseudo-hamatemesis.-Bile, red wine, the juices of vegetables and fruits, such as to- bacco, beets, haematoxylon, cranberries, raspberries, and cherries, and various mineral preparations, such as bis- muth and iron salts, may, when mingled with other egesta, present a certain resemblance to blood. The dis- crimination between these substances and blood is made by careful inspection, by the use of the microscope and spectroscope, and by the application of chemical tests for haematin, haemin, and bile. Dr. Welch 14 recommends that, in doubtful cases, the ejecta be diluted with water, which assumes a reddish hue if blood is present. The discrimination, by chemical or by physical tests, between blood which really originally proceeded from the body of an individual and blood which has been swallowed with a view to deceive, is practically impossible unless the blood has been borrowed from birds, reptiles, fishes, or certain animals (camelidae), and is sufficiently fresh and intact to exhibit the distinctive appearances of the red corpuscles belonging to the classes of creatures just enumerated. Malingerers can, however, generally be convicted of their fraud by a careful system of surveillance. 2. The differential diagnosis between hematemesis and other hemorrhages, resulting in the escape of blood through the mouth and nose, is ordinarily easy. Haemorrhage from the oesophagus can be differentiated from true haematemesis when proof of antecedent oesophageal dis- ease is afforded by pain in the oesophagus or by dysphagia, and is demonstrated by the use of the oesophageal sound and of the oesophagoscope. Epistaxis and haemorrhage from the nasal and buccal cavities can usually be readily diagnosticated by a thorough physical examination with the rhinoscope and the laryngoscope. The latter instrument may also demonstrate the exact source of pharyngeal and tracheal haemorrhages. Nocturnal epistaxis and buccal or (esophageal haemorrhages which have led to unconscious deglutition of blood are the most difficult of detection, and may precipitate attacks of haematemesis likely to be mistaken for that dependent upon gastrorrhagia or intes- tinal haemorrhage. The most frequent problem in the di- agnosis of haematemesis relates to the differentiation be- tween pulmonary and gastric haemorrhages, which may mutually simulate each other, blood being sometimes swallowed during haemoptysis, and occasionally finding entrance to the air-passages during the course of an at- tack of haematemesis. The following table, borrowed from Dr. William 11. Welch,14 presents, with admirable conciseness and comprehensiveness, the points upon which a differential diagnosis is to be based : result from haematemesis, thus precluding the possibility of making an examination. 3. Cause and Seat of the Original Haemorrhage.-When it has been definitely ascertained that haematemesis has occurred, it still remains to decide regarding the cause and the seat of the original haemorrhage. This can only be done by a careful review of the possible etiological conditions,, and by the exclusion of those against which conclusive evidence exists. Prognosis.-In considering the prognosis of haemate- mesis, we should remember that the quantity of vomited blood is not invariably a criterion for the quantity ex travasated, upon which alone the result depends. In most cases, however, the haematemesis is a sufficiently accurate quantitative index of the extravasation to jus- tify one in speaking of the prognosis as if it were depend- ent upon the vomiting of blood alone. The prognosis en- tirely depends upon the cause of the haematemesis, and relates to the prospect of recovery from (1) individual at- tacks, and from (2) the induced anaemia. Haematemesis is rarely immediately fatal, but is so when due to the rupture of aneurisms, and may be so in cases of hepatic cirrhosis and of gastric ulcer or cancer. Brinton esti- mated that from three to five per cent, of all gastric ulcers terminate fatally, either on account of the direct or of the indirect results of gastric haemorrhage. The propor- tion of cases in which cancer leads to a fatal haemorrhage is somewhat smaller. The diminution of arterial tension, and the pressure of extravasated blood upon the bleeding gastric vessels, may exert an effectual haemostatic influ- ence, even in cases of severe gastric haemorrhage. The vomiting of blood in the various dyscrasiae and acute in- fectious diseases mentioned under the caption Etiology, is serious because it either results fatally at once, or in- creases the asthenia engendered by the original disease. If the haematemesis be due to portal congestion, its im- mediate result will generally be to relieve the ascites and the gastric and intestinal symptoms occasioned by venous hyperaemia; but, since its causes are usually incurable thoracic or hepatic diseases, it ordinarily largely contrib- utes to a lethal termination of the case. Haematemesis resulting from intestinal, oesophageal, pharyngeal, nasal, and buccal diseases, is not of so grave prognostic import as that which depends on morbid gastric conditions, since it is ordinarily less severe and more readily controlled. Vicarious haematemesis, if moderate, is rather beneficial than otherwise, and the so-called idiopathic haematemesis is of no great importance from a prognostic point of view. In a few recorded cases, the vomiting has been so profuse that the blood, not finding exit with sufficient rapidity to prevent over-filling of the mouth and pharynx, has en- tered the respiratory passages, causing fatal asphyxia. Treatment.-This, like the prognosis, entirely de- pends upon the fundamental cause of the haematemesis, and is subdivided into prophylactic treatment, the treat- ment of the actual attack, and the after-treatment. 1. Prophylaxis.-The preventive treatment should em- brace measures for the relief of existing diseased condi- tions capable of occasioning haematemesis. In the pres- ence of any disease likely to produce vomiting of blood, active exercise should, therefore, be forbidden, and every thing tending to cause gastric congestion, especially alco- holic drinks and stimulating foods, should be studiously avoided. If existing cardiac disease is producing marked portal congestion, an effort must be made to establish a compensation for the heart-lesion by strengthening the cardiac muscle. In the presence of gastric ulcer or cancer, only the blandest articles of food should be allowed, or rectal alimentation should be resorted to in order that active congestion of the stomach be avoided. Portal hy- peraemia dependent upon cirrhosis may be measurably relieved by moderate catharsis. Vicarious haematemesis, in cases of suppressed menstruation, may be prevented by local treatment tending to produce determination of blood to the pelvis, as hot douches, hip-baths and fomen- tations, the application of electricity and leeches to the cervix uteri, the uterine sound and aloetic laxatives. Vicarious gastric haemorrhages, in cases of haemorrhoids, may be averted by abstraction of blood from the haemor- Haemoptysis. 1. Usually preceded by symptoms of pulmonary or of cardiac disease. Bronchial luemorrhage, however, without evidence of preceding dis- ease, is not rare. 2. The attack begins with a tick- ling sensation in the throat or be- hind the sternum. The blood is raised by coughing. Vomiting, if it occurs at all, follows the act of coughing. 3. The blood is bright red, fluid, or but slightly coagulated, alkaline, frothy, and frequently mixed with muco-pus. If the blood has re- mained some time in the bronchi or a cavity, it becomes dark and coag- ulated. 4. The attack is usually accom- panied and followed by localized moist rales in the chest, and there may be other physical signs of car- diac disease. Bloody sputum con- tinues for some time, often for days, after the profuse haemorrhage ceases. ITamatemesis. 1. Usually preceded by symptoms of gastric or of hepatic disease, less frequently by other diseases (see Etiology). 2. The attack begins with a feel- ing of fulness in the stomach, fol- lowed by nausea. The blood is ex- pelled by vomiting, to which cough, if it occurs, is secondary. 3. The blood is dark, often black and griunous, sometimes acid, and usually mingled with the food and other contents of the stomach. If the blood is vomited at once after the effusion, it is bright red and al- kaline, or it may be alkaline if ef- fused into an empty stomach. 4. After the attack, the physical examination of the lungs is usually negative, but there arc generally symptoms and signs of gastric or hepatic disease. Black stools fol- low profuse haematemesis. It is sometimes impossible to establish the diagnosis of haematemesis, if the patient does not come under obser- vation until some time after the attack, or if the haemate- mesis has been trivial. In rare cases, death may suddenly 449 HtetnatemesiK. Haematocele. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rhoidal veins. The prophylaxis also embraces appropriate treatment of various morbid blood states, notably of scor- butus, anaemia, and chlorosis, as well as of intestinal, buc- cal, pharyngeal, nasal, and oesophageal diseases. 2. Treatment of the Attack. - When haematemesis, due to gastrorrhagia or to any unknown cause, is actually oc- curring, haemostatic measures must be promptly adopted, and all sources of increased cardiac activity, and of con- sequently augmented intra-vascular tension, carefully avoided. The patient should be made to remain per- fectly quiescent in a recumbent dorsal position, should be forbidden even to converse, and should be reassured by the information that there is very rarely danger from any individual attack of haematemesis. The room is to be kept cool, and the bed coverings must be so light as not to interfere with respiration by exerting pressure upon the thorax. Restlessness and nervousness should be quieted, the effects of shock diminished and emesis pre- vented by a moderate dose of morphia, hypodermically administered. A fiat rubber bag containing pounded ice should be applied to the epigastrium, and small bits of ice be swallowed, at intervals of a few .minutes. Astrin- gents, if of sufficient strength to efficiently check haemor- rhage, tend to excite vomiting, and are therefore best avoided. Fenwick, however (loc. cit.), recommends the acetate of lead, in two-grain doses, either in pill form or dissolved in a solution of acetic acid. Twenty minims of a ten per cent, solution of ergotine, in equal parts of glycerine and water, may be subcutaneously injected, and repeated twice, at intervals of fifteen minutes, if the first injection should produce no effect. If syncope is imminent, liga- tures may be applied to the extremities for a few minutes, for the purpose of retaining the venous blood in the pe- ripheral veins, and of thus diminishing intra-vascular ten- sion in the gastric vessels. The same object is effected by the application of dry cups to the extremities. If syncope occurs, dilute aqua ammoniae is to be held to the patient's nostrils, his head placed in a dependent position, an ounce of brandy or whiskey, diluted with an equal amount of hot water, injected into the rectum, and several hypoder- mic syringefuls of ether injected beneath the skin. Care should, however, be exercised not to overstimulate the heart during syncope or collapse, since a moderately low arterial tension is in itself an efficient haemostatic agency. During syncope, the patient is to be kept upon his side, and his mouth held widely open to prevent the entrance of blood into the air-passages. Should blood neverthe- less enter the respiratory organs, it must be removed with the finger or by means of appropriate tenacula. If the syn- cope be persistent and collapse be threatening, four drops of the nitrite of amyl may be inhaled, one-fiftieth grain of digitalin be given subcutaneously, and if these meas- ures prove unavailing, transfusion of from four to six ounces of defibrinated blood, or of a weak saline solution, employed. In transfusion due caution must be exercised lest, by the injection of too large a quantity of fluid, the intervascular pressure be unduly increased, and the hae- morrhage thus aggravated. It has been suggested, by German authors, that a rubber bag connected with a stomach tube be introduced into the stomach and tilled with air or cold water to check alarming gastrorrhagia; but this measure, like transfusion, is of doubtful expedi- ency for obvious reasons, and, not being devoid of posi- tive danger, should only be regarded as a last resort. 3. After-treatment.-The treatment after the cessation of haematemesis embraces physical and mental quietude, best attained by the administration of small and dimin- ishing doses of morphia, and rectal alimentation by means of peptonized milk and Leube's beef solution, continued for at least several days before a gradual return is made to nourishment per orem. The first food given by mouth should consist of lime-water and milk, to which solid ar- ticles of food may, one by one, be tentatively added. Purga- tives are to be avoided for a long time, and evacuations obtained by laxative enemata, unless after haematemesis from portal obstruction, when moderate doses of salines are advisable, with a view to a derivative action on the portal system. Revulsion, by means of a blister to the epigastrium, may be advantageously employed. Anaemia, which is an almost constant sequela of haematemesis, claims careful treatment, and recurrence of haemorrhage must, if possible, be prevented by the adoption of the prophylactic measures already suggested. Transfusion of blood, although of doubtful utility during haemateme- sis, is a measure of undisputed value in the after-treat- ment, and cannot be too highly recommended. Prepara- tions of iron are to be administered at first by the rectum, and later per orem, until all evidences of anaemia have disappeared. William H. Flint. 1 Landau : Ueber Melaana, Habilitationschrift, Breslau, 1874. 2 Fenwick : Quain's Diet, of Med., N. Y., 1883, p. 562. 3 Oser : Real Encyclopiid. d. Gesamnit Heilk. Eulenburg, 1881, Bd. vii., 455. 4 Bristowe: Theory and Frac, of Med., Phila., 1879, p. 658. 5 Luton : Nouv. Diet, de Med. et de Ch. Pratiq., 1873, tome xvii., p. 260. 6 Jaccoud: Traite de Path. Int., Paris, 1871, t. ii., p. 290. 7 Bartholow: Treatise on the Prac. of Med., N. Y., 1880, p. 49. 8 Leube : Ziemssen's Handh. d. Sp. Path. u. Th., Bd. vii., i. Hiilfte, S. 162. 'Niemeyer: Text Bk. of Prac. Med., N. Y., 1876, vol. i„ p. 524. 10 Eichhorst: Handb. d. Sp. Path. u. Th., Wien u. Leipzig, 1883, Bd. i., 760. 11 A. Flint, Sr.: A Treat, on the Prin. and Prac. of Med., Phila., 1881. p. 513, and Clin. Med., Phila., 1879, p. 253. >2 Oser: Op. cit., p. 457. 13 Trousseau: Leets, on Clin. Med., Phila., 1870. III., 151, and IV., 183. 14 Dr. William H. Welch: Haemorrhages of the Stomach; Pepper's System of Practical Medicine, Phila., 1885, p. 585. H/EMATIDROSIS. This affection, known also as bloody sweat, ephidrosis cruenta, sudor sanguinosa, dia- pedesis, etc., is a haemorrhage from the unbroken skin through the orifices of the sweat-ducts. There is, per- haps, no such thing as an actual pouring out of blood as a secretion of the sweat-glands, the haemorrhage in ques- tion probably occurring from the plexus of blood-vessels surrounding the glands into the ducts of these glands. The affection, though excessively rare, is so striking as to attract universal attention, and, consequently, records of its occurrence are found, not only in medical, but also in historical, works. A shallow skepticism, denying all extraordinary phenomena not coming within its own im- mediate observation, had, at the beginning of this century, swept aside all accounts of sweating blood as fabulous. More accurate observation has of late years established rhe fact that, under certain conditions, blood, in a more or less pure condition, may exude from the orifices of the sweat-glands. The mechanism by which this exudation takes place has not as yet, however, been satisfactorily explained, nor is it likely to be explained until we know much more, both of the physiology of the sweat secretion and of the circulation of the biood. A haemorrhage takes place from the capillary plexus about the gland- coil and into the gland-duct, but whether this is the re- sult of passive dilatation, increased blood-pressure, altera- tion in the structure of the vascular walls, or in the composition of the circulating fluid, cannot, in the present state of our knowledge, be positively stated. The process has some points of resemblance with that which goes on in purpura (see Purpura). As regards the appearances presented to the eye, these vary in different cases reported. Sometimes blood oozes or spurts from the uninjured and unchanged skin. At other times an erythematous patch first forms, or a thin scale, which is later lifted up by the sanguineous exudation be- neath. At other times a miliaria-like, vesicular eruption precedes the diapedesis. Haematidrosis may occur in either sex, and among those apparently in the enjoyment of good health as well as among those who belong to bleeder families, or who are in a low state of vitality. In many cases the affec- tion occurs in connection with vicarious or disordered menstruation. At other times it may occur as the result of -an impoverished condition of the blood, or from sud- den and strong moral impressions, as fright, anguish, etc. At times fever with high blood-pressure precedes the effusion, while at other times a state of depression with slow pulse ushers in the phenomenon. Occasionally the affection is one of a number of symptoms connected with purpura, etc. The diagnosis of the disease presents no difficulty, ex- cepting in those rare cases in which simulation may be expected. 450 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hiematemesis. Haematocele. The treatment of the disease must in many cases be purely empirical, and be directed by circumstances. When, however, there are indications of increased excite- ment and vascular tension, the abstraction of blood by a vein is called for. Closely allied to haematidrosis is the curious affection known as Stigmata (q.v., as also the article on Purpura). this explanation of the formation of a limiting cyst-wall is faulty. Almost always it is the lifted peritoneum which forms the cyst wall or roof. Most frequently the effusion is into Douglas's cul-de- sac, or into the connective tissue between the uterus and rectum ; hence the term retro-uterine, so commonly em- ployed. Effusions between the uterus and bladder, ante-uterine, are rare. Barnes has recorded two ; Emmett, G. Braun, and Schroeder, each one. Amount of Blood Effused.-An haeinatocele varies in size from a collection so small that it can with difficulty be felt by vaginal examination, to a mass of enormous size completely filling, and rising out of, the pelvis. Barnes records one which contained 946 c.c. (2 pints). Duncan tapped below the umbilicus, and drew off 3,401 c.c. (115 oz.) of lymphy blood, the case ending in recovery. I have drawn off, per vaginam, 828 c.c. (28 oz.) from one situated behind the uterus, the case ending in recovery. The following figures illustrate the force of some of the above statements. Predisposing Causes.-This accident usually occurs in those suffering from general debility and some men- strual disorder, as amenorrhoea or menorrhagia-more frequently the latter. In some of the cases preceded by amenorrhoea it is probable that tubal gestation is present, the rupture of which causes the haematocele. The affec- Turek : Bur une homorrhagie cutanee. Gaz. des Hop., 1851. p. 551. Gendrin: Des Sueurs de Sang. Gaz. des Hop., 1856, Nos. 68-71. J. H. Ebers: Die Hamatidrosis Oder der blutige Schweiss, etc. Breslau, 1856. Anderson McCall: Case of So-called Ephidrosis Cruenta, or Bloody Sweat. Brit. Med. Jour., August 17, 1867. Hart: Cerebral Lesions, Multiple Haemorrhages, Bloody Sweat. Rich- mond and Louisville Med. Jour., January, 1875. Tittel : Ein Fall von Hamatidrosis. Archiv der Heilk., 1876, p. 63. E. Labee: Hamatidrosis. Le Mouvement M6d., 1877, p. 411. J. H. Pooley : Anomalies of Perspiration. Ohio Med. Recorder, Novem- ber, 1880. Arthur Van Harlingen. Bibliography. HEMATOCELE, RETRO-UTERINE OR PELVIC. The lesion to which this term is applied consists in an effusion of blood into the tissues of the pelvis. The term pelvic, which has been adopted by English and American observers, is better than retro-uterine, because more com- prehensive. Adopting a classification based upon the clinical history, we may instructively consider this sub- ject under three forms: (a) The grave form, called by Barnes cataclysmic ; (/>) the severe form, the one usually met with; (c) the mild form, sometimes chronic or re- current. Frequency.-This is a comparatively rare affection ; it is estimated by Schroeder to occur seven times in one thousand gynaecological cases, by Olshausen thirty-four times in eleven hundred. Owing to the suddenness of invasion it is rarely seen in this stage in hospital or dis- pensary practice. Sources of the Haemorrhage.-The blood may come from the ovary or its bulb, from varicose veins in the broad ligament, from a small aneurism, from a Graaf- fian follicle at a menstrual epoch, but only when an ab- normally large vessel is ruptured, from the vessels of a tubal gestation sac at the site of rupture, trom a small ruptured ovarian or parovarian cyst, from the vascular pseudo-membranes in peritonitis, from a rupture of a haemorrhoidal vein, or from dilated vessels in the pelvic connective tissue. In congestive ovarian or uterine dis- ease venous pouches may be formed, the coats of the vessels having lost tone from long-continued overdisten- tion. There may be a reflux of menstrual blood from the uterus, but only through dilated Fallopian tubes, since it has been proved that blood never passes from a distended uterus through normal tubes. Sites of the Effusion.-The blood may be effused into the peritoneal cavity behind and around the uterus, or outside the peritoneum, into the cellular tissue of the broad ligaments, or into that between the uterus and rectum, or between the uterus and bladder. Large effu- sions into the peritoneal cavity furnish examples of the grave form. Usually the severe form is extra-peritoneal, and the mild form is always so. A division into intra- and extra- peritoneal has been adopted by some observers, the peri- toneum forming the boundary line ; and intra-peritoneal hsematoceles have been divided into encysted and non- encysted. In the encysted form the exudation is sup- posed to be immediately covered or converted into a cyst by plastic material from peritonitis, the latter being caused by the blood acting as a foreign body. In the non-encysted form the blood is said to remain free in the cavity of the peritoneum, no exudation of lymph taking place. These divisions are to be rejected on account of their lack of clinical distinctness. Many cases classed as intra-peritoneal, and encysted, are extra-peritoneal, and covered with peritoneum instead of a roof of lymph. The peritoneum is an elastic, strong membrane, easily lifted from the viscera, and not a fragile, immovable membrane, rupturing from the slightest distending force. Blood alone does not, as a rule, excite peritonitis, and Fig. 1512.-Pelvic Hmmatocele (Emmett). Grave form : intra-peritoneal and peri-uterine. Recovery by slow absorption. tion is limited to the period of ovarian activity, and is most common between the ages of twenty and thirty-five. Overwork and fatigue have a causative influence ; also plethora and anaemia leading to congestion, and chronic ovarian or uterine disease. Doubtful in their causative influence are : scorbutus, purpura, lead poisoning, and haemophilia, producing the so-called cachectic or dyscra- sic variety. Exciting causes are menstruation and ovulation with the accompanying physiological hyperaemia, mechanical efforts to produce abortion, getting up too early after abortion, blows and falls, excessive coition near a men- strual period, violent lifting efforts, straining at stool, over-fatigue, exposure causing congestion of all the vis- cera, sudden checking of the menstrual flow from men- tal shock or exposure, and forcible traction upon the uterus by the tenaculum to facilitate applications to the endometrium. Emmett thus caused an hsematocele which nearly terminated fatally. Case XX. Symptoms.-1. The Grave Form.-Usually, near or during a menstrual epoch, without warning, unless it be a dull pelvic pain, the patient is seized with violent abdo- minal pain of cramp-like character, followed immediately by symptoms of severe concealed haemorrhage and pro- found nervous shock, partial or complete syncope, deathly pallor, hiccough, nausea and vomiting, and a sense of hopeless prostration. The patient usually tosses about, and in the intervals of quiet lies with both thighs drawn 451 Hsematocele. Hsematocele. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. up, the one upon the side of the effusion being sometimes the more flexed. Death may come at once, without ef- fort at reaction, but commonly the patient rallies for a time, and sinks in from twelve to twenty-four hours ; or reaction soon begins with rising temperature and pulse, and signs of returning strength. If decomposition be- gin, chills come on and are follow'ed by fever, indicating the inception of septicaemia. This may progress to a fatal termination or to recovery, according, in a measure, to the efficiency of the treatment. The amount of effu- sion is large, poured out rapidly, and is free in the peri- toneal cavity, and soon may separate into an irregular clotted mass in the pelvis, with semi-fluid blood overly- ing it (see Fig. 1514). The symptoms are like those at- tending rupture of any of the abdominal viscera, or of a tubal gestation, and like those of acute irritant poisoning. The resemblance to the last-named condition is so close that the suspicion has arisen that death was due to poi- soning. 2. The Severe Form.-In this class of cases there is the same array of symptoms as in the preceding, but they are of a milder type and less rapid sequence ; they consist in pelvic pain, nervous shock and prostration, and the sig- nificant attitude with the thighs drawn up. Death rarely results from the amount of the haemorrhage, and in from twelve to twenty-four hours reaction sets in, which grad- ually subsides as absorption goes on. Death may infre- quently occur from septicaemia. The amount of effusion care must be exercised not to attribute the increase of ma- laise and pelvic pain to periodical effusion, when it may be due to the hyperaemia of the organs, increased at such times. Indeed, only a careful vaginal examination can establish the diagnosis of a recurring menstrual haema- tocele. All good observers recognize the existence of the mild form, and consider it to be frequent and unattended by signs of much irritation. ' The forms herein described may run into one another, to wit, the mild may become grave, as in Emmett's case No. XIV.; or the mild may become severe, as in McClin- tock's case No. I.1 It must be borne in mind that this affection, like every other, may present an endless variety of cases, many of them atypical and obscure, with great diversity in clinical history and gravity. The importance of jaundice as a symptom is insisted upon by Wiltshire alone.2 The icterus is met with only in the grave and severe forms, is not usually very pronounced, and comes on in from a few days to two weeks. It is not biliary or hepatic in origin, but purely haematic, and due to absorption of the coloring matter of the extravasated blood. Physical Signs-1. The Grave Form.-Before any ex- amination is attempted the bladder should be emptied by the catheter. By external exam- ination an ill-defined mass can be felt filling the hypogastric and a part of the umbilical regions ; it is dull upon percussion. The abdo- men is more or less enlarged and tender. By vagi- nal examination, slight tenderness and fulness are de- tected behind the uterus and in the broad ligaments. No well-defined tumor is present. The mass feels soft a n d fluctuating, has no margins, soon grows harder and lesselastic, and later, when coagu- lation is complete, is quite solid. As a rule, there is no displacement of the uterus and only slight loss of mo- bility, but both po- sition and mobility may be altered. (See Figs. 1512 and 1513.) By the rec- tum the soft mass can be felt distend- ing Douglas's cul-de-sac. The posterior wall of the vagi- na does not bulge downward and forward. No explora- tion of the uterus by the sound or probe is allowable. 2. The Severe Form.-On external examination, the blad- der having been emptied, we may find the abdomen en- larged, tender, and dull upon percussion, but not in- variably so, and to a less extent than in the preceding form. On vaginal examination, the finger immediately impinges upon a mass with ill-defined margins, soft, fluctuating, and slightly tender, or hard and tense, ac- cording to the time which has elapsed since effusion took place. The tumor if retro-uterine pushes the posterior vaginal wall downward and forward, and, according to its size, partially or wholly occludes the vagina. (See Figs. 1516 and 1515.) The cervix uteri is found behind and above the pubis, slightly flattened by pressure, and with the os externum compressed into a narrow, transverse chink. The uterus is almost immovably fixed in this ele- vated position, and can usually be readily made out by Fig. 1513.-Pelvic Hematocele (Emmett). Grave form ; secondary to mild form. Extra-peritoneal and ante-uterine becoming, by rupture, intra-peritoneal and peri uterine. Death by haemorrhage and shock. in this form is also large, but it is less rapidly extrava- sated and rarely lies free in the peritoneal cavity, but is beneath the peritoneum, which exercises upon it an elas- tic and restraining pressure. This form may occur with- out urgent symptoms, and pursue a mild and chronic course, when the effusion is large but slowly poured out; the patient suffering from general malaise and aching pel- vic pain, with difficulty in emptying the rectum. There is ofttimes a history of intercurrent mild jaundice. 3. The Mild Form.-In this common and often unap- preciated form, which may be confounded with cellulitis or cold pelvic abscess, the symptoms are mild in charac- ter, developed gradually, and are not sufficiently charac- teristic to establish the diagnosis, this being never made without the aid of the physical signs. The symptoms are, back-ache, menorrhagia, pelvic weight and dull pain, and difficulty in defecation. Walking increases the distress in the pelvis and back, and the patient finds her general health and strength inexplicably failing. This history may have extended over a period of from six to twelve months, or of as many weeks only. Recovery is the al- most unbroken rule. There is no appreciable stage of in- vasion or reaction, but only a period of effusion which usually escapes notice, and one of absorption. This form may be recurrent or so-called menstrual, with an exacer- bation at each menstrual epoch, due to fresh effusion; but Fig. 1514.-Pelvic Haematocele. (Schroeder). Grave form; intra-peritoneal and ante-uter- ine, due to rupture in a tubal pregnancy. Douglas's cul-de-sac had been obliterated by adhesions, u, Uterus; tubal ovisac which ruptured : be, coagulated blood; / b, fluid blood overlying the coagulum. Death by haemorrhage and shock. 452 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ilaematocele. Haematocele. conjoined manipulation, the fundus lying forward. (See Fig. 1516.) But if it cannot be mapped out, the uterine probe may be gently used to define its position, but never until reaction is established. When the effusion is ante- uterine the probe maybe required. (SeeFig. 1514.) The uterus is softened and somewhat enlarged by congestive hypertrophy, measuring 7.6 or 8.35 centimetres (3 or 3f inches) in length. The lips of the cervix are shortened by traction upon the utero-vaginal junction, the posterior one more so. If the effusion is in a broad ligament the uterus will be pushed to one or the other side ; if it is anterior to the uterus, the organ will be displaced backward and a little downward. (See Fig. 1514.) When the effusion is retro-uterine on rectal examination with one or two fin- gers, this organ is found flattened and compressed against the sacrum. (See Fig. 1516.) With the thumb in the vagina, and the index-finger in the rectum, the lower por- tion of the mass can be examined, and its thickness and density determined Schroeder says: "In one case I could feel a peculiar crepitation, like that produced in crushing a snowball, which was caused by coagula being pressed together."3 3. The mild form.-By external examination nothing can be made out. By vaginal examination a small mass of varying hardness, but never fluctuating, is found, usu- the symptoms with gradual return to health, the rapidity of convalescence being governed by the amount of effusion and the strength of the patient. In cases extending over months, menstruation goes on quite normally or menor- rhagia is present; and it has been noticed at such times that, while there may be an aggravation of the symptoms by fresh effusions, there may also be a decided increase in the rapidity of absorption, so that the tumor disappears by monthly stages. Voisin noted the duration of absorp- tion in 7 cases to be : in 2 six weeks, in 3 four months, in 1 six months, and in 1 eight months. One of West's cases lasted thirteen months. Complete absorption may occur in three weeks, and the average time is from six to ten weeks. Sequelae.-These are : Congestive hypertrophy of the uterus, attended by menorrhagia and general malaise; retroflexion from contraction of the lymph exuded in Douglas's cul-de-sac, with shortening of the recto-uterine ligaments ; loss of mobility of the uterus and pelvic neu- ralgia, with inability to walk or sit long with comfort ; and a low grade of recurrent pelvic peritonitis. But se- quelae are usually absent. A recurrence of haematocele is rare, but until every trace of lymph has disappeared care should be exercised at the menstrual periods. Diagnosis.-The grave form, and the severe in its acute stage, are not difficult to diagnosticate, if the symptoms and physical signs are carefully observed. Two condi- tions may be confounded with them, acute irritant poi- Fig. 1516.-Pelvic Hrematocele (Emmett). Severe form ; extra-peritoneal and retro-uterine. Recovery after puncture and washing out cyst. Fig. 1515.-Pelvic Hsematocele (Barnes). Severe form; extra-peritoneal and retro-uterine. Recovery by absorption. H\ haematocele; U, uterus ; 2?, bladder; V, vagina ; R, rectum. soning already referred to, and rupture of an early tubal ovisac ; and, if death be sudden, differentiation may be impossible. Rupture of a tubal pregnancy may be the cause of an haematocele, and would not be suspected unless symptoms of pregnancy had preceded. The severe form supervenes upon a chronic course, and the mild form may be confounded with (a) chronic pelvic abscess, (J) acute retroversion of the gravid uterus, (c) tubal gesta- tion, and (d) prolapsed ovarian cyst. If the history and physical signs fail to establish the diagnosis, it is better practice to, aspirate than to make repeated examinations, which can hardly fail to aggra- vate any inflammation present, or feet it up anew, and may burst the blood-cyst, causing a fatal renewal of haemor- rhage or peritonitis. The finest puncture may, however, set up inflammation, and we must be prepared to follow it with a free opening, if necessary, in from twenty-four to forty-eight hours. Tait writes: " The risk of the aspirator is great." If coagulation has taken place, in- stead of blood only serum may escape, leaving the diag- nosis doubtful. We must be certain that the needle enters the cavity, and does not merely lift up a firm leather-like membrane, which sometimes lines the cyst. Braun believes puncture to be the only sure means of di- agnosis between an ovarian tumor and an haematocele. ' ' Simpson has repeatedly used the exploring needle to de- tect the nature and contents of various kinds of pelvic tumors, when no other means of diagnosis were sufficient for that purpose." No other conditions than those men- tioned are likely to be mistaken for haematocele. ally behind the uterus, or in a broad ligament, or rarely in front; causing little or no displacement of the uterus, but interfering somewhat with the action of the rectum. The position and dimensions .of the uterus can be safely determined by the use of the probe ; there is loss of mobil- ity and slight enlargement, and there may be displace- ment. By rectal examination a retro-uterine mass can be more distinctly felt, but such examination is rarely neces- sary in this form. Course, Duration, and Termination.-In the grave form the loss of blood may be so great as to rapidly de- stroy life, but in the severe and mild forms such termina- tion is extremely rare, and the course of the disease is favorable, as may be the case even in the grave form. The terminations which may occur are : absorption, gradual and complete (or if incomplete, with a nodule of lymph remaining), suppuration and septicaemia with or without spontaneous opening, and indefinite retention of a semi- fluid mass of altered blood. The abscess may discharge into the rectum or the vagina, infrequently into the blad- der, and very rarely into the peritoneal cavity. Increasing density and shrinking indicate that absorption is taking place. If at the end of seven or eight days the tumor is soft and fluctuating, and fever is present, suppuration is about to take place, and septic symptoms soon become marked. During absorption there is an improvement in all 453 Ha*matocele. Haematuria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Prognosis.-In the grave form there is great danger of sudden death from haemorrhage and shock, or from septicaemia. In the severe form there is at times imminent danger from rupture of the cyst into the peritoneum, or later, from prolonged suppuration with the formation of sinuses, especially when an opening has taken place into the rectum or bladder. In these two forms, however, the prognosis is generally favorable, provided no injudicious treatment is resorted to, such as premature and insuffi- cient puncture or incision. In the mild form recovery always takes place. Treatment of the Grave and Severe Forms.-In the early stage of nervous shock and haemorrhage the indi- cations are : (a) to check the haemorrhage ; (b) to avert death from prostration; (c) to relieve pain. To fulfil these, the patient should be confined absolutely to her bed, with her head low, and with warmth applied to the trunk and extremities. The bladder should be emptied by the catheter once in every eight hours. A large com- press of cottonwool should be firmly bound upon the abdomen, and a piece of ice should be placed in the fun- dus of the vagina. A hot vaginal douche would be use- ful, but should be omitted, as it would unduly disturb the patient. Some authorities recommend an abdominal ice- bag. Hot fomentations or poultices should be avoided, as tending to favor haemorrhage. The use of sulphuric acid, ergot, and gallic acid, is not efficient. Morphia is invaluable and should be administered at once, hypoder- matically, in doses of 0.01 gm. (gr. J), repeated every hour, both to quiet pain and for its stimulant effect. If collapse is imminent3.07 c.c. ( 3 j.) of sulphuric ether should be given hypodermatically, to be followed by fre- quent small doses of brandy. If vomiting is present the brandy should be administered per rectum, in 15 c.c. ( 3 iv.) doses, every half hour until reaction begins. If the rectum is intolerant, brandy may be used hypodermatically in 3.07 c.c. ( 3 j.) doses. The head should not be raised from the bed. Fresh air should be freely admitted to the room. If vomiting continue, nothing should be given by mouth, not even pieces of ice. In the grave form, haemorrhage may go on until it be- comes evident that these measures will not save the patient. The blood is probably pouring from a large varix or vessel of the ovary or broad ligament, or from a ruptured tubal ovisac, and is almost beyond our control. The only treatment holding out a ray of hope is lapa- rotomy, followed by clearing out the clots and ligature of the ruptured vessel. In case we must search for the bleeding vessel at night, the incandescent electric lamp, which can be carried into the abdominal cavity, will be found useful. Wiltshire, Tait, and Edis, unhesitatingly recommend this practice. In the severe form, when death is imminent from rupt- ure of the overlying peritoneum, accompanied by agon- izing bursting pain, which no dose of morphia can control, the rapidly increasing tumor should be punct- ured per vaginam with a large trocar. Emmet un- doubtedly saved a patient by this procedure. (Case XI.). In the stage of reaction the indications are to allay pain, and fever with its attendant symptoms. The patient should be kept sufficiently under the influence of morphia to cause full relief of pain and vesical and rectal tenesmus. If the stomach is quiet, small pieces of ice may be given every fifteen minutes, with 14.07 c.c. ( 3 iv.) doses of equal parts of brandy and milk every hour. Cold cloths or the Leiter coil may be applied to the head. If vomiting is present, nothing should be given by the mouth ; thirst can be allayed by an enema of 473 c.c., (one pint) of warm water, and stimulants and nourishment can be admin- istered per rectum in small quantities and at frequent intervals. No effort should be made to cause a move- ment of the bowels, which will occur spontaneously by and by, when the obstruction shall have diminished. Af- terward a daily evacuation should be induced by the use of enemas. Vaginal examinations, tending as they do to cause pain and congestion, are unnecessary and harmful. Vaginal injections, at a temperature of 112° F., will not only soothe pain and diminish congestion, but also hasten absorption. They can be gently admin- istered by means of the douche apparatus, and should be continued until absorption is complete. There are no medicines which promote absorption. As soon as convalescence is well established, small doses of ergotine and iron should be given, with the hope of di- minishing uterine congestion and menorrhagia, and of curing the acute anaemia. The patient should not sit up until all possible, or complete, absorption has taken place, and a succeeding menstrual epoch has passed by. If a stage of suppuration replace one of absorption, the indication is to prevent septicaemia and chronic suppura- tion by immediately opening the forming abscess per vaginam, inserting a drainage-tube, and washing out the cyst; otherwise we have to fear spontaneous opening into the rectum or bladder. The patient should be placed in Sims' posture, and the cervix and fundus vaginae should be exposed by the speculum. If there is any doubt of the ability of the patient to remain absolutely quiet, an anaesthetic should be administered before proceeding to operate, as quietude is essential to safety, and any sudden movement may cause the tissues to slide over one another, thus closing the opening made before a drainage-tube can be inserted. A trocar should be in- serted into the cyst directly behind and close to the cervix, and pushed upward and forward behind the uterine body. The stylet having been withdrawn, the canula should be left in situ until the cyst is empty. A probe should be passed into the cyst through the canula, which should now be withdrawn. Along the probe, as a guide, a uter- ine dilator should be inserted, and the opening torn to the size required to admit the rubber drainage-tube. A bistoury or Paquelin knife may be used to make the in cision, but the former method is more free from the danger of ha?morrhage. A drainage-tube 12.5 mm. (| inch) in diameter should be inserted 2.5 ctm. (1 inch) into the cyst, and left long enough to protrude the same distance be yond the vulva, in order that it may be easily held and steadied by the thumb and finger, when the pipe of the syringe is inserted and removed. The tube can be easily inserted in the grasp of the uterine dressing-forceps. Between the in- jections the tube should be held in place by a napkin firmly applied to the vulva. A hard rubber piston-syringe, holding about 118 c.c. (| iv.), should be used. I use water only, at a tempera- ture of 104° F., 946 c.c. (two pints) being sufficient for each injection, which should be repeated once in four hours until decided improvement take place. The injec- tions can be given by a nurse, the patient lying upon her left side with knees drawn up, without causing her any pain ; the practitioner thus being left free to continue his operative and obstetric practice with safety to his pa- tients. The drainage-tube should not be removed until there is an end of all discharge. In one of my cases the tube slipped out repeatedly, arid I now adopt the following device, by which this accident is effectually prevented. Making a slit in the tube, 6 mm. (| inch) from its ex- tremity, I pass through this a cross-bar of rubber tubing, allowing it to protrude 12.5 mm. (| inch) upon each side. (See Fig. 1517.) The lateral wings, bent flat against the tube and held in the grasp of the forceps, give no trouble in insertion. Slight traction will remove the tube, or if difficulty is met with, the cross-bar can be pulled out by passing a catheter wire, having a little hook bent at its extremity, up the tube and over the cross-bar. In one of my cases such a tube remained in place forty days. Fig. 1518 shows the position of the opening into the cyst, the tube in situ, and the lateral retaining wings. When the swelling is inaccessible by the vagina, and rises high up into the abdomen, an incision should be made in the median line in the hypogastric region, and a drainage-tube inserted, to be followed by frequent wash- ing out of the cyst. It is not good practice to select the rectum as the site of incision, since this organ is usually intolerant of a drainage-tube. •Fig. 1517. 454 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hspinatocele. Haematuria. In some cases absorption fails, and a mass remains for months in the pelvis in a semi-fluid condition, like re- tained menstrual blood. All efforts to cause absorption, including counter-irritation and blisters, are unavailing, and meanwhile the patient suffers from pelvic pain, menorrhagia, and gradually failing strength, with inability to walk or sit up for any length of time. In such cases the cyst may be opened and the case treated in the way just described, and a cure confidently predicted. By such means I cured a case of fourteen months' duration. In these sluggish cases, if no surgical interference is resorted to, absolute rest should be maintained at each menstrual period, and no undue fatigue or sexual inter- course allowed ; the bowels should be regulated, and blis- ters and iodine used to favor absorption, with every means calculated to improve the general health, as tonics, highly nutritious food, and change of air. Such practice is conservative beyond sound judgment, and I mention it only to condemn it, for the tarry fluid encysted in the pelvis cannot be absorbed, but will remain indefinitely (or until evacuated by the surgeon's knife) a source of danger and ill health. Treatment ok the Mild Form.-The indications are to relieve pain, Hasten absorption, and improve the gen- douches and gradual reposition, followed by the use of a retroversion pessary, the aim being to gradually stretch the contracted recto-uterine ligaments. Pelvic neuralgia should be treated with quinine per- sistently administered, and the douche. Recurrent peritonitis should be treated by prolonged rest in bed, vaginal douches, tonics, change of air, and separation a thoro. Literature.-The reader desirous of extending his information on this subject will do well to consult : Thomas, "Diseases of Women;" Barnes, "Diseases of Women ; " West and Duncan, " Diseases of Women ; " McClintock, "Diseases of Women;" Emmett, "Princi- plesand Practice of Gynaecology ; " Schroeder, Ziemssen's " Cyclopaedia of Practical Medicine," vol. x. This subject is treated of in many works and essays, a partial bibliography of which is given by Schroeder in the above volume. F. E. Beckwith. 1 McClintock : Diseases of Women. 2 Lancet, September 27, 1884, p. 531 el seq. 3 Ziemssen's Cyclopaedia of the Practice of Medicine, vol. x., p. 478, American edition. 4 Emmett: Principles and Practice of Gynaecology. H/EMATOZOA, as the name would imply (alga, blood ; l^ov, a living being), is a term applied to animals found in the blood, but, strictly speaking, the name should be re- stricted to those whose regular habitation is in that fluid. Some of the cases reported as haematozoa may have been shreds of fibrin. Various human parasites may find their way to their more permanent abodes in the body by passing through the blood. Thus cysticerci of taenia so- lium, of taenia echinococcus, etc., on their way to the brain or elsewhere ; distomata, on similar journeys to the liver, kidneys, etc.; and, possibly, trichinae on their way to the peripheral muscles, would temporarily be haemato- zoa ; but the filaria sanguinis hominis and Bilharzia or distoma haematobia would be genuine illustrations. In the lower animals, as the horse and the dog, certain nematode worms have been found in the blood-vessels as causes of aneurisms and other diseases. The writer does not know of any special work on this subject. Charles E. Hackley. H/EMATURIA. By this term is understood tlie presence of blood-corpuscles in the urine. Healthy urine is abso- lutely free from any of the formed elements of the blood, but in no specimen can they be declared absent without microscopic examination, for they may be present in such small quantity as not to alter the normal macroscopic ap- pearance of the fluid. Blood-corpuscles remain visible in urine of high specific gravity for an astonishing length of time. It is repeated by one author after another that the blood-corpuscles are soon dissolved in alkaline, and especially in ammoniacal, urine ; but this has not been the experience of the writer. To ascertain how long the blood-corpuscles continue visible in urine, I performed the following experiment: On March 11th, one hour after a hearty meal, I voided three ounces of urine which was acid, of specific gravity 1.027, perfectly transparent, and of a tint corresponding to No. 3 of Neubauer and Vogel's scale. Into this I let fall one drop of blood, ob- tained by puncture of the finger pulp. The urine was then briskly stirred to prevent coagulation of the blood, and examined in a good light with the naked eye. No one would have suspected that this urine, in which were at least fifty million blood-corpuscles, there being more than ten cubic millimetres in the drop, contained a trace of blood. It was then examined for albumen with Hei ler's test, and none detected. There was, however, one very decided change in the appearance of the urine, namely, a complete loss of transparency. Twenty-four hours later, some of the brownish precipitate formed by the corpuscles was removed with a pipette from the apex of the conical glass containing the urine, and examined under the microscope. The corpuscles were perfect in outline, none of them crenated or otherwise distorted. The only perceptible change was a coarsely granular ap- pearance of their stroma, undoubtedly due to a partial separation of the haemoglobin, for the granules, on care- Fig. 1518.-Modified from Barnes. Hsematocele Retro-uterine and In- fra-peritoneal, Cured by Use of Tube and Washing out Cyst. Ji, rectum; P, peritoneum ; 7/, the haematocele ; 77, uterus ; Ji, bladder; D T, drainage-tube; W, one of wings to retain tube in place. eral health. Iron and quinine should be given. The patient, who usually feels half sick, should be put to bed, to remain until absorption has taken place, using a bed- pan and not rising or sitting up in bed for any purpose. A vaginal douche at a temperature of 116° F. should be given four times daily, during a period of ten minutes. The bowels should be moved every day by enemas. Under treatment by rest and the douche the pelvic pain will subside without the use of an opiate, and absorption will be complete in from three to six weeks. In a case of this form recently treated in my practice, complete ab- sorption took place in two weeks. Many such cases are diagnosticated as pelvic cellulitis. Treatment of the Sequelae.-Congestive hyper-, trophy, with menorrhagia and anaemia, should be treated by tonics, the prolonged use of the hot vaginal douche, and rest in bed during menstrual periods. Retroflexion, a rare sequel, should be treated by vaginal 455 Hirmaturia. Haemoglobinuria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. time for intimate admixture with the urine, this fluid is free from clots and presents a brownish or smoky hue. Under the microscope blood-casts will be found in many cases. If the blood escapes directly into the renal pelvis, it may coagulate in that situation, and in passing down the ureter the coagulum may give rise to the same symp- toms as attend the passage of a renal calculus. Some of the blood may pass into the ureter in a fluid form and there coagulate in the form of long, cylindrical, worm-like clots which are highly diagnostic, since they demonstrate that the origin of the haemorrhage is either the renal pel vis or the ureter. When the haemorrhage is profuse, as it sometimes is in cases of malignant disease, the urine may be of a blood-red color. Aids to the diagnosis of haematuria and its seat are the presence of other symp- toms of those diseases giving rise to it; such as, in the case of the bladder, the symptoms of stone, tumor, pros- tatic disease, etc.; in that of the kidney, the presence of a tumor in the loins, and a history of nephritic colic. In the diagnosis of haematuria, certain sources of error are to be borne in mind. The blood, for example, may have been added to the urine for purposes of deception. An instance is related in which, on microscopic examination of the urine, the oval, nucleated corpuscles of the fowl were detected. When malingering is suspected the phy- sician should insist upon the patient's urinating in his presence. By this means Fagge exposed an attempt to obtain damages from a railway company after an acci- dent. Rhubarb and senna, taken internally, impart a red color to alkaline urine. This is readily distinguished from haematuria by the fact that it disappears on the addition of an acid, to reappear on adding an excess of alkali. I have noticed a peculiar smoky appearance of the urine after ad ministering large doses of gallic acid in cases of hiemop- tysis. Such urine becomes inky black on adding a little tincture of the chloride of iron. Treatment.-Haematuria being but a symptom, its radical treatment should be directed toward the removal of its cause, whether this be a neoplasm or ulcer of the bladder, an inflammation of the kidney, a vesical or renal calculus, or what not. Such measures include the opera- tions of lithotomy and nephrolithotomy, the solvent treat- ment of uric acid calculi, the removal of villous growths of the bladder, and other therapeutic procedures, both medical and surgical, which are described in appropriate sections of this work. Frequently, however, haematuria is so profuse as to render its speedy control a matter of vital importance. For this purpose, rest in bed and the application of ice-bladders over the seat of haemorrhage -to the lumbar region when the haematuria is renal; to the hypogastrium when it is vesical-are to be first em- ployed. In the latter form also, the injection of iced water into the rectum, or into the bladder itself, may be of decided service. When there is pain and spasmodic contraction of the bladder, opium should be given. The catheter should not be employed except for the purpose of overcoming obstruction to the outflow of urine caused by coagula, or for that of injecting styptics into the blad- der. For the latter purpose, nitrate of silver, one grain to four ounces of distilled water, may be used, or alum in the strength of twenty to forty grains to the pint; also the tincture of the chloride of iron, one drachm to four ounces of water. Internally, gallic acid, ergot, tincture of iron, sulphuric acid, alum, and turpentine are useful. The latter is contra-indicated when the haemorrhage is from the renal parenchyma. Besides the drugs just mentioned, the waters of the various chalybeate and alum springs have often been administered with marked benefit.- Haematuria (Endemic).-A form of haematuria de- pendent upon the presence of a parasite in the pelvis of the kidney, the veins of the ureter, bladder, or urethra, is so common in certain tropical countries as to merit sepa- rate notice. It is most commonly known as endemic haematuria, or endemic tropical haematuria, the latter be- ing the term employed by Guillemard in his interesting thesis upon the subject. The parasite was first discovered by Bilharz in the blood of the portal vein, while he was in Egypt in 1851. He gave it the name of distoma haema- tobium, but it is now known to be generically distinct ful focussing, were of a bright ruby tint. The urine was examined at intervals of a day or two until April 12th, more than a month later At that date, the urine had evaporated to less than one-third of its original bulk ; had long since become highly alkaline ; in fact it was posi- tively "gritty" with alkaline salts. Nevertheless, the corpuscles were plainly visible, and readily recognized by anyone familiar with their appearance in urine. In urine of low specific gravity the red corpuscles swell up, part with their coloring matter, and soon dissolve. The causes of haematuria have been divided into gen- eral and local. This is an improper division, and has arisen from the fact that haematuria has been, until quite recently, confounded with haemoglobinuria. (See article on Haemoglobinuria). Any cause giving rise to the es- cape of blood-corpuscles with the urine must be due to local injury or inflammation. The injury may be pro- duced by blows or falls, by tumors, or by calculi. The degree of violence necessary to rupture the blood-vessels in any portion of the genito-urinary tract, is so great, that there is generally a distinct history of its occurrence. In the great majority of cases haematuria is either of vesical or renal origin. Vesical haematuria from injury is easy of diagnosis. There are the history and, perhaps, the palpable signs of severe traumatism, such as fracture of the pelvis or wounds of the perineum or rectum. Pure blood escapes with the urine, or urine mingled with blood is removed by the catheter. Other causes of vesical haem orrhage are epithelioma, the so-called " villous growths," varix of the bladder, and calculus. Diagnostic marks of vesical haematuria are a bright red color of the blood, and when coagula are passed, a soft consistence and irregular shape of the latter. When the blood is small in amount it often escapes only at the end of micturition, the first portions of urine voided being apparently normal. Ca- tarrh of the bladder is often excited by the cause giving rise to the haematuria, or vice versa; the catarrh may have been primary and due to the irritation of ammoniacal urine, as in cases of enlarged prostate. In both instances, be- sides blood-corpuscles, the urine will contain pus-cells in abundance, bladder epithelium, and crystals of triple phosphate. It must be borne in mind that a brownish- red or blackish color of the urine does not necessarily ex- clude the bladder as its source ; it may merely indicate that the blood has remained for a long time in contact with the urine. Ultzmann has called attention to the fact that in some cases of villous growth the urine is of a light reddish-yellow color, and coagulates soon after be- ing passed. This condition has been called " fibrinuria," and is accounted for by the supposition that the blood in the villous loops is, during the frequent spasmodic con- tractions of the bladder, subjected to a degree of pressure short of that necessary to induce rupture of the vessels, but sufficient to cause abundant exudation of plasma. Among the numerous causes of renal haematuria may be mentioned embolism and thrombosis, the latter condition being favored by atheroma and calcification of the renal arteries. The collateral hyperaemia induced by these con- ditions may be sufficient to cause rupture of the vessels and escape of blood into the tubules or directly into the pelvis of the kidney. Obstruction to the return of blood through the veins caused by cardiac disease, cirrhosis of the liver, or the pressure of tumors upon the renal veins or their efflu- ents, may' give rise to renal haematuria ; also diseases of the renal vessels, especially aneurism of the renal artery or its branches. Other causes are tuberculous disease, renal calculus, and, the most frequent of all, acute parenchy matous nephritis. The latter condition is most common ly observed as a sequel of scarlatina; but is also due to exposure to cold and to the action of certain drugs, parti- cularly turpentine and cautharides. The latter substance, applied externally, has been known to give rise to fibrin uria, resulting in the formation of gelatinous coagula in the bladder, and thus causing serious obstruction to the outflow of urine. In the diagnosis of renal haematuria there are certain cap- ital points of distinction depending upon the place of exit of the blood from the vessels. If it has been gradually poured into the urinary tubules, so that there has been 456 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haematuria* Haemoglobin u ria. from the flukes, and is generally known as the Bilharzia haematobia, a name first proposed by Cobbold. The male animal is half an inch in length, white in color, and filiform in shape. The body is flattened anteriorly, but cylindrical posteriorly, the cylindrical appearance being due to the fact that the lateral borders of the worm are curved inward so as to form a gyntecophoric canal in which the female is received during congress. The fe- male is about four-fifths of an inch long, and almost cylindrical. The ova average from to inch in length, and are provided with a spine, either terminal or lateral, which is from -/0- to A the length of the ovum. The symptoms caused by this parasite are sharp pain in the urethra on passing water, and occasionally in the perineum in the intervals of micturition, and great irri- tability of the bladder. This irritability may cease, and the pain on micturition continue, so that the patient will delay emptying his bladder as long as possible. A pa- tient of Guillemard thus acquired the habit of passing water only once in twenty-four hours. With these symp- toms there is the constant passing of blood with the urine, with blood-stained shreds of mucus, in which are embedded the ova of the Bilharzia. The general disturb- ance of health is in many cases trivial. The affection is very common among boys at Natal, and is said to disap- pear at the age of puberty. In other cases the disease is attended with considerable anaemia and loss of flesh, with great irritation of the genital organs giving rise to pria- pism and seminal emissions. The ova have been often observed to form the nucleus of vesical calculi. The symptoms are due to the interference with the circulation, and the irritation caused by the ova on their way to the urinary passages. The exact mode in which this migra- tion takes place is not known. The adult animals lie in dilated blood-vessels in the neighborhood of the bladder or other urinary outlet. The mode by which the para- site gains entrance to the human system is unknown. By some it is thought to be taken in with the drinking-water, while in the cercaria stage. By others it is believed to undergo further development in an intermediate host. Finally, some hold the view that the adult animal enters the body by one of the natural orifices-the urethra and anus-and in this connection Guillemard mentions having been informed that the natives of Cambodia and Siam are in the habit of tying the prepuce while crossing rivers, in the belief that without this precaution a deadly parasite would enter the body by the urethra. Anthelmintics are useless in this affection, and opin- ions are divided as to the efficacy of intra-vesical injec- tions. A nourishing, non-stimulating diet and the free use of diluents are indicated. By way of prophylaxis, the following rules, laid down by Guillemard, should be observed by those inhabiting the countries-especially the African Continent and Arabia-infested by this dan- gerous parasite : " 1. The water drunk should come as much as pos- sible from deep wells or springs, and all shallow pools of drinking-water should be avoided. " 2. All drinking-water should be filtered and boiled. "3. Bathing should not be indulged in, excepting in the sea. "4. Watercress, fresh-water fish of all kinds, and small Crustacea, should be avoided." Other Forms of Haematuria.-Less frequent forms of parasitic haematuria are those caused by the Strongylus Gigas and the Filaria Sanguinis. The former is exceed- ingly rare in man. Of sixteen recorded cases, Davaine accepts only seven as trustworthy. The filaria is quite common in certain tropical and subtropical countries, es- pecially in China, and has quite recently acquired a new interest from the discovery, by Dr. John Guiteras, that it is indigenous to the United States {Medical News, April 10, 1886). To* the chyluria, which is the most striking symptom of the presence of this parasite in the body, is frequently joined haematuria, the concurrence of the two symptoms being indicated by the term " haemato-chy- luria." The mode of production of the haematuria is probably not the same in all cases of chyluria, but in some it is undoubtedly due to the passage of lymph-clots along the urethra, which give rise to great pain and vio- lent vesical tenesmus. Frederick P. Henry. HEMOGLOBINURIA (Haematinuria). Definition.- By haemoglobinuria is understood the presence of haemo- globin in the urine without red corpuscles, or, if these be present, they are in such small number as to bear no relation to the amount of coloring matter. Recent re- searches of Ponfick, Heinemann, and others demonstrate that the separation of haemoglobin from the red corpus- cles does not take place in the kidney, as was formerly supposed, but that it is conveyed to those organs, for the purpose of excretion, in a state of solution or suspension in the blood plasma. It is a pure excretion, not a secre- tion. Haemoglobinuria is but one, although the most striking, symptom of a well-recognized state of the blood known as haemoglobinaemia. Doubtless this blood state may exist without haemoglo- binuria, but at present the latter is the only symptom by which it can be certainly recognized, and for this reason it is given a precedence to which logically it is not en- titled, and is described as though it were an independent affection. Causes.-For many years a number of agents have been known to possess the power of producing haemoglo- binuria. Of these the chief are the transfusion of foreign blood, extensive burns of the surface, the inunction of pyrogallic acid and naphthol, inhalation of arsenuretted hydrogen, and, by the stomach, potassium chlorate and an edible fungus, the morchella esculenta. Professor Ponfick was the first to call attention to the destructive effect upon the blood-corpuscles, and the consequent hae- moglobinuria, produced by eating this substance {Berlin Klin. Woch., 1883). To the above substances may be added glycerin, toluylendiamin, anilin, and dimethylan- ilin. The last two bodies were used hypodermically by Litten, for the purpose of experimentally separating the coloring matter from the corpuscles in the living animal. Ponfick has ably investigated the subject of transfusion of alien blood, and has determined the minimum dose req- uisite to produce haemoglobinuria in the dog, cat, and rab- bit, employing in his experiments the blood of the lamb, calf, pig, rabbit, man, fowl, etc. The subject of haemo- globinuria from burns of the surface has been exhaus- tively studied by von Lesser (" Ueber die Todesursachen nach Verbrennungen," Virchow's Archit, Bd. 79), who found in the blood of animals, a few minutes after the ap- plication of heat to their integument, not only extensive alterations in shape and decolorization of the corpuscles, but also a red color of the serum. In these experiments, haemoglobin appeared in the urine in from sixty-three minutes to several hours. Von Lesser attributes the dyspnoea in cases of burns to this destruction of the red corpuscles, by which, as a matter of course, the respira- tory capacity of the blood is to a greater or less extent abolished. He compares the condition, in so far as the respiration is concerned, to that existing in cases of car- bonic-oxide poisoning, in which the corpuscles are func- tionally incompetent on account of their oxygen having been replaced by CO. (See article on Blood in vol. i. of Handbook.) Dr. Albert Neisser (Centralblatt fur die med. Wissen- schaften, July 23, 1881) has contributed an article upon haemoglobinuria resulting from the inunction of naph- thol, and refers to a case observed by himself, of a healthy man whose blood underwent fatal dissolution from the inunction of pyrogallic acid. Dr. Charles W. Allen, in an article entitled " Some of the Uses of Pyro- gallic acid in Dermatology, and the Dangers Attending its Application" (Jour, of Cut. and Ven. Diseases, January, 1886), also cites cases of haemoglobinuria from the inunc- tion of pyrogallic acid. Dr. Eitner reports the case of a professor of physics (Berlin, klin. Wochensch., 1880, p. 256) who was attacked with haemoglobinuria after inhaling hydrogen gas in order to test the statement of Tyndall, that the voice is altered in pitch after such inhalation. The cause of the affection would probably not have been discovered but for the fact that several days later, not only was he again at- 457 Hemoglobinuria. Hiemoglobiiiuria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tacked with haemoglobinuria after a second inhalation, but three assistants, who took part in this experiment, were affected in a precisely similar manner. It was then ascertained that one of the materials used in making the gas contained a considerable amount of arsenic. In the same article are references to nine miners poisoned by in- haling arsenuretted hydrogen, of whom three died ; and to four Italians, who were in the habit of filling toy bal- loons with hydrogen gas. Of the latter, one died. The gas used by these Italians was impure, as in the case of the professor of physics. Of late years the attention of the profession has been called to cases of poisoning by potas- sium chlorate, and it is now well established that the care- less use of this drug is not unattended with danger. Dr. A. Jacobi, in The Medical Record for March 15, 1879, urges the necessity of caution in its employment; and Hofmeier {Deutsche med. Wochensch., 1880) has collected twenty- seven cases of poisoning from its careless or reckless ad- ministration, all but four of which were fatal. The major- ity of them were attended with haemoglobinuria. At the International Medical Congress, London, 1881, Dr. Dresch- feld and Mr. Stocks, of Manchester, reported the case of a woman who "was suddenly seized with cyanosis and dyspnoea, and who passed masses of haemoglobin, both per rectum and per vaginam ; the urine and the vomited matter also contained masses of haemoglobin." There was jaundice on the third day, and on the fourth day she died. The only lesion found was enlargement of the spleen. The leucocytes were increased in number, but the blood-corpuscles "showed nothing very abnormal." The tubes of the kidney, both convoluted and straight, were filled with coloring matter ; but the glomeruli were perfectly intact. The patient had taken an ounce and a half of potassium chlorate in the course of twenty-four hours, for a slight sore throat. In the discussion Dr. Stephen Mackenzie confirmed Dr. Dreschfeld's statements as to the influence of potassium chlorate in producing haemo- globinuria, and mentioned a case under his own observa- tion in which moderate doses of this drug had proved fatal. The action of edible fungi in producing haemoglobinu- ria has been investigated by Ponfick and Bostroem; by the latter in an elaborate article in the Deutsches Archie fur klin. Med. (" Ueber die Intoxication durch die essbare Lorchel-Helvetia Esculenta"). The above-mentioned sub- stances are such as disintegrate the red corpuscles in any individual. For their action no personal predisposition is necessary, and, on this account, they have been exten- sively employed in the experimental study of the symp- toms and pathology of haemoglobinaemia and its results. There is, however, a well-defined disease, of which the principal symptom is haemoglobinuria, and for the occur- rence of which a marked individual predisposition is in- dispensable. It has been described by the following names, of which the first is at present most generally em- ployed : Paroxysmal haemoglobinuria, paroxysmal hae- maturia, intermittent haematuria, paroxysmal haematinu- ria, winter haematuria, etc. French writers complicate matters still further by the unnecessary employment of another adjective, as in the title of the Paris thesis of Dr. Maurice Barrion: V De ITIemoglobinurie Esscntielle Paroxystique." Historical Notice.-According to Dr. J. Wickham Legg (" St. Bart. Hosp. Rep.," vol. x.), the first recorded case of paroxysmal haemoglobinuria is that by Charles Stewart, in Duncan's "Medical Commentaries for 1794." The patient was a male, aged fifty-one, and was cured by bark, port-wine, and good diet. In such early cases it is difficult to obtain satisfactory evidence of the correct- ness of the diagnosis, and according to Dr. Legg himself, the case has only a ' ' faint resemblance " to the disease in question. In a clinical lecture at St. Thomas's Hospital, on December 19, 1831, Dr. Elliotson presented a case of intermittent haematuria, which was undoubtedly a case of paroxysmal haemoglobinuria. The man had recently suffered from the Walcheren fever, and was "laboring under frequent chills, but had not regular paroxysms of ague." . . . " The singular circumstance, how- ever, in this man's disease was, that when his paroxysms came on he discharged bloody urine." The patient was treated with sulphate of quinine, which was pushed up to ten grains thrice daily. He recovered, notwithstanding the fact that on November 24th, he was " bled to a pint, on account of a full, sharp pulse : on the 25th to another pint," and "again, on December 6th, to six- teen ounces " {Lancet, January 7, 1832). The third case on record is that of M. Gergeres. It is entitled hema- turie a type quotidien, and is contained in the Gazette Medicate de Paris, 1838, p. 151. It is a well-described, typical case. The patient was a young sea-captain, and was cured by large doses of quinine sulphate. " Ce moyen mit tin a tons les accidents et empecha leur re- tour." The fourth case is that of M. Defer, at that time (1849) physician to the hospital at Metz. It was communicated to the Societe de Biologic by M. Bayer, and was con- sidered by the reporter-Defer-as an example of ' ' inter- mittent nephritis." It was an undoubted case of parox- ysmal haemoglobinuria, and was also cured by quinine sulphate. Notwithstanding the fact that Bayer, observing that they were exceptional in several fundamental particulars, classified these and other similar cases of so-called haema- turia under the head of essential haematuria (hematuries essentielles), their true nature was not recognized until 1865, when Harley, in the " Medico-Chirurgical Transac- tions," vol. xlviii., p. 161, published the result of the first thorough microscopic examination of the blood in this dis- ease. He noted that no blood-corpuscles were to be found in the urine, and recognized the fact that it was the " hae- matoglobulin itself which was excreted by the kidneys." The appearances of the pigment casts and the granular pigment, so often observed since, are shown in this arti- cle by means of excellent engravings. According to Dr. Legg, Dressier was the first to appreciate the true charac- ter of the urinary coloring matter in this affection. Dressier's paper, entitled "Ein Fall von intermittirender Albuminurie und Chromaturie," is to be found in Vir- chow's Archiv, vol. vi., 1854. The case is an undoubt- ed one of paroxysmal hsemoglobinuria, and Dressier re- ports the absence of red corpuscles from the urine. There was, he says, much amorphous and granular dirty- brown coloring matter. The urine was faintly acid, and with nitric acid threw down a dark, flocculent precipi- tate. Although a well-described and undoubtedly genu- ine case, Dressier does not explicitly state, as does Har- ley, that the coloring matter was that of the blood. Sir William Gull was the first to observe the coloring matter in the urine in the form of crystals. In the urine of a case which was well pronounced in every feature, he ob- served numerous ' ' small prismatic crystals of haematin " ("Guy's Hosp. Bep.," 1866). This observation has since been repeated by Dr. Strang, who detected in the urine of a case under the care of Dr. Grainger Stewart a solitary haematin crystal {Brit.Med. Jour., July 20, 1878). The urine in this disease was first examined with the spectroscope by Gscheidlin, in a case reported by Secchi, in the Berlin, klin. Wochensch. for 1872, p. 237, and the characteristic absorption bands of haemoglobin detected. Clinical History.-The attack almost invariably be- gins after exposure to cold, and is ushered in by a feeling of malaise, yawning, stretching, and drowsiness, followed by chills. A sensation of weight and oppression at the epigastrium, colicky pains in the abdomen, pain in the back, and tenderness on deep pressure over the kidneys, are among the most frequent symptoms, to which may be added nausea and vomiting and intense prostration. The urine voided after these symptoms contains blood- coloring matter, and is bright red, dirty red, brown, or even black, according to the quantity of lurmoglobin ex- creted. It is usually of high specific gravity. In one of Dr. Stephen Mackenzie's cases it ranged from 1.026 to 1.037. The paroxysms often subside with profuse sweat- ing. The temperature may be normal during an attack, or much above normal. Saundby observed it as high as 105.2° F. (40.6° C.), and it reached 40.5° C. in a case re- ported by Dr. Heinemann, of Vera Cruz, in Virchow's Archiv, Bd. 102. The appearance of blood-coloring 458 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemoglobinuria, Haemoglobinuria. matter in the urine may be preceded by albuminuria. Rosenbach had the opportunity of studying the urine just before a paroxysm in a boy of seven. The father, judging from the child's behavior that an attack was imminent, took him to Rosenbach, who examined the urine and found a copious precipitate of albumen. The child had been under observation before, and the urine found to be normal. With the spectroscope it was found to be free from haemoglobin. The temperature in the rectum was 37.4° C. (99.5° F.). In a few minutes the boy began to yawn and to stretch himself, grew pale, and the hands and feet became cold.' The temperature was now 38.8° C. (101.8° F.), and ten minutes later 39.1° C. (102.3° F.). The child, who had fallen asleep, was now awakened and made to urinate. It was just twenty minutes since the first examination of the urine. About twenty cubic cen- timetres of a dark blood-red urine, of sp. gr. 1.009, were now voided, which threw down a copious precipitate of albumen, and contained a number of haemoglobin casts and hyaline casts with particles of embedded haemoglo- bin. The absorption bands of haemoglobin were obtained with the spectroscope. In a quarter of an hour the tem- perature reached 39.5° C. (103.1° F.), and then began to descend. In half an hour it was normal. Certain cases of paroxysmal haemoglobinuria, attended with extreme local ischaemia, bear a remarkable resem- blance to Raynaud's disease ; so much so that either the two affections have been confounded or there is no well- marked line of demarcation between them. Thus Dr. Fagge mentions " several instances in which the ears not only turned livid during the seizures, but failed to regain their natural appearance afterward, so that a reddish- brown eschar formed along the edge of the helix, leading to a permanent loss of its substance." In the opinion of the writer such cases belong to the category of Ray- naud's disease. Jaundice is a frequent result of the se- verer paroxysms, furnishing complete evidence of the haematogenous form of icterus. When the attack falls short of the production of jaun- dice, the countenance generally presents a sallow, so- called ' ' bilious " appearance. The rapidity with which recovery from a paroxysm takes place is remarkable. A patient may have voided urine the color of port-wine or porter, and an hour or two later it will be normal in every respect. The bodily strength is regained with al- most equal rapidity. In one of Mackenzie's cases the patient went out shooting the day after his first attack, a very severe one. Pathogeny.-Our knowledge of the true nature of paroxysmal haemoglobinuria is of quite recent date. It was formerly held that the kidneys were primarily at fault. Harley considered that the condition pointed to "intense congestion of the chylopoietic viscera of a tran- sient and periodic character." This was also the opinion of Sir William Gull. Dr. Stephen Mackenzie at one time held the view that "in the attack, owing to chilling of the surface and contraction of the cutaneous vessels, blood was driven into the renal glomeruli under such pressure that the haemoglobin was expressed from the corpuscles and excreted from the kidneys." These theories were of necessity abandoned when it was discov- ered that the separation of haemoglobin from the red cor- puscle does not take place in any particular organ, but that the serum of blood taken from any part of the body during a paroxysm is charged with haemoglobin. It is now generally accepted that the haemoglobin in the urine is a mere excretion of that which has been previously dissolved in the blood plasma, or, in other words, that haemoglobinaemia invariably precedes haemoglobinuria. Kuessner (Deutsche Med. Woch., 1879, p. 477) withdrew blood from a patient by means of cups, and found that during the attacks the serum was ruby red, while in the intervals it was of the natural clear yellow color. This experiment was repeated in six attacks with the same re- sults. The serum also gave with the spectroscope the ab- sorption bands of haemoglobin. Ehrlich (Deutsche Med. Woch., 1881) experimented by ligaturing the finger of a patient and immersing it in cold water. This sufficed in this individual, so marked was his susceptibility to the influence of cold, to bring about a condition of local hae- moglobinaemia for, in blood drawn from the finger pulp, besides numerous normal red corpuscles, there were also observed numbers of completely decolorized disks-Pon- fick's " Schatten," or phantom-corpuscles. Dr. Carl Heine- mann, of Vera Cruz, withdrew blood from a patient by means of a cupping-glass applied to the thorax, and ex- amined it under the microscope. All the corpuscles were found deprived of their coloring matter and swam as pale colorless disks in a deeply colored plasma. They were all diminished in size, their rounded border having appar- ently been partially melted away. Ten preparations were examined with identical results. The result of this separation of haemoglobin from the body of the corpuscle is that the substance which we are accustomed to regard as the most vital becomes a foreign body to be discharged by the excretory organs. How is this depurative process accomplished ? In that form of haemoglobinaemia due to the breaking up of the corpus- cles into fragments, as in the case of burns, the spleen, according to Ponfick, is the organ chiefly concerned in their removal and destruction. The result of this abnor- mal activity is a swelling of the organ, which may form an easily perceptible tumor. In that form of haemoglo- binaemia in which the corpuscles retain their shape, the haemoglobin being, as it were, extracted from them, the displaced coloring matter is more difficult to get rid of. The organ chiefly concerned in its removal is, not the kidney, as one would naturally suppose from the promi- nence given to haemoglobinuria as a symptom, but the liver. It is a normal function of the liver to convert the coloring matter of the blood into that of the bile, and in cases of haemoglobinaemia the activity of this function is greatly increased, as manifested by the blackish-brown color of the faeces. This compensatory action of the liver has its limit, which is reached, according to Ponfick, when the amount of haemoglobin to be separated is more than one-sixtieth of the total amount in the blood. When the quantity is greater than this, blood-coloring matter makes its appearance in the urine. To the hypercholia is added haemoglobinuria. Litten (Deutsche Med. Woch., 1883, No. 50) has confirmed the statement of Ponfick, that considerable quantities of haemoglobin may be dissolved in the plasma without a trace of haemoglobinuria, by finding a normal urine in an animal whose blood serum was colored a deep ruby red and gave the spectrum of oxyhaemoglobin. He compares this condition with that in which there may be more than a normal amount of sugar in the juices and organs without glycosuria. There are great differences in regard to the constancy of haemo- globinuria as a symptom of haemoglobinaemia. In some of his experiments Litten found that this symptom ap- peared soon after the administration of a haemoglobin- dissolving substance, and continued as long as the haemo- globinaemia lasted ; while in others, although the haemo- globinaemia continued several days, haemoglobinuria was of only occasional occurrence during that time. In none of his experiments, however, was the urine free from hae- moglobin during the entire period of haemoglobinaemia, although the haemoglobinuria might be so slight as only to be detected by the spectroscope and chemical tests. With reference to the fundamental nature of paroxys- mal haemoglobinuria, it can only be said that the union between the haemoglobin and the substance of the red corpuscle is more readily dissolved than in health ; and, even in this disease, the tenacity of this union is very va- riable. Thus, in some cases, the mere immersion of the finger in iced water will bring on a paroxysm, while in others it will only follow prolonged bodily exposure to severe cold. Anatomical Characters.-Macroscopically the blood presents certain striking peculiarities. Although it leaves the arteries of a bright red color, it soon changes to the color of cafe an lait or chocolate, and, if exposed to the air, may assume the appearance of a fat emulsion, al though microscopically entirely free from fat. Micro- scopically, besides the decolorized phantom-corpuscles, Ponfick's Schatten, it contains numerous morphological constituents resembling the endothelium of the vessels, 459 Haemoglobinuria. Haemophilia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and Litten queries whether these cells are due to the ac- tion of the free haemoglobin upon the intima of the ves- sels. Haemoglobin does not begin to be excreted by the kidneys until certain changes, due to the elimination of this substance, have taken place in other organs. The first of these is intumescence of the spleen, first observed by Ponfick in dogs poisoned with morchella esculenta, and confirmed by Litten in his experiments on rabbits. The remains of broken-down and decolorized corpuscles were found in large numbers in this organ by Litten, as well as large protoplasmic cell-like masses in which were embedded round yellowish-red drops of various size, which were undoubtedly haemoglobin. They were col- ored a deep red by eosin, and brown by osmic acid. If the haemoglobinaemia is of slight degree, the splenic swelling may be the only lesion, but if more severe the liver is next involved. Fragments of broken-down cor- puscles are detained in this gland, and may be seen in its capillaries. These and the dissolved haemoglobin are converted into biliary coloring matter. An increased produclipn of bile is manifested by injection of the bile capillaries, and by the dark color of the faeces. The third organ to participate is, according to Litten, the bone-marrow. The same large protoplasmic cells, con- taining drops of haemoglobin and fragments of broken- down corpuscles, are here also found, and the marrow exhibits a red hyperplasia. The kidneys, finally, are im- plicated. The descriptions of the changes in these organs are very various, and the discrepancies are due to the varying degree of haemoglobinaemia in each case. In the milder forms, in which the urine is transparent and col- ored a more or less deep red, the excretory function of the kidney may be not materially impaired ; but when more severe, the urine is of a brownish tinge and depos- its a copious sediment, and there may be an enormous ex- cretion of haemoglobin, plugging the tubuli to such an extent as to lead to complete anuria. Litten has never, like Ponfick, seen haemoglobin in crystalline form in the tubuli, and attributes this discrepancy to the smaller doses of cythaemolitic substances employed in his experi- ments. The question of the part of the kidney, the par- ticular cells, concerned in the excretion of haemoglobin, is an interesting one. Litten does not deny the appear- ance of haemoglobin in the space between the glom- erulus and its capsule, but has often failed to find it there, and thinks this mode of excretion insufficient to account for the large quantities which pass out with the urine. He is inclined to attribute the larger share in the process to the epithelium of the convoluted tubes. This is also the opinion of Lebedeff, who has minutely studied this question, and given the results of numerous experi- ments with cythaemolitic substances upon animals, in an elaborate article in Virchow's Archiv, Bd. xci., 1883, en- titled, "Zur Kenntniss der feineren Veranderungen der Nieren bei der Hamoglobinausscheidung." This author found coagulations in the space between the glomerulus and its capsule. They were of semilunar form, contained numerous vacuoles, and were without distinct color. The epithelial cells of the glomeruli were without any perceptible alterations. The epithelium of the looped tubes and of the collecting tubes were either unaltered or, if alterations from the normal were found, they con- sisted of simple flattening, and were evidently due to pressure from the contained cylinders of haemoglobin. The changes observed in the epithelium of the convoluted tubes were identical with those found in cases of acute nephritis, and consisted chiefly of swelling of the cells, which also contained numerous vacuoles. In many por- tions that part of the cell turned toward the lumen of the tube, i.e., the free portion, seemed to have been dissolved away, sometimes with escape of the nucleus ; at others the nucleus retained its connection with the attached por- tion of the cell. The changes which ensue in the kidney after recovery have been studied by Litten, who pre- served some of his animals for this purpose. In one case there was complete restitutio ad integrum. In another, after three weeks, there were found cylinders of haemo- globin in the tubes, above which were marked dilata- tions. In a third there were small indentations on the surface of the kidney corresponding to groups of com- pressed tubules. The tubes were blocked up with hae- moglobin cylinders to a great extent, and above these pluggings there was decided cystic dilatation. There was also considerable round-celled infiltration of the inter- stitial substance. Etiology.-The most important predisposing factor is sex. Dr. Legg states that, of the cases of paroxysmal haemoglobinuria on record, only one had, up to the date of his paper (1874), been in a female. This case is re- ported by Greenhow in the "Trans. Clin. Soc." vol. i. Other undoubted predisposing causes are malaria and syphilis. It is most common among adults, although it has also been described as an epidemic among new-born children. The most common exciting cause is exposure to cold, hence the term winter haematuria. Diagnosis.-The microscope does not suffice for the diagnosis of haemoglobinuria as it does for that of haema- turia. The absence of blood-corpuscles in a bright red, dirty red, brown, or black urine will naturally give rise to a strong suspicion of haemoglobinuria, and, taken in connection with certain facts in the history of the case, may furnish evidence that is practically conclusive ; but it must not be forgotten that such colors may have been imparted to the urine either accidentally or for the pur- pose of deception. The diagnosis can only be positively made by the spectroscope, and by certain chemical tests. The spectrum of haemoglobin or methaemoglobin (see vol. i., article Blood) will be obtained by the former. Of the latter, Heller's test, and what is known as the guaiacum test, are usually employed. Heller's test depends upon the reaction produced by boiling urine to which caustic soda solution has been added. " The earthy phosphates precipitate and entangle as they settle, the haematin (re- sulting from the decomposition of the haemoglobulin), which is thus carried in the sediment to the bottom of the tube, and presents sometimes a brick-dust, and at other times a bright-red, color, the fluid often exhibiting a di- chroistic green color to reflected light." The guaiacum test is applied by "adding to a small quantity of urine a drop of freshly-prepared tincture of guaiacum, and shaking it up with a few drops of ozonic ether." If blood (or its coloring matter) is present, a " bril- liant blue color appears in the layer of ether that collects on the surface of the fluid when it has stood for a moment or so." As is the case with so many chemical tests for organic substances, there are sources of fallacy with both of these. With the first, rhubarb and senna will give the same reaction as haemoglobin ; and with the second, the same is the case with regard to saliva, nasal mucus, and iodide of potassium. In cases of haemoglobinuria, strict inquiry is to be made with regard to the possible ingestion or inhalation of such substances as are known to be destructive of the red corpuscles. A list of the chief of these has been given in the first portion of this article. Paroxysmal haemoglobinuria, as above stated, almost invariably follows prolonged exposure to cold, so that in the great majority of cases inquiries concerning the recent employment, or amusement, of the patient suffice to elicit the true nature of the attack. There are cases on record, however, in which mental emotion of a de- pressing nature appears to have been the exciting cause. Haemoglobinuria may be complicated with hematuria, or the latter may be mistaken for the former, even by a careful observer. We have no knowledge of the escape of the red corpuscles from the vessels, except as the re suit of inflammation or traumatism ; therefore, when blood-corpuscles are found in the urine, but in such scanty numbers as to be utterly inadequate to account for the deep, perhaps porter-like, hue of this fluid, the case is either one of haemoglobinuria complicated with haema- turia, or one of pure haematuria, the blood-corpuscles having been dissolved to a great extent on account of the low specific gravity or alkaline reaction of the urine. Prognosis.-Notwithstanding the alarming nature of an attack of paroxysmal haemoglobinuria, it has never, according to Fagge, been known to destroy life. A malignant, malarial form is, however, met with in the 460 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemoglobin u ria. Haemophilia. southern portion of the United States, in which, with aggravation of all the symptoms above described, death commonly occurs in from twenty-four to sixty hours. In respect to prognosis, it is radically different from the haemoglobinuria produced by chemical substances, for although cases of the latter variety are not sufficiently numerous to furnish accurate statistics of mortality, yet enough is known to warrant its being regarded as always of grave import. The occurrence of jaundice in this form is of ominous significance, for it demonstrates the incapacity of the spleen, liver, and kidneys to eliminate the large amount of haemoglobin set free from the corpus- cles. Its gravity as a symptom may be reckoned by the time of its appearance. The earlier it appears, the graver the prognosis. In the paroxysmal form, predictions with regard to future attacks are to be made with great caution. As a rule, unless the case promptly yields to treatment, attacks are liable to recur on every fresh exposure to cold ; nevertheless, without apparent reason, years may pass without a paroxysm. Thus, in one of Mackenzie's cases, the first attack was excited by prolonged exposure to cold while rigging a vessel. Fresh attacks recurred at short intervals, ami then, although constantly exposed to the vicissitudes of the weather, a period of eighteen years passed by without a paroxysm. In January, 1883, an attack was induced by exposure on a very cold day. Treatment.-The treatment of the chemical form consists in the administration of the proper antidotes to the poisons inducing it, and need not be here considered. In the treatment of the paroxysmal form much may be done in the way of prophylaxis by wearing warm woollen underclothing, warm stockings, and gloves. Exposure to the morning air before breakfast should be sedulously avoided. Removal to a warm climate during the winter season is to be recommended, and when this is impracti- cable, a change from outdoor to indoor occupation. Stim- ulants are to be avoided, the inevitable depression which follows their administration rendering the patient still more vulnerable to cold. Among drugs, quinine occupies the first rank. It must not be forgotten that the first recorded cases, namely, those of Stewart, Elliotson, Gergeres, and Defer, were all cured by this substance. It should be always given the first trial unless there is a clear syphilitic history, in which case potassium iodide and mercurials are, of necessity, indicated. Under no other circumstances should mercurials be employed. In the absence of a history of syphilis, and after the failure of quinine to effect a cure, arsenic is to be exhibited. Dur- ing a paroxysm the patient should be put to bed and warmth applied to the extremities. Pain in the abdomen and back may be relieved by sinapisms or dry cups, or, these failing, by an opiate. Nourishment in the form of hot soup should be administered. Alcoholic stimulants had better be withheld during the paroxysm, unless the prostration, as indicated by the pulse, is extreme. Frederick P. Henry. ture. The early writers first demonstrated its hereditary nature. In the second and third quarters of this century the Germans were prolific workers. Nasse, Rieken, Schon- lein, and others, were of the earlier writers. Wachsmuth's monograph, Lange's statistics, Virchow's complete de- scription in his " Handbuch," the monograph of Grandi- dier, the most complete published, and the article in " Ziemssen's Handbuch," by Immermann, familiarized modern German physicians with the affection. The ex- haustive monograph of Legg is the principal contribution made by any English physician. Etiology.-Sex and heredity are the most important factors in the etiology of haemophilia. It occurs with greatest frequency in the male, the ratio having been put as high as eleven males to one female. Females do not usually present typical cases, and danger to life is less in the latter sex. Hereditary disposition is so essential that its absence in a supposed case is sufficient to negative the diagnosis, al- though, it is true, it is difficult, often impossible, to trace genealogy among the lower classes. Legg believes all or nearly all cases may be traced to an hereditary origin. It has been suggested that this hereditary tendency is the result of the intermarriage of near relations. The fact that it occurs largely among Germans and Jews favors this argument, for in both classes such marriages are common. A common ancestry for all bleeders has been assumed by some authors. While the females are not the bleeders of a haemophilic family, the disposition is transmitted through them. The mother, not a bleeder, will transmit the tendency to her sons. They in turn are not likely to conduct the disease to their children, but the tendency passes through the daughters to the grandson. The females that transmit the tendency are usually in perfect health, although cases have been reported, in rare instances, in which the mother, a bleeder, transmitted it to the children of both sexes. The cases are still more rare in which the father, a bleeder, will pass down the tendency to either the sons or the daugh- ters, respectively. A male non-bleeder, in a haemophilic family, seldom transmits the disease to his descendants, Transmission through the female line is the rule. It is said that the first-born of a family are less liable to be- come bleeders. This tendency to bleeding may continue for many generations. The Clitherow family, reported by Legg, have exhibited the tendency for two hundred years. The families of Tenna, Switzerland, trace the dis- position through five generations. One peculiarity of bleeder families that has been noted is the marked intellectual power of the individuals ; an- other, the great fertility of the families. Although they have many children, few reach adult age, as the number is much lessened by death from haemorrhages in early life, the mortality at that period being very great. The disposition to bleed, Grandidier believes, may grad- ually be lost in a family. He has himself seen one such example, and another has been reported by Legg. It was noted above that among Germans haemophilia is common. In fact, some think it a disease peculiar to the Anglo-Germanic races. Dunn's analysis of 219 fami- lies shows its distribution about as follows : Germany, 94; Great Britain, 52 ; North America, 23; France, 22; Prussia and Poland, 10 ; Switzerland, 9; and the re- mainder in other European countries. Haemophilia spares no social class, though cases are reported more frequently from the middle and lower classes. Its presence or absence is not influenced by geo- graphical position, and the nature of the food is also with- out effect on it. While it has been asserted of many cases of haemo- philia, that they arose spontaneously, yet nothing is known of the circumstances contributing to their origin. Legg rightly criticises the case of Mutzenbecher, in which the disease was reported to have arisen de novo. A mother, suckling her child, received a great fright, after which the child nursed. Shortly afterward symptoms of haemophilia developed. Two other sons, also bleeders, were subsequently born, a fact which renders very prob- able the hereditary transmission in this case. H/EMOPHILIA. Synonyms.-Haemorrhagic Diathesis or Idiosyncrasy, Haemorrhaphilia, Haematophilia, Hered- itary Haemorrhage ; Ger., Hdmophilie, Blutenkrankheit, Blutsncht, Blutungssucht ; Fr., Hdmophilie. Otto, an American physician, gave the name Bleeder (Ger., Blutej'; Fr., Homme saignant) to an individual patient. Definition. -An hereditary and congenital disease, characterized by a tendency to frequent, obstinate, and prolonged haemorrhages, external or interstitial, spontane- ous or traumatic, associated with swelling of the joints. History.-Our knowledge of this disease is modern. Its historians have been able to find the records of but few probable cases or families prior to the present cen- tury, and even these, with the exception of the cases re- ported by Hochstetter and Sir W. Fordyce, may all be considered doubtful examples, and Legg cannot admit Ban- yer's case to be beyond doubt. It was left for American physicians to accurately fix the characteristics of the dis- ease. Otto, E. II. Smith, Hay, the Buel Brothers, and Coates, in the early part of the century, and Hughes, Gould, Harris, Hutchinson, Holton, and Dunn, in the past thirty years, have been the chief contributors to its litera- 461 HHemophilia. Haemoptysis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The circumstances, aside from traumatism, influencing the occurrence of haemorrhage, or which may be the pre- disposing or exciting causes of the accident, in a person belonging to a haemophilic family, are the age, the consti- tution, and the temperament of the individual ; the time of day, the season of the year, and the climate. Haemor- rhages have not appeared for the first time after the twenty-second year ; it is rare for them to appear after the twelfth year, and in the larger number of instances the first attack occurred before the fifth year. Its most usual appearance is about the end of the first year. Hae- morrhage from the umbilicus, after sloughing of the cord, is very rare. Bleeders are always in good health, except that they suffer from anaemia, They often have blue eyes, light hair, a thin skin, and prominent veins. Instances are recorded in which the haemorrhages oc- curred most frequently at night, and the winter season and a cold, damp climate favor attacks of haemorrhage. Symptoms.-The occurrence of frequent, obstinate, and prolonged haemorrhages, spontaneous or traumatic, with their sequelae, and the joint manifestations, are the essen- tial symptoms. Legg makes three degrees of haemophilia : in the first form, the most typical and severe, there is a tendency to every kind of haemorrhage, spontaneous or traumatic, in- terstitial or superficial. The joint swellings are also marked. In the second form, spontaneous haemorrhages only are present, with rheumatic pains. In the third de- gree spontaneous ecchymoses alone are observed. The first degree is most often seen in men, the second in women, and the third in members of bleeders' families. External Hemorrhages.-They are usually capillary. Even a traumatic haemorrhage is of that nature. In one case (Blagden's) a vessel which had been ligated soon gave way on account of the thinness of its coats. One of the cases reported by Dunn had an ulcer in the nos- tril, from which the spontaneous haemorrhages would spring. Spontaneous haemorrhages are often preceded by pro- dromal manifestations. These are usually the symp- toms of plethora or nervous symptoms. In children great cheerfulness and liveliness, attacks of crying, morbid fears, and even convulsions, have been noticed. In adults, a good temper, with great restlessness and sensitive emo- tions, are seen. Pain is often complained of in the local- ity in which the haemorrhage is about to occur. These prodromal symptoms disappear after the haemorrhage sets in. The seat of the haemorrhage in the spontaneous form varies with the age-in childhood, the nose and mouth are the most frequent localities; in adult life, they also occur in these situations, and quite frequently from the stomach, the bowels, the urethra, the lungs, the female generative organs, etc.* The frequency of occurrence of spontaneous haemor- rhages varies. They may occur daily, or at intervals of days or weeks. Resal (Legg) points out two forms of spontaneous haemorrhages. In one they are small in quantity, but frequently repeated, occur without prodro- mal signs, and always from the same mucous surface. In the other form there are prodromes, the haemorrhage is excessive, and does not usually cease spontaneously. Just as it is impossible to estimate the usual frequency of oc- currence, so it is difficult to calculate the length of time the haemorrhages may continue. It is variable, from a mo- ment to weeks, the latter with varying intermissions. Epis- taxis is the most fatal of all forms of spontaneous hae- morrhages ; it has proved fatal in twenty-four hours. Traumatic haemorrhages are due to blows, cuts, scratches, etc. Even after the most trivial operation the haemor- rhage may be fatal. The amount of bleeding from a wound varies in bleeders from time to time-at one time scarcely any haemorrhage will be observed ; at an- other, with the same wound, the bleeding can scarcely be checked. So, too, families appear to differ as to the extent of injury they can suffer with impunity. In one family venesection can be performed ; in another the ap- plication of blisters would be dangerous (Legg). A superficial lacerated wound is thought to be more serious than a deep, clean-cut one. The healing of a wound may occur with or without suppuration ; a profuse bleeding, when it occurs, will prevent healing by first intention. The amount of blood lost by either form of haemor- rhage is sometimes enormous. The famous case of Coates lost half a gallon in twenty-four hours, and three gallons in ten days. Thore's case (Legg), a boy, aged five, lost nearly a pound from a small wound. The result of these repeated haemorrhages is a profound, and often fatal, anaemia. Digestive troubles also often develop afterward, and in some cases a depraved appe- tite has been observed (Buchs). Ecchymoses and Petechia, Interstitial Hemorrhages.- They may be spontaneous or traumatic. The spontaneous varieties may occur without external bleedings, or may precede a haemorrhage. They are seen in early child- hood. They are similar in appearance to purpura, and are seated chiefly on the trunk and limbs. They vary from a pin's head to a quarter of a dollar in size, are ten- der on presslire, and on disappearing pass through the same changes that an ordinary traumatic ecchymosis does, and exhibit the same play of colors. The traumatic ecchymoses are larger than the spontaneous; they may cause death by haemorrhage into the connective tissue. Blood-tumors-haematomas-may follow the slightest blow. They may become as large as a child's head, and are of a bluish-black color. By some authors it is thought they may arise spontaneously. Joint Affections.-Legg believes that the joint affections are sometimes due to traumatism. In other instances the origin is idiopathic, the exciting causes being exposure to cold or dampness, and variations in temperature, particularly in the spring and autumn. The larger joints, chiefly the knee-joint, are the ones affected. They become painful, hot, much swollen, soft, and boggy. Often the affection develops suddenly. Marked constitu- tional symptoms, as fever, anorexia, and general pains, attend the attack. The pain is increased by motion. The duration of the affection varies from a few days to many months. It may change from joint to joint, or the swelling may alternate with a haemorrhage. Once af- fected, the patient is liable on the slightest provocation to have a recurrence of the disease. Repeated attacks may lead to destructive lesions in the joints, with crippling and deformity. Persons affected with haemophilia often suffer from general rheumatic pains, which vary in degree with at- mospheric changes. It is said that some bleeder families are very sensitive to cold and dampness, and that bleeders are very suscep- tible to the action of mercury. They are not differently affected by various diseases than are non-bleeders. ' ' They appear more liable to acute affections within the chest " (Legg). Rheumatism and scrofula are said to occur fre- quently ; gout is very rare. Gangrene is especially liable to occur after traumatic haemorrhage. The blood is usually normal. After a profuse haemor- rhage or a series of small ones, it partakes of the nature of the blood of anaemia. The white corpuscles have been found in excess under these circumstances. The salts are said to have been increased. Morbid Anatomy.-There are no characteristic ana- tomical changes. Blagden called attention to the thin- * The following statistics are interesting, mainly from Grandidier, also quoted by Legg, and by Osler. Spontaneous Haemorrhages-localities and frequency: From the nose, 169 times ; the mouth, 43 ; stomach, 15; bow- els, 36; urethra, 16; lungs, 17 ; cerebral haemorrhage, 2; swollen place on scalp, 4; tongue, 4: finger-tips, 4; ear, 5; eyelids, 2 ; tear-papilla, 3; female generative organs, 10 : ulcer of skin, 2; navel (long healed), 2. Fatal haemorrhages have occurred from the following wounds : Blow on head, 11 times ; slight scratches on skin or abrasion of dermis ; laceration of franum of the lip ; slight cut in a duel wound ; bite of the tongue (7 cases); fall on the mouth ; blow on the nose ; blow of a stone on the finger: cut in paring the nails; fall on the head with meningeal haemorrhage (2 cases, brothers): and rupture of the hymen on the wed- ding night. Deaths after operations: Cutting of fraenum linguae, 1; leeching, 5 : venesection, 4; blister, 2; extraction of tooth, 12; circumcision, 8: cut- ting umbilical cord, 4 ; vaccination, 2; fistula, stone, ligature of carotid, of radial, of ulnar, of femoral arteries, amputation of arm and of thigh, 1 each : phimosis, 2. 462 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemophilia.. Haemoptysis. ness and transparency of the vessels. One observer found the large vessels smaller than normal; another, an increase in the size of the superficial, in proportion to the central vessels (Immermann). Wilson thought that the arteries resembled the veins. Fatty degeneration of the heart has been found. Kidd observed proliferation of the endothe- lial cells in small arteries and veins, and "hydropic degen- eration " of the muscular fibres. Klein, Ackland, and other observers fail to confirm these studies. The joints, when involved, are the seat of blood extravasation ; not only the cavity but the tissues around are infiltrated. Inflamma- tion, and subsequently erosion and destruction of carti- lage, may take place after a time. Pathology.-This is obscure. While a congenital fragility of the vessels is said to exist, it has never been proven. It has been observed that bleeders always suffer from prodromic symptoms, which are due to an increase in the volume of the blood. Hence,'variability in the volume has been invoked as causal. Disturbed innerva- tion, diminishing from time to time vascular tone, is thought by many to be the pathological factor. It is merely an hypothesis, as have been all suggestions thus far put forward regarding the pathology of haemophilia. Diagnosis.-Many cases of a haemorrhagic diathesis occur, the exact nature of which it is difficult to deter- mine. Especially is it so with this diathesis in women. If, however, there is no history of heredity, if the haemor- rhages did not occur in early life, prior to twelve years, and if she should not transmit it to her sons, it is not likely to be a case of haemophilia. The hereditary predis- position, the spontaneous and traumatic haemorrhages setting in early in life, and the joint symptoms, are conclu- sive evidence of the nature of a case. Cases arise, no doubt, in which heredity cannot be determined, and which may yet be the founders of a stock of bleeders. One of the writer's cases is possibly of this class. Since the age of five months spontaneous bleedings, often to syncope, have occurred ; since puberty (the patient is now twenty- two years of age) plethoric prodromes have preceded the attacks. The patient undertook to learn carpentering, but had to give it up on account of the traumatic haemor- rhages. Extractions of teeth have caused serious haemor- rhages. Annually the patient is afflicted with severe joint symptoms, rheumatic in character. Umbilical haemorrhage in the new-born is not due, or but rarely, to haemophilia, but is usually the result of liver disease or syphilis. Purpura, simplex and haemor- rhagica, scurvy, peliosis rheumatica, toxic aud septic pur- pura, must be excluded. Prognosis.-The first bleeding is rarely fatal. The younger the patient, the more grave the prognosis. Hae- mophilia is more serious in boys than in girls, and more so in the delicate than in the strong. With advancing years the prognosis improves. Often, especially if the patient suffer from joint complication, the tendency to haemor- rhage may disappear for a number of years. Long-con- tinued oozing is a serious form of haemorrhage. The bleeding after the extraction of a tooth is very serious, as is also the haemorrhage from lacerated and contused wounds. Face injuries are also serious. Treatment.-If a person suffering from haemophilia present the symptoms indicative of an attack of haemor- rhage, an active purgative should be administered and the patient put on low diet without stimulants. Often an attack is averted thereby. Otto advised the sulphate of soda; Fordyce, the sulphate of magnesia. Venesection has been resorted to under similar circumstances. If a spontaneous haemorrhage occur, opinions differ, whether to check it or not is advisable. Wachsmuth, Legg, Frish, and others claim that apoplectic symptoms or grave dys- pnoea may arise if it is checked. The latter author advo- cates venesection. It is certain, if the haemorrhage is not too profuse, a bleeder always feels better after it. When it is decided to check the haemorrhage the method of treatment depends largely on the seat of the bleeding, and is similar to the plan adopted in the traumatic varieties if it arise from external parts. Internal remedies are more frequently required in the spontaneous form, but are used in both. Ergot or ergotine, the latter by mouth or hypoder- matically, hamamelis, gallic acid, opium, alum, turpen- tine, and preparations of iron, have been used with ben- efit. Legg recommends the tincture of the perchloride of iron, thirty to forty minim doses, every two hours, together with a purge if there is no intestinal haemor- rhage. Transfusion may be resorted to when external and internal remedies are used without avail. The principles that govern the treatment of any trau- matic haemorrhage apply in a case of haemophilia. A few of the usual methods must be modified as follows : Liga- tion of the artery should never be performed ; the actual cautery should be used as a last resort only ; care in exer- cising pressure should be used on account of the possibil- ity of ecchymoses and sloughing taking place ; plugging of the nares should only follow failures to control bleeding by other means. The wound should be cleansed, rest se- cured, compression used, the artery pressed upon if pos- sible, cold, and especially ice, or very hot water, applied to' the bleeding parts, and finally, styptics, as the astringent salts of iron, preferably Monsel's solution, the nitrate of silver, alum, and other well-known astringents should be tried. The famous styptic of Pancoast is a clean and most efficient application. A haemorrhage from the ex- traction of teeth may be controlled by the means indicated above, by replacing the tooth in its socket, by taking a plaster of Paris cast of the jaw, by retaining the jaw in posi- tion by a roller bandage, or finally by the cautery. Traumatic haemorrhage must be prevented by avoiding all surgical operations on a person affected with haemo- philia, unless life is in peril, and by preventing him from engaging in any occupation in which he is liable to re- ceive an injury. A tooth should not be extracted under any circumstance. In the interval between the haemorrhages the patient should use a generous but non-stimulating regimen, should live in the fresh air, should avoid exposure to cold and dampness, and should be free from all excitement. Iron and cod-liver oil should be used, unless plethora should ensue. I am confident that the prolonged use of the Rock Bridge alum water, of Virginia, has been of service in my cases. Haemorrhages did not occur so frequently nor so profusely. Surgical principles must be invoked in the treatment of the joint affections. Residence in a damp locality, or exposure to cold and dampness is particularly likely to cause and aggravate these complications, if they are obstinate, a warm, dry climate must be sought after. The marriage of the daughters of a family of bleeders should be prohibited. In this way only can the advance of the disease be checked. If the brothers are marked subjects of the disease their marriage should be prevented. J. H. Musser. H/EMOPTYSIS. Etymologically considered, the word haemoptysis signifies the expectoration of blood, without regard to its source or quantity. Practically, however, the term has come to indicate the expectoration of pure, or of almost pure blood, emanating from the respiratory organs, viz., from the larynx, trachea, bronchi, or lungs. The expectoration of rusty, prune-juice, or greenish sputa, in pneumonia ; of blood-streaked sputa in bronchitis ; of jelly-like masses, as in cancer; or of chocolate-colored ma- terial in hepatic abscess, does not, therefore, properly con- stitute an example of haemoptysis in the ordinary accep- tation of the word. The term is, however, applied by some authors to the expectoration of blood in sufficient quantities to be microscopically discovered, even if the sputa containing it be largely composed of other constit- uents.1 The spitting of blood which, having been extra- vasated at points more or less remote from the respiratory organs, and having reached the pharynx, has gravitated into the air-passages (as in haematemesis, and in buccal, oesophageal, or nasal haemorrhages), may be designated as pseudo-haemoptysis or spurious haemoptysis. The ex- pectoration of blood follows bronchorrhagia and pneu- morrhagia in so large a proportion of cases that only haemoptysis due to these causes will be considered in this place, the reader being referred, for information regard- ing laryngeal aud tracheal haemorrhages, which are com- 463 Haemoptysis. Haemoptysis. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. paratively rare, to the articles in this Handbook treating of diseases of the larynx and trachea. An absolute discri- mination between bronchial and pulmonary haemorrhage being very difficult, and of slight importance from a thera- peutical standpoint, will not be insisted on in the present article. Etiology.-The etiology of haemoptysis embraces re- mote or predisposing, and direct or exciting causes. An exact discrimination between these two classes of etiolog- ical agents is, however, sometimes impracticable because certain conditions may simultaneously act both as predis- posing and as exciting causes. I. Remote or Predisposing Causes.-This class of causes comprises all pathological conditions tending to gradually diminish the resisting power of the pulmonary or bron- chial vascular walls, thus rendering them more liable than healthy blood-vessels to rupture under the influence of exciting causes. These diseases of the vascular walls are: 1, Chronic arterial hyperaemia; 2, chronic venous hyperaemia ; 3, certain obscure vascular degenerative changes, either congenital or incident to depraved blood states, in the infectious diseases and the dyscrasiae; and 4, degenerations of a special, non-inflammatory character. 1. Chronic arterial hyperaemia of the vascular tunics may depend upon protracted bronchitis, peribronchitis, lobular pneumonitis or interstitial pneumonitis, whether of simple or of tuberculous origin. Haemoptysis occur- ring as the initial symptom of pulmonary tuberculosis, which disease is its cause in the overwhelming majority of cases, as well as that which takes place during phthis- ical consolidation is, according to Rindfleisch,2 chiefly referable to a tuberculous degeneration of the tunicae in- tima et media, with which process inflammation, of course, coexists. Jaccoud3 refers the haemorrhages oc- curring under these circumstances to collateral hyper- aemia due to the obstruction of pulmonary capillaries by growing tubercular nodules. Carson4 states that a suffi- ciently uniform correspondence has been established be- tween the percentages of hereditary phthisis and of hae- moptysis, in these hereditary cases, to prove the causative influence of phthisis upon pulmonary haemorrhage. Hae- moptysis which happens while excavation is progressing in phthisis, pulmonary abscess, or gangrene, in bronchiec- tasis and during the growth of neoplasmata, as hydatids, cancer and sarcoma, is either the result of involvement of the vessels in a general ulcerative process, or of the burst- ing of miliary pulmonary or bronchial aneurisms. These aneurisms owe their origin, in turn, to chronic inflamma- tion or atheroma of the vascular "walls, and, when devel- oped in cavities, partly to a failure of the support afforded the vessels by a healthy pulmonary parenchyma. 2. Venous Pulmonary Hyperaemia. Chronic passive pul- monary hyperaemia is incident to many uncompensated organic cardiac diseases. Chief among these are mitral obstruction and insufficiency, fatty and parenchymatous degeneration, myocarditis and pericarditis, which diseases lead to dilatation or enfeeblement of the right heart. Pressure from tumors, such as enlarged bronchial glands,5 may also occasion mechanical pulmonary hyperaemia. One effect of passive congestion is the production of cer- tain undetermined trophic disturbances in the vascular walls which yield to the increased intra-vascular tension and permit of haemorrhage by rhexis or by diapedesis. Another result of venous hyperaemia is the formation of thrombi in the right auricle and ventricle, which, occa- sioning pulmonary embolism, induces that form of pul- monary haemorrhage known as haemorrhagic infarction (quod ride). Emboli derived from marantic thrombi in the veins of the extremities; from puerperal uterine or ovarian thrombi; from thrombi in the cranial sinuses, and from many other sources may each produce pulmon- ary haemorrhagic infarctions, as may also, more rarely, fatty emboli, which find entrance to the patulous veins of fractured bones. 3. Unknown Trophic Vascular Changes in Dyscrasiae and in Infectious Diseases. The existence of these path- ological processes, although not demonstrated, may be rationally assumed. Haemoptysis has been observed in cholaemia,6 haematophilia, purpura, scorbutus and melan- aemia. The acute infectious diseases occasion haemopty- sis more rarely than the dyscrasiae just enumerated. A list of these diseases which may occasionally be compli- cated by haemoptysis can be found under the heading Etiology, in the article on Haematemesis. 4. Non-inflammatory Degenerations. Amyloid, fatty, and syphilitic degenerations of the arteries anil varicosities of the veins may, finally, be mentioned as possible pre- disposing causes of bronchial and pulmonary haemor- rhages. Haemoptysis is most frequent between the ages of fifteen and thirty-five, and men are more often its vic- tims than women. II. Director Exciting Causes.-These etiological agents occasion haemoptysis either (a) by suddenly augmenting the intra-vascular tension to such an extent that the ves- sels are unable to resist the blood-pressure, or (6) by sud- denly producing solution of continuity in the vascular walls. (a) A degree of arterial tension, sufficient to rupture damaged pulmonary or bronchial vessels, may be pro- duced by any cause of arterial hyperaemia or of acute in- flammation. As examples of these causes may be cited violent physical exertions, such as running, riding, danc- ing, lifting, paroxysmal coughing and loud speaking ; mental perturbation; greatly diminished atmospheric pressure, as at very high elevations, or in caissons ; the in- halation of irritating vapors and gases, or of very hot or cold air ; acute simple, fibrinous, or putrid bronchitis, pneu- monitis, and vicarious luemorrhage in cases of amenor- rhoea,' and during pregnancy or lactation.8 A degree of intra-vascular tension, incompatible with the retention of the blood within the vessels, may be gradually produced by excessive venous hyperaemia, in which case the passive congestion may properly be said to have acted both as a predisposing and as an exciting cause of haemorrhage. (b) Rupture of the pulmonary or bronchial vessels may, rarely, result from penetrating or non-penetrating tho- racic wounds, from violent concussions of the chest inci- dent to falls and blows, from epileptic and other convul- sive paroxysms, and from the introduction of irritating foreign bodies into the air-passages. III. Miscellaneous Causes.-Haemoptysis has been ob- served in hysteria, chorea, epilepsy, cerebral haemorrhage, and in inflammation of the brain and spinal cord, and has usually beeu referred to obscure vaso-motor disturbances, but a causative relation between these diseases and hae- moptysis has not been definitely established. So-called essential or idiopathic haemoptysis is that in which there is no demonstrable cause for the attack, which is perfectly innocuous in its immediate results, and is not succeeded by symptoms indicative of any pathological condition.9 These cases are analogous to the familiar attacks of idio- pathic epistaxis. Mobbid Anatomy.-I. Bronchial Haemorrhage.-If the examination be made soon after the bronchial haemor- rhage, fluid and coagulated blood will be found in the bronchial tubes, the bronchioles, and the alveoli. The blood reaches the latter by gravitation, and microscopical examination shows that it even penetrates the intra-alve- olar tissues. The mucous membrane of the bronchi is sometimes swollen, softened, friable, reddened and ec- chymotic. In cases of profuse haemorrhage it is, how- ever, anaemic and shrunken. The lungs may present a mottled appearance, because of the contrast between the general anaemia of the pulmonary parenchyma and the brighter spots due to the presence of blood in the air-cells. The lungs are abnormally heavy and resisting, and, if the bronchi are completely or considerably obstructed by the extravasated blood, do not readily collapse when the thorax is opened. If the autopsy be made some days after the haemorrhage, decolorized and disintegrating coagula may occasionally be found in the bronchi, the bronchioles and the alveoli, which may be discolored or inflamed (broncho-pneumonia) from contact with the decomposing coagula. In most cases, however, the extravasated blood has undergone complete reabsorption, the mucous mem- brane presents a perfectly normal appearance, and the seat of luemorrhage eludes observation. II. llcemorrhage from Cavities.-Pulmonary cavities 464 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemoptysis. Haemoptysis. possible occurrence of haemoptysis may be derived from the previous history, particularly if this includes evidences of phthisis, of cardiac disease, or of the dyscrasiae. Pro- dromi may be observed several days before a pulmonary haemorrhage, recurring at irregular intervals before the attack, or they may directly precede the haemoptysis. II. Actual Symptoms, or those of the Attack.-In an or- dinary case of haemoptysis, whether inaugurated by pre- monitory symptoms or not, the patient experiences a sen- sation such as might be referred to the trickling of a warm liquid beneath the sternum, perceives a saline, sweetish taste, and, on clearing his throat, expectorates blood with- out effort. Cough, attended by characteristic large, moist, tracheal and bronchial rales, now begins, or may have pre- ceded the first bloody expectoration, and each paroxysm of coughing leads to the expulsion of a variable quantity of blood, which is generally fluid, arterial in color, of alka- line reaction, frothy from the admixture of air, and often mingled with mucus or muco-pus. If the quantity of blood be small, and its expulsion gradual, it is often venous, or even Wack in color, and more or less completely coagu- lated. Coagula emanating from the lung are usually of low specific gravity, on account of the air-bubbles which they contain. Blood-casts of the bronchi may be expec- torated. The quantity of blood rejected varies within wide limits. In some cases only a few drachms are ex- pectorated ; in others, particularly in haemoptysis from ruptured aneurisms, from phthisical or other cavities and in pneumorrhagia, several pounds may be rejected. If the blood is so abundant that it fails to find a ready exit through the buccal cavity, which rarely happens, it flows in an almost uninterrupted current from both nose and mouth, quickly producing syncope, or even convulsions and death. A certain quantity of blood is often swal- lowed, giving rise to hsematemesis oi' to melaena. The uninterrupted duration of haemoptysis is very variable, ranging from a few minutes to several days. A single attack sometimes occurs, but haemoptysis is generally re- current. The intervals between successive attacks vary from a few' hours or days to months or years. Eichhorst11 affirms that malarial haemoptysis recurs periodically at the time when a febrile paroxysm should be expected. A similar periodicity may obtain in amenorrhoeal haemopty- sis. Haemoptysis manifests a strong tendency to self- limitation, but it may, in exceptional cases, especially when dependent upon phthisis or on haematophilia, recur so often as to cause death by exhaustion. Only in rare instances does the spitting of blood prove immediately fatal from rapid asthenia, or from asphyxia due to ob- struction of the air-passages. The first sight of blood, especially in an initial haemop- tysis, engenders characteristic excitement and terror on the patient's part; but when a few safely surmounted paroxysms have demonstrated their comparative innocu- ousness, his mental equilibrium is often little disturbed by the onset of a new' haemorrhage. In cases of moderate haemoptysis the constitutional symptoms, aside from men- tal perturbation, betrayed by an anxious expression and by gentle tremor, are, at first, those of slight shock, i.e., pallor, faintness or nausea, chilliness, and enfeeblement of the pulse. These symptoms are succeeded by conges- tion of the face and by augmented force and frequency of the heart's action, which phenomena gradually disap- pear after the cessation of the haemorrhage. In cases of more copious haemoptysis the facial congestion gives place to returning pallor, the pulse becomes irregular and com- pressible, the respiration suspirious, the surface clammy, and the mind apathetic. Restlessness, tinnitus aurium, urgent thirst, falling temperature, nausea, muscae voli- tantes, dimness of vision, increasing asthenia, transient syncope and convulsive twitchings are symptoms which complete the clinical picture. In the worst cases of hae- moptysis the phenomena just enumerated appear in rapid succession, and death results either from syncope or from suffocation, due to obstruction of the air-passages by fluid and coagulated blood. Haemoptysis from haemorrhagic infarction generally ensues forty-eight hours, or even later, after the occurrence of pulmonary embolism, which, if the embolus be of septic character, is frequently an- into which a fatal haemorrhage has occurred, and the bronchi leading to these cavities, are, on examination, found partly or completely filled with semi-coagulated or coagulated blood. In many cases the ruptured blood- vessel may be discovered on the wall of the cavity or upon trabeculae stretching between its parietes, present- ing, at the point of rupture, either aneurismal dilatation, varicosities, or ulcerative erosions. III. Haemorrhage from Cardiac Disease.-The morbid anatomical changes in haemorrhage dependent on heart- disease, if observed soon after the attack, may merely resemble those described under the caption Bronchial Haemorrhage. There are, however, usually present those other pathological conditions, to which the collective title Browm Induration {quod vide) is applied. More fre- quently still the morbid changes are those of haemor- rhagic infarction, for a full account of which the reader is referred to the appropriate article in this Handbook. The infarctions are generally found in the posterior por- tions of the lower lobes and near the surface, but they may occur in any part of the lung. Infarctions may be either single or multiple. They may be only as large as a cherry, but may, in rare instances, occupy the greater part of a lobe. Their shape is that of a wedge or cone, the base of which is directed toward the surface of the lung. Their color is reddish-blue or reddish-black, and their consistency firm. They project above the level of the surrounding pulmonary parenchyma, and are devoid of air. On section, a reddish-browm, viscid, partly coagu- lated, bloody fluid, containing amorphous detritus, can be scraped from the granular cut surface of the infarction. The microscopical examination of an infarction shows a large number of red corpuscles in the air-vesicles and the intra-alveolar tissues, the blood-vessels being distended with blood. The surrounding pulmonary tissue is ordi- narily congested and oedematous. The autopsy, if made long after an attack of haemoptysis from cardiac disease, sometimes discloses only brown induration of the lung, or those pathological conditions resulting from retrogres- sive changes in haemorrhagic infarctions, viz., fatty de- generation, caseation, calcification, cyst-formation, cica- tricial induration, abscess, or gangrene. Haemorrhagic infarctions which owe their origin to the lodging in the lung of septic emboli, emanating from peripheral thrombi, are those which habitually eventuate in abscess and gan- grene. In some cases the infarction may undergo com- plete reabsorption, usually leaving deep pigmentation of the pulmonary tissue as evidence of its occurrence. IV. Pneumorrhagia {Pulmonary Apoplexy).-In this form of pulmonary haemorrhage the lung-tissue is found more or less extensively lacerated, compressed and dis- integrated by fluid and coagulated blood. Even the vis- ceral pleura is sometimes ruptured, and haemothorax pro- duced by the entrance of blood into the pleural cavity. Again, the extravasated blood may form a subpleural haematoma by insinuating itself between the visceral pleura and the pulmonary parenchyma. Symptomatology-The clinical history of haemoptysis embraces: I. Prodromal symptoms; II. Actual symp- toms, or those of the attack, and III. Consecutive symp- toms, or sequelae. I. Prodromal Symptoms.-Premonitory symptoms are often absent in haemoptysis, particularly if it be due to traumatic causes, to the rupture of aneurisms, or to incipi- ent phthisis.10 Under these circumstances the haemorrhage either occurs without an evident exciting cause, while the patient is quiescent, or it is precipitated by some physical effort, such as lifting, riding, running, or dancing. Sub- jective precursory phenomena generally precede haemop- tysis from active or passive congestion, and in cases of recurrent haemoptysis. The most noteworthy .premoni- tory symptoms are cold extremities, accelerated pulse, vertigo, cephalalgia, epistaxis, thoracic oppression, con- striction, distention or warmth, a dry hacking cough, vague general discomfort, slight dyspnoea, and cardiac palpitation. An objective prodromal symptom is cere- bral congestion, accompanied by flushing of the face, throbbing of the carotids, and augmented rapidity and force of the pulse. Important suggestions relative to the 465 Haemoptysis. Haemoptysis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nounced by a chill. For the symptoms peculiar to hae- morrhagic infarction, vide the article in this Handbook treating of that subject. Haemoptysis from the other predisposing and exciting causes described under the caption Etiology, as cancer, aneurisms, abscess, and gan- grene, will, of course, be accompanied by the symptoms peculiar to these diseases. That pulmonary or bronchial haemorrhage and haemoptysis are not convertible terms is shown by the fact that haemorrhages from the lungs sometimes occur without giving rise either to the prodro- mal or to the actual symptoms of haemoptysis. These symptoms may be absent either if the quantity of extrav- asated blood be insignificant and undergo reabsorption, or if it be so large as to preclude the possibility of its expectoration by causing sudden death. The physical signs, aside from those due to the diseases causing haemoptysis, are usually unimportant. If the attack be slight, there may be no physical signs, or moist rales may show the presence of blood in the alveoli, bron- chioles and bronchi. No additional signs will be discov- ered, unless considerable consolidation has been produced by the accumulation of blood in the air-passages and the interstitial pulmonary tissues, when dulness, and, provi- ded that the bronchi be unobstructed, broncho-vesicular or bronchial respiration and increased vocal fremitus may be found. If the bronchi are completely or considerably obstructed, there will be diminution or absence of respir- atory and of vocal signs. III. Consecutive Symptoms, or Sequelae.-The expectora- tion of bloody sputa, or of coagula in various stages, of de- colorization and of disintegration, nearly always persists for several days after an attack of haemoptysis. Anaemia is another sequel of haemoptysis, and corresponds, in du- ration and gravity, with the degree of asthenia or of dys- crasia produced by the attack and by the original disease. The description of symptomatic anaemia may be found in the article devoted to that subject, and its symptoms are briefly enumerated under the heading Symptomatology, in the article on Haematemesis. In certain fortunate cases the after-effects of haemoptysis just described are alone observed, the patient is soon restored to perfect health, and his haemoptysis is not followed by any dis- eases etiologically connected with it.12 In other cases a fever, due to the absorption of septic matters from co- agula decomposing in the bronchi, and to local inflam- matory processes excited by the coagula, continues for a variable time after the attack. Dry pleurisy, or pleurisy with effusion, sometimes follows the spitting of blood, particularly if the latter be due to haemorrhagic infarction or to tuberculosis. Broncho-pneumonia, or lobular pneu- monia, may directly result from haemoptysis, and usually undergoes resolution. In other cases it terminates in re- trograde metamorphosis and disintegration of hing-tissue. Acute phthisis (phthisis florida, acute pulmonary tuber- culosis) occasionally follows haemoptysis, no evidences of that disease having existed before the pulmonary haemor- rhage. Niemeyer 13 held the view that haemoptysis di- rectly causes tuberculosis, but his theory is now sup- planted by the opposite doctrine, in accordance with which tuberculosis leads to haemoptysis by producing the degenerative vascular processes mentioned under the caption Morbid Anatomy. Diagnosis.-The task of the diagnostician, when con- fronted with a supposed case of haemoptysis, is fourfold. He must first discriminate between true haemoptysis and pseudo-haemoptysis, i.e., haemorrhage from the nose, mouth, and pharynx. He must then make a differential diagnosis between haemoptysis and haematemesis, and ex- clude the feigned haemoptysis of malingerers and of hyster- ical persons. Finally, he should endeavor to discover the essential cause of the haemoptysis. Epistaxis may be mistaken for spitting of blood when the latter, having es- caped through the posterior nares and descended into the pharynx or to the entrance of the larynx, is thence ex- pelled by acts of expectoration. If the epistaxis be in progress, a diagnostic error may be avoided by causing the patient to flex his neck upon the thorax, whereupon the blood, which is ordinarily venous, partly coagulated, and unmixed with air, will escape through the nostrils. The history will, moreover, frequently point to the occur- rence of nose-bleed before the supposed haemoptysis. The rhinoscope and laryngoscope will dispel all doubts by disclosing the source of the nasal haemorrhage, if the latter be still in progress, or the presence, in the nasal fossae, of coagula and blood-stained mucus, if the haemor- rhage has ceased before the examination. Direct inspec- tion of the mouth and pharynx will suffice for the exclu- sion of buccal and pharyngeal haemorrhages, which are ordinarily caused by ulcerative gingivitis, tonsillitis, or pharyngitis. The discrimination between haemoptysis and haematemesis is made with more difficulty, because some of the blood rejected from the respiratory organs during haemoptysis may be swallowed and subsequently vomited, while blood emanating from the stomach may descend into the air-passages and be expectorated. The reader will find, under the caption Diagnosis, in the arti- cle on Haematemesis, an excellent table borrowed from Dr. Wm. H. Welch, which emphasizes, antithetically, the distinctive features of these respective haemorrhages. Even if some blood, having been swallowed during haemoptysis, should excite haematemesis, more blood, em- anating from the lungs and presenting the characteristics described in the table, will still continue to be expecto- rated. Moist bronchial rales will be generally present in haemoptysis, and absent in haematemesis. The color of blood from the lungs may not only be dark because of its retention and coagulation, but because its source was a large branch of the pulmonary artery, in which deoxy- genated blood circulates. The exposure of the feigned haemoptysis of malingerers is not difficult, provided that a careful system of surveillance be unrelentingly pursued. If the blood of the ovipara or of the camelidae has been used by the malingerer, the fraud is detected by the mi- croscope. If red wine or the vegetable juices enumerated under the caption Diagnosis, in the article on Haemate- mesis, have been •employed, the spectroscope and chemi- cal tests will facilitate the culprit's conviction. If nasal or buccal haemorrhages have been purposely induced, there will be evidence of traumatism, while a careful system of observation will prevent the malingerer from mingling foreign blood with the sputa. The diagnosis is not com- plete until the physician has ascertained the cause of the haemoptysis, i.e., whether it be idiopathic, vicarious, or symptomatic. This information can only be obtained by a thorough inquiry regarding the presence or absence of each possible etiological condition, particularly of aneu- risms, cardiac diseases and tuberculosis. The differen- tiation of pulmonary and bronchial haemoptysis is usually attended with insurmountable difficulties, nor is the dis- tinction of practical importance, from a therapeutical standpoint. Prognosis.-A rational prognosis must be based upon the probable immediate and remote effects of the haemor- rhage, and upon the comparative gravity or innocuous- ness of the disease upon which a given case of haemoptysis directly depends. The prognosis, so far as immediate danger to life is concerned, is generally favorable. Only in rare cases does profuse haemoptysis, ordinarily inci- dent to pulmonary excavation, to grave cardiac disease, to pneumorrhagia, to rupture of aneurisms and varices, or to haemorrhagic infarction, cause death by rapid ex- haustion, or by asphyxia from occlusion of the air-pas- sages. The grave character of haemorrhage from a cavity is due to its frequent dependence upon the erosion or rupture of arteries, or of miliary aneurisms, the rent in which is prevented from closing by paroxysms of cough- ing or by efforts at expectoration. The remote effects of haemoptysis are, per se, usually devoid of gravity. Anae- mia, which is the chief sequel, although intractable, is not incurable, and the lobular pneumonias following the spitting of blood generally undergo resolution. Repeated attacks of haemoptysis may, it is true, gradually exhaust the patient's vitality, or hasten the lethal issue of pre- existing chronic disease. The progress of phthisis seems, however, to be sometimes retarded by the intercurrence of pulmonary haemorrhage, which fact may possibly be explained, if the bacilli tuberculosis be regarded as the active cause of tuberculosis, on the supposition that the 466 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ha*nioptysis. Haemoptysis. luemorrhage expels a certain number of the micro-organ- isms. Phthisical patients often volunteer the informa- tion that their general health has been favorably affected, and their pulmonary discomfort greatly relieved by a haemorrhage from the lungs. A rapid development of pulmonary tuberculosis follows haemoptysis in rare in- stances, and was attributed by Rindfleisch to the stop- page of bronchioles by extravasated blood, and the conse- quent occurrence of atelectasis and lobular pneumonia. The prognosis, so far as the ultimate recovery of a patient attacked by haemoptysis is concerned, is almost always unfavorable, not from an inherent fatality pertaining to haemoptysis, but because the complaints upon which the spitting of blood generally depends are themselves incu- rable. In the vast majority of instances, especially if the patient has reached the age of fifteen, and has not sur- passed that of thirty-five years, haemoptysis is indicative of pulmonary tuberculosis, and yet a large number of cases have been reported in which the spitting of blood recurred at short intervals, during months and even years, without being either accompanied or followed by phthisis or by any other disease.14 The examination of the ex- pectorated blood for bacilli should never be omitted in doubtful cases, and their discovery will afford convincing proof of existing incipient phthisis. A reliable prognosis can only be made in cases of initial haemoptysis, after careful observation during a reasonable period. Should thorough and repeated physical examinations prove neg- ative, should no bacilli be discovered in the sputum by frequent microscopical examinations, and should no grave dyscrasia be present, a favorable prognosis, as to recovery, is warrantable. This is equally true of haemoptysis when produced by the inhalation of irritating substances, by excessive cardiac action due to violent exertions, by rare- faction of the atmosphere, by penetrating pulmonary ■wounds without the lodgement of foreign bodies, by ma- laria and by vaso-motor diseases. Vicarious haemoptysis must be regarded with suspicion, as possibly dependent upon tuberculosis, which disease often occasions amenor- rhoea. Haemoptysis is also of grave significance when it complicates cardiac disease, since it affords evidence of inadequately compensated organic lesions, and when a complication of pulmonary septic embolism, malignant neoplasmata, abscess and gangrene, or of scorbutus, pur- pura, yellow fever and other severe infectious diseases, it is a symptom of most serious import. Treatment.-The indications for the treatment of haemoptysis are: first, the arrest of an actual attack; second, the prevention of its recurrence by treatment of the causative affections ; and finally, the relief of its con- secutive symptoms. Energetic therapeutical measures are not indicated in mild attacks of haemoptysis. Inasmuch as local deple- tion exerts a beneficial effect upon pulmonary congestion, which is the cause of most slight haemorrhages, it is ad- visable not to interfere with nature's efforts for the relief of excessive intra-vascular tension, but to second them by measures tending to the accomplishment of the same end. Whether, therefore, the congestion be active or passive, perfect quiescence, in a semi-recumbent position, should be strictly enjoined upon the patient. The statement that haemoptysis is useful in relieving pulmonary congestion, and that its occurrence, given the usual pre-existing con- gestion, is desirable, should be confidently made, and is usually effective in quieting the patient's apprehensions. The sick-room must be kept cool, well ventilated, and free from all persons whose demeanor would tend to ex- cite misgivings in the patient's mind. The bed-coverings are to be so light as not to compress the chest. The pa- tient should be frequently reminded to persistently re- strain his desire to cough. Mild revulsive measures, such as the application of mustard-leaves, or of dry cups, to the exposed parts of the chest, and of stimulating pedi- luvia, are in order, as is derivation by means of a gentle saline purgative. If the pulmonary hyperaemia be active, cardiac sedatives may be employed, one of the best being the tincture of aconite, in two-drop doses, every twenty minutes, until a reduction in the force and frequency of the pulse, or tingling in the throat and finger-tips are observed. Should the hyperaemia be passive, as in un- compensated lieart lesions, the tincture of digitalis, in ten-drop doses, should be administered, every hour, for the purpose of strengthening the heart's action. In cases of more profuse or protracted haemoptysis the same rules regarding the patient's position and surroundings should be rigidly enforced, and more potent therapeutical meas- ures adopted. If the haemorrage be occasioned by ex- cessive active hyperaemia, the patient being strong and plethoric, or by so great passive congestion as to threaten cardiac paralysis, venesection, to eight or ten ounces, affords prompt relief. This treatment is particularly adapted to the initial haemoptysis of tuberculosis, and to pulmonary haemorrhage from rarefaction of the atmos- phere, from the inhalation of irritating substances and from violent physical exertions. If the patient will not submit to the operation of phle- botomy, active congestion may be measurably controlled by a brisk saline purgative, by emetic doses of ipecac., as recommended by Trousseau and Graves, and recently ad- vocated by Massina and Peter, but which must be avoided in haemoptysis from cavities, because of its tendency to prevent closure of bleeding vessels, or by the following therapeutic agents, which are useful in all varieties of profuse pulmonary haemorrhage. The most potent of these is cold, which is best applied by means of an ice- bag, of moderate weight, placed over the primary bronchi, or on that part of the chest to which the detec- tion of rales points as the probable seat of haemorrhage. Small pieces of ice should be constantly dissolved in the mouth and swallowed. The best form of nourishment is cold milk, taken in quantities of eight ounces, at intervals of two or three hours. Physical examinations should be studiously avoided, as calculated to increase and to ex- cite haemoptysis, and as affording no important results. Ligation of the extremities, which is sometimes a very efficient haemostatic measure, acts by retaining the venous blood in the limbs, while the arterial current is not ar- rested, but it must be cautiously employed, lest syncope or venous thrombosis be induced. These untoward results may be prevented by the simultaneous ligation of only two members, by leaving the ligatures only a few min- utes, consecutively, and by removing them so soon as haemoptysis ceases. Ligation must, naturally, only be undertakeh under the physician's immediate direction and supervision. Ergot is, probably, the most efficient haemostatic remedy. It may be exhibited in the form of the fluid extract, in doses of one or two drachms, diluted with an ounce of water, every half-hour or hour, until the haemorrhage ceases, or a decided diminution in the force and frequency of the pulse is observed. Should the stomach prove rebellious, half an ounce of the fluid extract, diluted with an equal quantity of lukewarm water, may be given by rectum, and repeated every hour until the physiological effects are produced. If it is desirable that the action of the drug be very speedily exerted, half a drachm of the fluid extract, or three grains of ergotin, dissolved in equal parts glycerine and water, should be subcutaneously administered, every half hour, until the desired result is obtained. One grain of opium, or one-fourth grain of the sulphate of morphia, prefer- ably in fluid form, must be immediately administered for the purpose of checking cough, and of inducing mental and physical quietude. The opiate should be re- peated in doses of half the size mentioned, every two hours, until haemorrhage ceases, or the physiological effects of the medicine are obtained. The most speedy and satisfactory method of administering the narcotic is by hypodermatic injection of the sulphate of morphia, par- ticularly if simple emesis or haematemesis coexist with the haemoptysis. Opiates are contraindicated when fatal accumulation of blood in the air-passages is threatened. At such times expectoration should be encouraged and facilitated. Many authorities recommend that several teaspoonfuls of dry common salt be administered, if no other remedy be at hand, largely for the desirable moral effect resulting from medication in general, and partly on account of the unexplained but well-attested restrain- ing effect of salt upon haemoptysis. Inhalations of as- 467 Haemoptysis. Haemorrhage. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tringents, preferably of Monsel's solution, or of the liquor ferri sesqmchloridi, diluted twenty-five times with water, and administered in the form of spray generated by an atomizer, are sometimes usefid. The acetate of lead, in two-grain doses, or gallic acid, in twenty-grain doses, every three hours, are often administered internally, al- though the question of their value is still debatable. Bar- tholow extols the virtues of turpentine in haemoptysis de- pendent upon haematophilia and purpura.13 It may be exhibited by mouth, in twenty-drop closes, in emulsion, or on sugar, or its vapor may be inhaled, for one-quarter hour, at intervals of two hours. After-treatment.-The objects of the after-treatment are the prevention of a recurrence of haemoptysis, and the re- lief of its consecutive symptoms. The former indication is best fulfilled by the removal of predisposing morbid conditions, and by the avoidance of exciting causes. Many of the diseases predisposing to haemoptysis, al- though, unfortunately, not amenable to curative meas- ures, may be favorably influenced by judicious treatment. Pernicious malarial fever, of the haemorrhagic type, may be controlled by quinine and by other antiperiodics. Vi- carious amenorrhceal haemoptysis is to be combated by means tending to excite the normal menstrual flow, and scorbutic pulmonary haemorrhage by good food and veg- etable acids. In cases of puerperal or marantic venous thrombosis, the utmost quietude should be enjoined, in order that pulmonary embolism, resulting in infarction and haemoptysis, may be averted. Acute and chronic pulmonary inflammations must be subjected to appropri- ate treatment, and earnest efforts made to establish a compensation for existing organic cardiac diseases. The exciting causes of haemoptysis most easily avoided are those producing active pulmonary congestion, such as violent physical efforts, mental excitement, great rarefac- tion of the atmosphere and the inhalation of irritating vapors and gases. The chief direct sequelae of haemop- tysis are bronchitis, broncho-pneumonia, anaemia and asthenia. The first and second are to be treated in ac- cordance with generally recognized methods. The anae- mia and asthenia are to be combated with tonics, prepa- rations of iron, nourishing food, moderate and regular out-of-door exercise in pleasant weather, and, if extreme, by alcoholics rationally administered. If no other cause for a given attack of haemoptysis can be discovered, it should be regarded as a probable initial symptom of pul- monary tuberculosis, and appropriate prophylactic meas- ure (vide Phthisis) should be immediately inaugurated. William H. Flint. 1 Eichhorst: Handbuch d. Spec. Path. u. Th., 1883, Bd. I., p. 490. 2 Rindfleisch: Ziemssen's Cyclopred. of Prac. Med., vol. v., p. 657. New York, 1875. * Jaccoud: Traite de Path. Int., t. ii., 21. Paris, 1871. 4 Carson: Pepper & Starr, System of Prac. Med., vol. iii., p. 272. Philadelpia, 1885. 6 R. Douglass Powell: Quain's Diet, of Med., p. 571. New York, 1883. 6 Eichhorst : op. cit., p. 491. 7 P. Guttman: Eulenberg's Real-Encycl., Bd. vi., p. 222. 8 Chas. Fernet: Nouv. Diet, de Med. et de Ch., t. xvii., p. 382. 9 A. Flint, Sr.: Treat, on the Princip. and Prac. of Med., p. 271. Phila., 1881. 10 J. Hughes Bennett: Reynolds' System of Medicine, vol. vii., p. 124. Philadelphia. 11 Eichhorst: op. cit., p. 497. i2 A. Flint, Sr.: Clin. Med., pp. 64 and 144. Phila., 1879. 13 Niemeyer : A Text-Book of Prac. Med., vol. i„ p. 148. New York, 1876. 44 A. Flint, Sr.: Phthisis, p. 86. Phila., 1876. 15 Bartholow: Prac. of Med., p. 378. New York, 1880. recognize no traumatism such as would rupture a healthy vessel, yet some increase of intravascular tension, or some pressure from without, really effects the solution of continuity in the vessel. Undoubtedly, under increased vascular tension, diapedesis of the red blood-corpuscles does take place through a damaged vessel wall without recognizable solution of continuity, but the view pro- pounded above seems the more probable. Such sponta- neous bleedings mark the course of purpura, haemophilia, scurvy, poisonings by certain drugs, as phosphorus-where undoubted fatty degeneration of the vessel-walls has been detected,-and in a number of other affections. Embolic processes, as in the case of the duodenum, by producing ulceration are productive at times of otherwise unex- plainable intestinal haemorrhages. A still further prac- tical subdivision may be made as to the place where the blood finds exit, whether upon a free surface, as the exterior of the body, one of the hollow viscera or a se- rous cavity, or into the substances of organs or the gen- eral cellular tissue. In the last event the haemorrhages, when small, are termed ecchymoses or bruises, when larger, extravasations. Internal haemorrhage is a term in- dicating effusion of blood into the abdomen, pleura, me- diastinum, or pericardium. Localized collections of fluid blood are called haematomata, and sometimes even in the cellular tissue, haematoceles, as that of the neck or sper- matic cord, but the latter term is also applied to effusions of blood into some of the serous sacs, as that of the tunica vaginalis testis. Again, traumatic haemorrhages are naturally separable into four distinct classes or groups, viz : 1, Primary ; 2, intermediary ; 3, secondary ; and 4, parenchymatous. 1. Primary haemorrhage is that which immediately fol- lows the injury, and in amount varies with the vessel wounded or the kind of traumatism. An incised wound bleeds more freely than a contused or lacerated one, whole limbs being frequently avulsed with only an insig niflcant amount of haemorrhage. 2. Intermediary haemorrhage is that which comes on between the stage of shock and that marked by suppura- tion. Bleeding results either from the increased vascular tension of reaction, or from the too early removal of ex- ternal pressure, the coagula w hich occlude the vessels becoming loosened. 3. Secondary haemorrhage is that which occurs after suppuration has been established, and is consequent upon the separation of sloughs, eschars, etc., from the injured vessels. 4. Parenchymatous haemorrhage is a general capillary oozing, due either to inflammatory dilatation of the capil- lary vessels, or to thrombosis of the principal veins. Constitutional Signs of Haemorrhage.-The coun- tenance, especially the ears, lips, and conjunctivae, as well as the general integument, are of a pallid color and shrivelled, pinched appearance. The general surface is bathed in a clammy sweat, the countenance is vacant, the pupils are dilated. From anaemia of the brain, hum- ming, roaring, or ringing sounds are heard. A thick mist, or even darkness, alternating, perhaps, with flashes of light, comes before the eyes. General sensibility is benumbed, and unconsciousness with syncope or convul- sions follows. In the intervals of consciousness the de- bility is great, evinced by the faint whispering voice, the feeble sighing respiration, marked dyspnoea, and small, frequent, fluttering, or almost imperceptible pulse. If the loss of blood be not fatal the patient rallies for a time. With each new bleeding the patient faints, and with in- creasing difficulty is restored to consciousness. Dyspnoea becomes more marked and the pulse increasingly frequent and feeble, while the slightest bending of the head or the sudden assumption of the upright posture endangers fainting. The face is waxy pale, the lips bloodless, the flesh is soft, the movements feeble and languid, and the blood now effused is little more than bloody serum ; dropsy appears, and now the slightest loss of blood proves fatal When death results from a sudden loss of blood, as from a w'ound of a large vessel or a ruptured aneurism, the blood, instead of being forced onward by the elastic H/EMORRHAGE (a<>a, blood ; pfryvum, I break forth) must be considered first as to its source or sources. Thus it may be arterial, venous, or capillary, or it may arise from all three sources. In most wounds the blood flows from all three sets of vessels, but, unless arteries of a cer- tain size be opened, natural haemostasis soon checks the venous haemorrhage, next the arterial ceases, while later we have only to contend with the capillary oozing. Haemorrhage should also be studied as to its cause. Thus, when arising from cuts, blows, etc., it is termed traumatic, while those haemorrhages which take place without tangible cause are called spontaneous. In this latter class of cases it is in the highest degree probable that they are always due to structural alterations in the vessel-walls or the blood itself, and that, while we can 468 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemoptysis. Haemorrhage. recoil of the arteries, runs backward from all parts of the body toward the opening in the vessel. The pressure in the veins being thus relieved, the blood no longer flows toward the heart, which ceases to act, and the face, as in asphyxia, becomes somewhat livid in hue, from the stag- nation of venous blood. Suddenly the face becomes deathly pale, except a livid circle around the eyes, the lips are purplish, and the extremities cold. Syncope occurs, is recovered from and recurs, the voice is whisper- ing, nausea sets in, and the pulse becomes almost imper- ceptible. Tossing of the limbs, especially of the arms, be- comes marked and incessant, the head is at times suddenly raised, and the patient gasps for breath with a face ex- pressive of intense anxiety ; convulsive, sighing respira- tion, with an almost imperceptible pulse, comes on, and the patient expires. The face has not the waxen translu- cent pallor of one dead from slow loss of blood, but is- of a clayey leaden hue. In both varieties of fatal haemor- rhage the previous constitutional state, whether robust or the reverse, has much to do with the result. Haemorrhagic Fever.-Great irritability of the heart and arteries is apt to follow severe losses of blood, result- ing in the so-called "irritative fever." The number of red corpuscles, i.e., the oxygen carriers, being notably diminished the heart tries to overcome this deficiency by passing the blood through the organs more rapidly. This condition is characterized by a hurried, jerking, flutter- ing, irregular pulse, slight flushings of the face, and brilliancy of the eyes, alternating with pallor and syncope, while if the haemorrhage prove fatal, delirium with con- vulsions and an extreme, indescribable restlessness precede death. Haemorrhagic Convulsions.-These are of an epilep- tiform character, and usually follow sudden copious losses of blood. They are generally not dangerous when treated properly, viz., as for bad syncope. It must not be forgot- ten that in the cases of those predisposed to convulsions, a small loss of blood may produce eclampsia. General Treatment oe Haemorrhage.-A few re- marks applicable to the treatment of haemorrhage in gen- eral, will prevent needless repetition. Great losses of blood are dangerous at the time, from the risk of fatal syncope. This is to be combated by all those means which will favor the retention in the brain of a function- ing quantity of blood, especially in the respiratory cen- tres. The head and shoulders should be at once lowered and kept so by raising the foot of the bed twelve or more inches, while not even a bolster should be left beneath the head. The limbs should in addition be raised nearly at right angles to the body, and so maintained. In the worst cases, Esmarch's elastic bandages can be applied to one or all of the limbs, thus utilizing most of the blood of the extremities. If elastic bandages are not available, ordinary muslin ones may be used, and finally, in default of either kind of bandage, digital or instrumental com- pression of the arteries of the limbs in the raised position may be tried. The most essential, if not all, of the above measures can always be put into practice at once, with- out attempting the removal of the patient to a distant home or hospital; by neglecting the immediate use of these expedients, many lives are lost. Next, stimulants by the mouth or rectum must be administered. Turpen- tine, one-half to one fluid ounce, emulsified by beating up with a raw egg and water, is the best stimulant to give by the rectum. Subcutaneously, whiskey, brandy, or, better still, ether, as frequently repeated as seems necessary to ward off syncope, is indicated, and at times atropia sub- cutaneously acts well as a respiratory and cardiac stimu- lant. External heat by hot bottles, etc., should be as- siduously applied, and a sinapism over the heart is never amiss. If all seems likely to fail, transfusion of blood or of Little's saline fluid should be used (see article on Transfusion): Chloride of sodium, 50grains ; chloride of potassium, 3 grains; sulphate of sodium and carbonate of sodium, each 25 grains ; phosphate of sodium, 2 grains ; water; 1 pint. The temperature should be from 98° to 100 F. A few ounces usually suffice, but this must be regulated by the effects. Of course, as occasion permits, concentrated hot meat-essences, containing an abundance of sodium chloride, and milk, must be given, or in other words, fluids, which by their rapid absorption may sup- ply the heart with a sufficient bulk of fluid to carry on the circulation. As the patient rallies, first the bandage on one limb may be partially removed, then entirely. If the pulse does not flag after an interval, the bandage from another limb should be removed, and finally from all the limbs, similar advice being ap- plicable to those cases where in- strumental or digital compression has been used. Last of all, the limbs may be lowered one by one, but the dependent position of the head and shoulders must be unin- terruptedly maintained, sometimes even for days, and always for some hours, until the bulk or quality of the blood has improved to a de- gree compatible with a more or- dinary position, which must also be gradually assumed by lowering the foot of the bed by degrees. The above remarks chiefly apply to a first and copious haemorrhage, but are applicable according to their degree to recurrent attacks. As soon as seems advisable, the in- ternal use of iron and albuminous articles of food must be resorted to ; after a single copious haemorrhage, to ob- viate the secondary evil consequences of the blood loss ; in the recurrent form of haemorrhage, to keep up the sup- ply of the vital fluid so that new losses may not prove fatal, and also to prevent or cure the dropsical condition often induced by repeated haemorrhages. To prevent the return of haemorrhage the internal use of the oil of tur- pentine, oil of erigeron, acetate of lead, and dilute or aro- matic sulphuric acid in conjunction with opium should be tried. Last, but best, fluid extract of ergot in doses of twenty to thirty minims should be exhibited every half, one, or two hours, as seems indicated. Our own experi- ence would indicate that one of the dilute preparations of sulphuric acid occupies the second place, while the third in rank is acetate of lead, given in two-grain doses every one or two hours, combined with an appropriate quantity of opium. Oil of turpentine is thought most Fig. 1519.-Pyramidal Com- press. (International En- cyclopiedia of Surgery.) Fig. 1520.-Improvised Tourniquet. (Esmarch, International Encyclo- paedia of Surgery.) highly of by some, in doses of ten to fifteen drops every half hour or hour until relief is obtained, but we have no personal experience bearing on this point, although we have been disappointed in the oil of erigeron, which is essentially a turpentine. Of late the fluid extract and distilled extract of hamamelis virginiana (witch-hazel), have been extolled as internal haemostatics. 469 Haemorrhage. Haemorrhage. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The local means for the temporary arrest of haemor- rhage are, in the order of their availability, local compres- sion over the wound by means of fin- gers, compresses, bandage, tourniquet, etc. ; compression of the wounded ves- sels in the'wound by similar means- it matters not whether the vessel injured be artery or vein,-compres- sion of the main trunk-vessel, either by the finger, impro- vised tourniquet, or ordinary tourniquet, including forced flexion and position. Forcible flexion hasoften proved useful in cases of injury of the arteries of the forearm and hand, or of the leg and foot. A roll of lint or some other soft material should be placed in the flexure of the joint, and the limb then bent until the luemor- rhage is arrested, and maintained in this position by a handker- chief or bandage. When the bleed- ing is from the vessels of the leg or foot the effect is materially increased by flexion of the thigh upon the abdomen, as well as of the leg upon the thigh. Some of these measures may also be relied upon for the perma- nent arrest of certain varieties of haemorrhage, and may be, in exceptional cases,* available for all. Styptics.-From the multitude of these such only "should be selected for use by the surgeon as imitate, hasten, or assist the natural process of haemostasis, or ex- cite analogous ones ; that is, such as act by arousing the contractility and retractility of the coats of arteries and veins and capillaries, thus lessening the size of the aper- tures, or by forming occluding coagula artificially, thus plugging and closing the apertures completely ; or by exciting adhesive inflammation within and around the apertures, thus making their closure permanent " (Liddell, " Encyclopaedia of Surgery," vol. iii., p. 63). Cold.-This is the oldest and best known haemostatic. Exposure to the air alone, after removing all clots, fre- quently stops troublesome bleedings from wounds that ooze continuously when closed and covered up with cum- brous dressings. Fanning or blowing upon the wound surfaces increases the effects of atmospheric cold. Still more powerful in their effects are compresses, dipped in iced water, squeezing the contents of a sponge dipped in ice-water over the wound, or syringing it out with the same. Finally, ice itself, either in substance or in blad- ders or india-rubber bags may be tried. Heat.-Hot water at the temperature of about 125° to 130° F., roughly estimated, the greatest heat bearable by the back of the hand, directed upon the wound in a stream from a sponge or syringe, but best of all applied by means of a towel wrung but in it and steadily pressed upon the wound, is far more efficient than cold, and not depressing but actually stimulant. Alcohol, either pure or diluted, acts admirably, both contracting the blood-vessels and forming coagula at their orifices. Iodine, in the form either of the pure tincture or va- riously diluted, acts well, both it and alcohol possessing the additional advantage of being antiseptic. Turpentine applied upon dossils of lint laid over the bleeding points, seems to have proved usefid in passive haemorrhages. Perchloride and subsulphate of iron are popular but unreliable styptics. Undoubtedly they control capillary bleeding, but this can usually be done by less objection- able means. The main objection is that their coagulating power is not instantaneous ; so that, used where blood is flowing freely, an outside crust is formed, inside of which is fluid blood, while the gaping vessel itself is not acted upon, the only means by which the haemorrhage can be permanently arrested. Monsel's solution is less objection- able than the perchloride, but a hard, insoluble coagulum is formed, difficult to detach, and an absolute bar to rapid union. In leech-bites, however, a morsel of cotton or sponge moistened with Monsel's solution and pressed well down into the wound is a useful means to arrest ob- stinate bleeding. Transfixing the edges of the minute wound with a fine sewing-needle and throwing around it a figure-of-eight ligature is, however, a more certain and usually less objectionable measure. Liable to the same objections, but in less degree, are tannic and gallic acids, alum, chloride of zinc, etc. Alum is least objectionable, and may be applied in a tepid state by means of sponges, absorbent cotton, lint, etc., saturated with it, the warm solution on cooling, depositing fine crystals of the salt around the vessel-mouths. We cannot help thinking that much of the good effects ascribed to such treatment is due to compression exercised by the lint, cotton, or sponge. The Actual Cautery.-The best form is the Paquelin thermo-cautery. The hot iron is tlie most certain and powerful of all styptics. Leaving as it does a charred surface-which is antiseptic-and an eschar, which, when it separates leaves a healthy granulating surface, i.e., one usually an efficient bar against purulent ab- sorption, it is our most effective haemostatic in certain operations where union by first intention is not to be expected. If we were de- prived of the cautery the checking of oozing from separated adhesions in many of the abdominal opera- tions would prove a far more diffi- cult and fatal procedure than it now does.* We do not think that the cautery should be used to seal arte- ries of any considerable size, except, perhaps, in the removal of the su- perior maxilla, where the vessels oftentimes cannot be isolated and ligatured, but it is an admirable rem- edy for venous or capillary oozing. The irons should be at a black, or dull-red heat, since a higher tem- perature destroys the tissues too rapidly. Cautery irons can be im- provised out of telegraph-wire, the poker, or any conve- niently shaped piece of metal. The measures adapted to the permanent arrest of hae- morrhage are torsion, forcipressure, ligature, and acu- pressure, with the occasional successful employment of the measures suggested as temporary expedients, especially pressure and forced flexion. Torison.-This is only applicable to completely di- vided vessels. Although special instruments have been devised (Hewson's artery forceps, etc.), the simplest method is to use two pair of strong catch-forceps with ac- curately fitting serratures. The whole cut end of the vessel should be seized with one pair and drawn out from its sheath for about half an inch, when it must be grasped by the second forceps close to the tissues. The end may then be twisted off by about a dozen turns of the first pair of forceps, or better still, three or four sharp turns should be given until the inner and middle coats are felt to give way, when all resistance to further torsion apparently ceases. This method of torsion is only applicable to the larger vessels. Those of small size which cannot be iso- lated must be grasped with some of their surrounding Fig. 1521.-Compression of the Brachial Artery by Screw Tourniquet. (Esmarch.) The tour- niquet plate is displaced to show the applica- tion of the compress in the line of the artery ; the plate is adjusted immediately over the com- press before the strap is tightened. (Interna- tional Encyclopaedia of Surgery.) Fig. 1522.-Cautery Irons Improvised from Tele- graph Wire, after Bran- dis. (Esmarch, Inter- national Encyclopaedia of Surgery.) * Baron Larrey reports a successful case of compression of the external carotid artery ; a solitary exception, not a rule. * No eschar seems to be separated in intra-abdominal operations, tho charred tissue being removed by aseptic absorption. 470 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemorrhage. Haemorrhage. tissue, which with the end of the vessel must be twisted off. Small vessels in structures normally dense, or ren- dered so by inflammation, cannot be treated by torsion, forcipressure proving more available. Torsion is a reliable haemostatic, but more troublesome than the ligature. Forcipressure is effected by seiz- ing the bleeding point or mass of tissue and crushing it by means of catch-forceps, having strong, short, deeply serrated blades. In many cases their careful removal in a few minutes is followed by no bleeding, and they may even be left on twelve or twenty-four hours. Ligature.-Properly prepared an- tiseptic catgut and silk are the best materials for ligatures. When tying a divided vessel, as in an am- putation, the mouth of the artery must be seized and drawn outward, either by a tenaculum or by artery forceps. The latter is the better instrument in most cases, since the tenaculum may accidentally punct- ure the vessel behind the part liga- tured, resulting in ulceration of the arterial coats and secondary haemorrhage. The tenacu- lum, however, is indispensable when the vessel is small and situated in dense tissues, since then the noose of the ligature must include not only the vessel but also some of the surrounding tissues. In this event the tenaculum should be slightly withdrawn as the first half of the knot is tight- ened in order to insure a firm hold on the in- cluded tissues. Sometiines a curved needle armed with a ligature can be more convenient- ly used than either forceps or tenaculum, by passing it under and around the bleeding point including some of the surrounding tissues, but as little as will enable the ligature to hold. When tightening the knot the surgeon must be sure that the thread completely surrounds the cut end of the artery, and that the tips of his forefingers or thumbs are in close contact with the forceps or tdhaculum, so as to press the ligature somewhat down, thus preventing dragging off of the instrument or pulling the vessel too much away from its sheath, which endangers its nutrition and so favors secondary haemorrhage. The first part of the knot should be tightened until the internal and middle coats are felt to give way. With the catgut ligature this is not so essential, a less force answering. The knot used should always be the square or reef-knot, never the "granny." The surgeon's knot may be used, but should be re-inforced by a second tie. If the artery be wounded in its continuity, the surgeon must reach the injured part by a careful dissection, avoiding all unnecessary in- jury of neighboring parts. Both the proximal and distal ends must be tied, or, if not entirely divided, two ligatures must be passed beneath the vessel by means of an aneurism needle or eyed probe with the least possible disturbance of parts. One ligature must be tied above the wound and one below. If these do not stop the flow, the sides a nd under surface of the part included between the ligatures must be carefully ex- amined for some small branch re- turning blood by means of the col- lateral circulation. Neglect of the imperative rule of tying both ends of a wounded artery at the point injured rarely ends in any- thing but disaster : tying the main vessel at a distance from the wound hardly ever proves successful, besides entail- ing other dangers. (See article on Ligature of Arteries.) Direct pressure is chiefly efficient for small vessels and is usually only applicable when the vessel overlies a bone. Sometimes, however, the firm, uni- form pressure of a bandage is ef- fectively used to check oozing, or a sand- or shot-bag may be employed, or filling the wound with shot proves successful. These measures are chiefly applicable for recurrent haemorrhages after ligature of ar- teries, where no room remains for a new' ligature, as in the innominate -or where the bleeding conies from the distal end, in which event methodic bandaging and direct compression with a graduated com- press should be tried before the vessel is ligatured higher up, or amputation is performed. Whether a graduated com- press or a pointed vial cork be used, the artery should be controlled above by digital or other compression, the wound cleared of clots, and the compress accurately ap- plied over the bleeding point. Less force is requisite than the profession seems to think, and even this had better be carefully relaxed after twenty-four to thirty-six hours, al- though the compress must be allowed to come away of itself, lest a slough and con- sequently secondary bleeding occur. Ob- stinate bleeding from hollow cavities, such as the rectum, vagina, or nares, can only be checked by pressure, i.e., packing with cotton, pledgets of lint, or pieces of sponge, impregnated with some styptic, or not, as the surgeon prefers. Acupressure.-By this is meant the occlusion of an artery by the pressure of a pin or needle so placed as to control the blood- current. Various methods have been described by Sir James Simpson, its origi- nator, but only two will be described and figured. A needle threaded with a piece of twisted iron wire is passed beneath the artery, entering and emerging from the contiguous tissues a few lines from the vessel. A loop of iron wire is then throwm over the point of the needle, carried across the vessel with sufficient force to compress it, and secured by a half-twist around the eye end of the needle. The needle is readily removed by trac- tion on the twisted wire, when the wire loop can be with- drawn. A long and strong steel pin may be passed through the skin at one side of the vessel, beneath it, and made to emerge through the skin on the distal side. The pressure of the needle does not divide the inner and middle arterial coats, so that the permanent ar- rest of haemorrhage depends upon the formation of a clot between the acupressured point and the nearest collateral branch, with perhaps some inflammatory exudation at the point compressed. Dependent upon the size of the vessel, the needle should be removed in from thirty to sixty hours. Fig. 1526.-The "Granny." (International Encyclo- paedia of Surgery.) Fig. 1523.-Forcipressure Forceps. Fig. 1527.-The Surgeon's Knot. (Interna- tional Encyclopaedia of Surgery.) Fig. 1528.-Acupressure. (After Er- ichsen.) Fig. 1524.- Self-hold- ing Artery Forceps. Fig. 1529.-Acupressure. (Interna- tional Encyclopaedia of Surgery.) Fig. 1525.-The "Reef" or Square Knot. (In- ternational Encyclopae- dia of Surgery.) 471 Hsvniorrlia^e. Ha*morrhol<ls. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Since the introduction of absorbable ligatures acupressure is chiefly valuable as a prompt and ready method of arrest- ing haemorrhage in an emergency. Arterial Haemorrhage.-The chief danger is the amount of blood lost, or its pressure upon important parts or organs, when not occurring externally. Whether the blood escapes externally, into the areolar tissue, or into a serous sac the constitutional effects are the same for the same amount of blood escaping during a given period. An oblique cut in an artery gapes more than a longitudi- nal one from the combined retraction of the circular and longitudinal coats, while, from these causes, the same ves- sel completely divided may permanently cease to bleed; this method of haemostasis was formerly sometimes used in bleeding from the temporal artery. A small twig di- vided close to the parent trunk will bleed as furiously as a similar sized wound of the main vessel, and must usu- ally be treated as if the trunk-vessel were wounded. Although a wounded artery usually throws out a jetting stream of scarlet blood, yet in a deep narrow wound-a stab for instance-we have seen a wounded brachial with only a steady flow of venous-hued blood at the margins of the stream, while in the centre a tiny thread of ar- terial blood could be readily detected. While a fine needle- puncture of an artery will heal, there is no proof that larger ones do without an obliteration of the vessel's lumen. If, then, the current of blood be not permanently arrested by the ligature or some other means, the arterial wound remains open and repeated haemorrhages occur if the soft parts do not heal, while in the latter event a traumatic aneurism will form. Treatment.-This has already been indicated, viz., liga- ture or acupressure above and below the wound for a vessel wounded in continuity ; ligature or acupressure for a di- vided vessel, say in an amputation, and, under certain con- ditions pointed out above, forcipressure, direct press- ure, the actual cautery, etc. Secondary haemorrhage is to be treated on the same lines as primary. The bleeding vessel must be, when possible, secured at the point where it bleeds. If the haemorrhage comes from the dis- tal extremity of an artery ligatured in its continuity, methodical bandaging of the limb with local compression in the wound should be tried ; next, the same with liga- ture of the main trunk higher up ; finally, amputation of the extremity. This latter extreme measure would be indicated in almost every case of aneurism of an ex- tremity which has ruptured externally. Ligature, ex- cept under the circumstances just given, of the main trunk for secondary haemorrhage at a distance from the wound is bad surgery ; but in the case of a stump which has become soundly healed, except for a few narrow sinuses, tying the vessel just above the stump is good practice. Venous Haemorrhage.-From a blow or strain, or in reducing a dislocation, a large vein may be ruptured sub- cutaneously, producing at times a dangerous loss of blood. From direct injury or strain the saphenous vein is that most commonly ruptured. There are especial dangers inherent in wounds of certain veins dependent upon their size and position. For instance, haemorrhage from the internal jugular is not dangerous so much from its amount, but because the brain is directly depleted, re- sulting in rapid and fatal syncope. Wounds of veins at the root of the neck or in the axilla are dangerous, in ad- dition to the amount of blood lost, from the risk of the en- trance of air into the circulation. In general terms this accident results from permanent canalization of the vein by inflammatory thickening, or a similar temporary con- dition from tension of tissues. A third danger is sep- tic or spreading inflammation. That a haemorrhage is venous can be determined by observing that the blood is poured out from one or more points in a steady stream and of a venous hue ; that, contrasted with capil- lary haemorrhage, the flow is greater, and can be arrested by pressure on the distal side of the wound alone, unless one of the largest of the venous trunks be wounded ; and finally, anatomy will indicate in many instances that a vein and not an artery is implicated. Occasionally, the blood from the distal extremity of an artery of the lower extremity, ligatured in its continuity, is of so much darker a hue than ordinary arterial blood that it may be readily mistaken for venous, especially as it flows in a steady stream and is arrested by pressure below the wound. Bearing this fact in mind,' when bleeding occurs after tying a main artery, will prevent any mistake. Position, with compresses and bandage, will check bleeding from any superficial vein, by which means the lips of the wound in the vein come together and heal without obliteration of the vessel. Large veins like the jugular, should be tied above and below the wound with antiseptic ligatures. Although a small puncture has often been successfully treated by picking up the vein- wall with fine forceps and applying a ligature laterally, the younger Gross has shown that it is a far more fatal procedure than complete ligature of the vessel. Capillary Haemorrhage.-This can never be of se- rious import, except in the case of " bleeders," or in those excessively rare cases of purpura haemorrhagica in which, as we have once seen, fatal effusion occurs into the brain. When the wounded surfaces can be seen the blood is observed to come either from a series of mi- nute points or as a general ooze from the whole surface. If the wound be a deeper one, it gradually and steadily fills up, pressure at no one point more than at another being effective for its arrest. The color of the blood is intermediate between arterial and venous. Position, ex- posure to the air, hot water, alcohol, or some other of the styptics mentioned, will suffice to check this form of bleeding. Prolonged bleeding after extraction of a tooth is best arrested by placing a vial cork, cut to fit, in the socket, and binding the jaws together. In the parenchymatous form, due to inflammatory dilatation of the capillaries, hot water, the actual cautery, or Monsel's salt may be necessary. When the haemorrhage is the result of thrombosis of the chief veins ligature of the main artery or amputation higher up is indicated. Charles B. Nancrede. H/EMORRHOIDS. This is probably the most common of all surgical affections. The tumors form either just within or just without the orifice of the rectum, hence the two varieties to be described, of internal and external haemorrhoids. Both originate in a varicose condition of the haemorrhoidal plexus of vessels, the veins being those chiefly affected. The veins of the lower one or two inches of the rectum are of considerable size, ramifying in the sub- mucous connective tissue, and emptying into the inferior mesenteric vein, a radicle of the portal. The veins around the anal region anastomose freely with those of the haem- orrhoidal plexus, even in the substance of the sphincter muscle. It will thus be seen that there is no real differ- ence between an external or an internal pile, except that of its relation to the sphincter muscle. All these veins are valveless, and are therefore liable to overdistention when- ever the abdominal circulation is sluggish, whether from an overloaded colon, diarrhoea, a "congested liver," or dur- ing pregnancy, from the pressure of ovarian or other ab- dominal tumors. Individuals who are compelled to stand or sit for hours together, such as printers, dentists, car conductors, and literary men, are peculiarly predisposed to haemorrhoids, although no age or occupation is entirely exempt. If we add indulgence in stimulants and large quantities of animal food, i.e., those aliments which over- work and thus congest the liver and intestines-excessive smoking, uterine diseases, the use of printed paper as a detergent, the neglect of local ablutions, straining, how ever induced, and heredity, nearly all the predisposing causes have been named. The principal exciting cause is irregularity in emptying the bowels, with the consequent voluminous, costive movements, requiring for their extru- sion forcible efforts which overdistend the lower rectal veins, contusing them as well as the adjacent tissues. Picture a mass of dilated veins projecting into the lower part of the rectum or just at the anal verge, subjected to such frequent acts of violence. What results ? A con- stantly recurring congestion and partial stasis in the efforts at repair ; the perivascular tissues are infiltrated and pro- liferate, and now all the necessary pathological processes for the formation of an haemorrhoidal tumor have been initiated. In thin-skinned persons a circular plexus of 472 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemorrhage. Haemorrhoids. irregularly dilated veins can often be detected just exter- nal to the sphincter, but communicating with the hfemor- rhoidal plexus, covered with extremely delicately textured skin. Ordinarily invisible, during forced defecation they are apt to become much distended, and at times they give way; blood is extravasated into the surrounding connec- tive tissue, a purplish, globular, painful tumor being formed at the anal verge. Incision of a pile of this kind will give egress to a soft, solid, black, rounded coagulum, leaving a cavity with smooth, shining walls. When left to itself the tumor becomes inflamed, hot, very painful, plastic exudates are thrown out, and a tendency to suppu- ration is often manifested, resulting then in a "marginal abscess." Owing to the yielding character of the rectal walls this form of pile is almost of necessity external, rupture evidently resulting from the venous pouches being pressed against the rigid and distended sphincter muscle. As a rare event these tumors may ulcerate, giving rise to one form of hfemorrhage from an external pile. Instead of being contained in one large space in the connective tissue, the blood may be generally infiltrated into the sub- stance of the pile, so that after incision no clot rolls out, and the tumor can only be emptied by squeezing.* When no venous rupture has taken place, an external pile ap- pears as a rounded, purplish, venous-looking tumor, with an ill-defined base, just at the anal verge, running up into the bowel, with the thin skin of the part smoothly spread over it. Another variety consists of a mass of " spongy cavernous tissue, the meshes of which are dilated veins." In this latter form it can remain for but a short time, since the violence of the frequent acts of defecation soon induces changes such as have been already described. These may indeed take place without pain, but, when rapidly induced, there is congestion, cellular prolifera- tion, heat, tension, some pain, a sensation as of a foreign body in the anus, producing a tendency to strain, which only aggravates the trouble-in other words, ' ' an attack of the piles," which, when severe, results in great suffer- ing, furred tongue, fever, etc. An " attack of the piles " may terminate in (1) complete absorption of the effused blood and inflammatory exudates, leaving only a little tab of skin ; (2) after a week or ten days of suffering the acute symptoms may subside, leaving a tumor, no longer acutely painful, only tender, but larger and harder from oedema ; and finally (3) the pile may suppurate, evacuate itself, and leave a soft tab of skin.f A recently formed pile, or an older one which has been accidentally contused, j: is the most common condi- tion for which the surgeon is consulted, on account of the great pain and inconvenience experienced. The local in- flammation often produces general systemic disturbance, evinced by fever, furred tongue, and anorexia. Owing to the pain, a movement of the bowels has probably been resisted by the patient, so that the first indication is a mild laxative, say of castor-oil, aided perhaps by an enema. A warm bath, when obtainable, should be taken. Either painting the pile with a four per cent, solution of cocaine hydrochlorate, or keeping the same constantly applied by means of absorbent cotton, often relieves the pain and also acts antiphlogistically. Pounded ice in a partially filled bladder or rubber bag moulded to the parts, acts as an excellent sedative, ami occasionally aborts the in- flammation when used during the early stages of the at- tack. If not seen until later on, a flaxseed poultice, to which lead water and laudanum have been added, will prove a better application.§ The recumbent position with the hips elevated should be enforced, and the bow- els.be kept in a soluble condition, after action from the oil has ceased, by precipitated sulphur, a seidlitz powder, or the compound licorice powder. These measures, when resorted to early, will afford re- lief in from one to three days, the tumor gradually shriv- elling up to a flap of skin, which will rarely cause fut- ure trouble if costiveness be avoided and frequent local ablutions be employed. If pus forms, a free incision is indicated. Much pain is often produced by the spasmodic and irregular contractions of the irritated sphincter and levator ani muscles, which suddenly arouse the patient just as he is falling asleep. These contractions of the sphincter occasionally interfere with the circulation of a pile, rendering it cedematous. As the pain has usually sub- sided by the time this condition has supervened, nothing more is needed than applications of lint soaked in strong liq. plumb, subacetatis, or an ointment composed of equal parts of the ointments of tannic acid and of belladonna. Such tumors, however, take a long time to shrink. The rule is that the bulk of external piles disappears by ab- sorption. Sometimes they remain painless, but little de- creased in bulk, liable to become inflamed, and always annoying. If frequent ablutions and regular action of the bowels do not prevent trouble, the pile may be ex- cised after the manner advised by Van Buren. An in- cision radiating from the anus should be made through the integument, which must be separated from the tumor well down to its base ; the pile is then to be seized with toothed forceps, and excised by scissors curved on the flat.' By this mode of operating, all risk of contraction of the anal orifice is avoided. After the removal by incision of the clot in the first variety of pile described, it is better to place a little cotton at the bottom of the wound, and confine all in place by a compress and T-bandage, since we were once compelled, in consultation, to use the clamp and cautery to arrest repeated bleedings from one such pile, which had been incised by the family attendant and the clot turned out. Owing to the irritation of the sphinc- ter caused by the excision of external piles, which results in uncontrollable pinchings of the small wounds, these operations should never be done unless really necessary, owing to the troublesome, painful, and tedious inflamma- tions which sometimes follow. Diagnosis.-This must be made with the eye. No false delicacy should be permitted to induce the practi- tioner to treat any rectal ailment from the patient's de- scription alone, since fistula, painful fissure, warty growths, enlarged sebaceous follicles, elevated mucous patches, and tertiary gummatous lumps may be, and are, called by patients "piles." If, after inspection, there re- mains any doubt as to whether a pile be external or in- ternal, or whether it is both, Allingham's device of returning all the protrusion possible within the sphincter ani by gentle pressure, while the patient is directed to draw up the lower part of the gut, will resolve all doubts, i.e., that which remains outside is external pile. Preventive Treatment.-This should primarily in- clude a regular daily time for the movement of the bow- els, a habit which it may possibly need months to acquire, but which is worth any trouble. Simple, well-selected food, consisting largely of fish, fresh, well-cooked vege- tables, and ripe fruits, should be used. Strong coffee, stimulants, condiments, and tobacco should be eschewed. When possible, an abundance of out-door exercise with- out over-fatigue should be indulged in ; or, if this be im- possible, light gymnastics in some form, avoiding all those which necessitate straining. Cathartics must be avoided. If laxatives are absolutely necessary, the nat- ural aperient waters, especially Friedrichshall and Hun- yadi, may be used. To give the patient a fair start in forming the habit of having a regular daily stool, the following pill (Allingham's), which has for years proved successful in our hands, may be prescribed : B. Ferri sulph. exsicc gr. vj. Ext. nucis vomic., Ext. aloes aquos aa gr. viij. Rhei pulv gr. xxiv. Quinise sulph 3 ss. Ext. gent q. s. Ft. mass, et in pil. no. xxx. divid. Sig.-One pill once, twice, or thrice daily at first, then gradually re- duced to one at night, one every other night, or when needed, but finally to be dispensed with. * In some cases the clot may occupy a dilated vehous pouch, and not lie in the connective tissue at all. + Occasionally a minute fistula or sinus is thus produced. t Not from external violence, but by straining at defecation, etc. § Some authorities advocate the excision of intlamed piles after freezing with the spray, or under an anaesthetic, maintaining that the suffering is rapidly relieved and the cure hastened. Having never seen any neces- sity for a resort to such severe measures, we cannot deny its merits, while we do not feel inclined to give it our assent. 473 Haemorrhoid*. Haemorrhoid*. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Self-injection of a small quantity of water before the attempt at a daily stool may suffice without the above pill. (These remarks apply also to the preventive treat- ment of internal haemorrhoids.) On rising in the morn- ing, after each movement, and on retiring at night, free bathing with cold water is not only preventive, but curative ; a little castile soap should be used at the morn- ing and evening ablutions. In concluding our remarks upon external piles, we shall quote from Vau Buren's lectures: ' ' The points to be remembered concerning external piles are : 1, their identity, as to etiology and pathology, with internal piles ; 2, their preventability by intelligent hygiene ; 3, the liability to mistake other growths at the anus for external piles; 4, that they may become inflamed without involving internal haemorrhoidal tumors if these are present; and, finally, the dominant influence of the powerful external sphincter muscle in obstructing their circulation, in aggravating pain when they are inflamed, and in delaying their cure. The chief characteristics of external piles, we have learned, are temporary inflammation and pain, but inter- nal haemorrhoids, or "bleeding piles," is a much more serious affection, tending to break down the general health, to materially interfere with the patient's useful- ness, and in the worst forms to imperil life. Internal piles are much more slowly developed than the external variety, and are only exceptionally acutely painful or swollen. An invariable accompaniment is a greater or less degree of prolapse of the mucous membrane of the rectum, and, as their name indicates, they are the source of more or less frequent bleedings. We must here briefly allude to the observations of Ribes, and also of Verneuil, thus completing what has been said as to the etiology and morbid anatomy of haemorrhoids. These authors have shown that the veins of the lower rectum pass out from the mucous membrane through elliptical openings in the dense muscular coat. These openings are greatly reduced in size during strong contraction of the rectum, as in defecation, thus strangulating the veins, producing overdistention of the extreme capillaries and veinules. These latter form well-defined groups, or districts, under the mucous membrane of the lower end of the gut, each group collecting blood separately for its venous outlet. Let us trace the formation of internal piles to the condi- tion in which they are usually seen by the surgeon, viz., tumors involving the mucous and submucous tissues just above the external sphincter, which rarely number more than three or four, and consist of rounded masses of en- larged arterioles and veinules surrounded by hyperplastic connective tissue, and covered by mucous membrane. Habitual overdistention of one or more groups of capilla- ries, arterioles, and veinules, each emptying by one rectal vein, occurs from any of the causes already mentioned. The overlying mucous membrane becomes congested and granular, looking somewhat like a strawberry. Fre- quent / and habitual bleeding occurs, at times a minute stream spurting out for some distance when the patient strains at stool; and whether this be so or not, the blood is often of a bright arterial hue. Arterial haemorrhage arises from rupture of one or more arterioles, the result of obstruction of the capillary area. This variety of pile sometimes gives rise in comparatively early life-even in childhood-to marked anaemia, without either noticeable protrusion or complaint of local uneasiness, although questioning may elicit the latter fact. Constant bruising and exposure, when prolapsed, cause inflammatory thick- ening of the mucous membrane covering the pile, which becomes smoother and less vascular and t his kind of bleed- ing then becomes less urgent.* In females arterial haemor- rhage is rather uncommon, since their piles belong chiefly, if not entirely, to the variety called venous haemorrhoids. In consequence, in women, internal piles usually lack the velvety appearance so common in men. Although the pressure of the gravid womb and displacements of this organ are peculiar to women, and irregular, constipated bowels are exceedingly common among them, females far less frequently demand operative interference for piles than males. "The greater capacity of the pelvic cavity may lessen the influence of these causes." A gouty diathesis exists in a large proportion of those af- fected with bleeding piles. Heredity is said to be more influential in women than in men. Allingham maintains that the stage of recovery after childbirth is peculiarly favorable to, if it does not actually give rise to, internal haemorrhoids. Irregularity, and neglect of evacuating the lower bowel, sitting long at stool, and prolonged straining, are both the most efficient predisposing, and the commonest exciting causes of internal piles. Groups of varicose vessels, such as we.have described, imbedded in indurated connective tissue, tend to project more and more, as time goes on, into the lumen of the gut, where they act as an impediment to the free passage of faeces. During the extrusion of the faecal matter the piles tend also to be forced out, thereby stretching the lax submucous connective tissue, until on some occasions they actually slip down, carrying with them more or less of the mucous membrane, constituting prolapse of the same. The sphincter at once contracts behind them and prevents their return, leaving a cluster of partially stran- gulated, purplish, vascular tumors from whose surface blood oozes rapidly, or actually flows in a stream. The protruded masses suggest to the patient that there remains a portion of faeces not yet extruded, and he consequently strains, increasing the haemorrhage and prolapse. On as- suming the upright posture the sphincter relaxes and the piles spontaneously recede. This is true, however, only in their incipiency, for, after having been repeatedly ex- truded, the piles become larger, the submucous tissue more lax, and the sphincter weaker, so that the pilesnow require reduction by the hand or by prolonged sitting on some prominent object, as the arm of a chair. As time goes on the sphincter yields more readily, the piles come out at other times than when at stool, from some slight effort or from the mere weight of the superincumbent viscera. The sphincter now, however, resumes its neg- lected functions, contracts and painfully nips the pro- lapsed parts, compelling the patient to retire and " put up his piles." Suppose the patient, for some reason, is pre- vented from, or neglects replacing his piles, what occurs? They become strangulated and irreducible from interfer- ence with the return of blood-perhaps acutely inflamed. Occasionally strangulated and irreducible piles become gangrenous, sloughing off either partially or entirely ; in this latter event a cure results, but if the destruction of tissue be excessive there is some danger of anal stricture resulting. Age bears an important relation to internal haemorrhoids, since they belong chiefly to the middle pe- riod of life, while after fifty years of age the tendency to bleed gradually grows less and finally disappears. The tumors may indeed remain, especially if they be much indurated, and with them the old tendency to prolapse, but generally they atrophy, leaving little if any future discomfort unless the prolapse is bulky. When there is a marked hereditary tendency aided by faulty habits, the disease may appear at puberty, or-as in one case reported by Allingham-even so early as three years. Loss of acute sensibility of the anus and a relaxed, atrophied sphincter, is in old-standing cases a not infrequent cause of incontinence of flatus, and even of faeces, besides fa- voring prolapse. Unless irritated by remaining in the grip of the sphincter, internal piles are not usually pain- ful, and even then complete reduction and the recumbent position generally relieves this. Occasionally, however, portal obstruction or a local gouty congestion may, even after reduction of the piles and rest, produce a sense of uneasy fulness in the rectum unless the piles bleed. Re- lief of this so-called " haemorrhoidal fluxion," as the old writers term it, can be afforded by blue pill, followed by a saline laxative, with the exhibition of colchicum in the gouty, and the avoidance of stimulants or much nitroge- nous food. Of course, strangulated internal piles are ex- cessively painfid. The haemorrhage from internal hae- morrhoids is often unsuspected ; its amount is usually * The pile has now reached the stage of the " arterial hremorrhoid " of Allingham, who calls it in the primary condition a '•capillary" hiemor- rhoid. 474 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. HieinorrlioidS' Haemorrhoids. underestimated, and persists often for years. The degree of debility seems disproportioned to the losses of blood, as stated by the patient, often amounting to profound anaemia, with its symptoms of languor, dyspnoea, palpita- tion, inability for exertion, sallow complexion, pale lips, etc. Often the patient can hardly be persuaded that his troubles are not due to some other cause rather than to the-to him-trivial daily loss of blood. As haemorrhage is usually more copious before the full formation of the haemorrhoidal tumors, it may escape the patient's notice, so that in cases of apparently causeless anaemia an inquiry should always be made as to whether blood is lost at stool or any protrusion occurs at that time. These queries should always be supplemented by an examination of the anus, which should be gently pulled apart while the pa- tient strains, when oftentimes an unsuspected pile is dis- covered. The symptoms such as we have described are, in our experience, those common in this affection, yet authors describe a train of symptoms, before either hae- morrhage or protrusion occurs, which are stated to be characteristic, such as ' ' difficulty in micturition, dimin- ished sexual power and desire, pain in the genitals, loins, and thighs, and formication in the lower extremities." These symptoms are certainly not characteristic of piles, and are mainly due to anaemia, which we believe has been induced in these cases by slight unsuspected losses of blood, which care and attention would detect, since a mere varicose condition of the lower rectal vessels, with- out protrusion of the masses and consequent irritation, is entirely inadequate to produce the alleged symptoms. Diagnosis.-Unless indurated, an internal haemorrhoid often escapes detection by the examining finger if the pa- tient is recumbent. An injection of warm water, followed by straining efforts, or a gentle dilatation of the sphincter under an anaesthetic, is the most satisfactory method of detecting them ; sometimes a speculum will suffice, with- out either injection or dilatation. Careful examination by the finger should be made of the rectum higher up, since the piles may be symptomatic of a stricture of the rectum. Treatment.-Palliation is all that many patients will permit the surgeon to attempt. In addition to the ab- stinence from excess of animal food, stimulants, and tobacco, with the regular evacuation of the bowels and cold bathing after stool, advised when treating of exter- nal piles, the remedies to be recommended as palliatives are but few. Where prolapse at stool is habitual, the use of the bed-pan for a considerable period is advisable. Either an ointment of subsulphate of iron ( 3 j.- § j.)may be smeared over the prolapsed piles, or after their reduc- tion a suppository, containing grs. ij. to grs. v. of the drug, may be introduced into the rectum at night. Again, in the so-called capillary pile, which is most common in young plethoric subjects, where the haemorrhage is free, pure nitric or carbolic acid may be applied to the red, vascular, velvety surface whence the bleeding proceeds. In a certain proportion of cases this will actually cure, if the patient will live judiciously afterward ; in nearly all it will arrest the haemorrhage for months-perhaps longer. The same end may be attained quite as well by the use of the Paquelin thermo-cautery at a dull red heat. If either of the acids just named be used, they must be cautious- ly applied to the previously dried diseased surface of the pile by means of a round-ended glass rod or piece of wood, carefully avoiding contact with the surrounding healthy surface. Thus used, these acids are not painful applications, but in a nervous patient the previous appli- cation of a four per cent, solution of hydrochlorate of cocaine will enable us to promise that there will be no discomfort even. Such remedies, however, can effect but a temporary diminution of haemorrhage, if tumors have already formed and prolapse has commenced. A cold- water enema just before going to stool, softening the lat- ter, and causing contraction of the blood-vessels of the pile, is of benefit, as it also stimulates the muscular coat of the rectum and the sphincter, preventing prolapse. After an evacuation, any existing protrusion should be returned, and a couple of ounces of iced or cold water should be thrown into the rectum aud allowed to remain. The venous form of piles can often be much benefited by the correction of displacements of the womb, by restric- tion of the amount eaten and drunk by habitual over- feeders, and by relieving portal congestion. In all varie- ties of piles, if there be stricture of the rectum or urethra, correct these conditions; if the prostate be enlarged per- form no operation, or at most inject with carbolic acid ; if there be phymosis, circumcise ; if there be a vesical calculus, remove it. The administration of a blue pill every other day for a week, with or without some mild laxative, will usually be beneficial to any case compli- cated with hepatic trouble, and will be advisable as prep- aratory treatment for these cases, when they demand surgical interference. By some or all of the means sug- gested we have afforded relief for such long periods as to induce the patients to consider themselves cured. For the radical cure of internal haemorrhoids three procedures are available: 1, Injection ; 2, strangulation with the ligature, and 3, the clamp and cautery. Exci- sion must never be contemplated, since fatal haemorrhage has often followed it. The ecraseur is only mentioned to be condemned. 1. Injection.-For this purpose pure carbolic acid is far superior to all other agents, although the daily injection of a solution composed of fluid extract of ergot, f 3 ss. to water f 3 ss., has been used with a good result. Al- though Kelsey and some others contend that all varieties of piles are adapted for the carbolic-acid treatment, we consider this to be an error, and one calculated to bring this method of operating into disrepute, as it has done that by nitric acid in the past. Only those piles which are non-indurated and situated well above the sphincter should be injected. In this form there are merely blood- vessels, whose contents can be coagulated, or whose walls, can be stimulated to contraction after partial or complete thrombosis of some of their tributaries has decreased the intra-vascular tension. In the indurated pile the mass is largely composed of hyperplastic connective tissue, which, owing to the stagnant and relatively deficient blood-sup- ply, can only rarely be absorbed, so that, unless actual sloughing be induced, but slight if any improvement can be effected. According to its most ardent advocate, " the tumors are not removed, except when sloughing occurs, but are rendered inert, so that they no longer bleed nor come down outside the body." The explanation is that hyperplasia of the connective tissue is induced, which by its contraction strangulates the vessels of the pile. This, certainly cannot be the correct explanation, since all in- durated piles are hyperplastic to excess, yet go on grow- ing. Our experience of this method is but limited, and is not very favorable. We cannot help thinking that if these injection cases are followed up for long periods, they will be found, in many instances, to be obnoxious to the charge of a liability to prolapse, bleeding indeed no longer-as is so commonly the natural history of piles in those over fifty years of age-but not really radically cured, unless sloughing has occurred. Although often unattended even with discomfort, this method sometimes gives agonizing pain. Small mar- ginal fistulas may result, requiring slitting up if they do not spontaneously heal. If the injection, especially if strong, be thrown beneath the pile into the general sub- mucous tissue, or if a strong solution be used for a small pile, a most serious ischio-rectal abscess often results. Ulceration is not uncommon, but is said to be tractable. Operation: The tumors must be well exposed by a previous warm-water enema, aided by the patient's strain- ing. If this do not suffice use a speculum, or draw down the tumors by toothed forceps or a tenaculum. An or- dinary hypodermatic syringe will do, but the one specially constructed for the purpose, as sold by most instrument- makers, is better. The needle-point must be entered " perpendicularly from the apex, and not passed upward under the mucous membrane in a longitudinal direction, so that the injection reaches the central tissue of the pile." After injection, the pile, if prolapsed, must be gently re- placed, and " each injection should be followed by a day's rest in the horizontal position." Provided the patient's bowels act regularly, no after-treatment is required. 475 HtmiorrlioidH. Hair. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The strength of the solution varies with the result aimed at. Kelsey advocates the injection of five drops of pure carbolic acid into large, vascular, well-defined, prolapsing tumors, "expecting to produce a circum- scribed slough, resulting in a radical cure." Such an in- jection will, in some instances, produce evanescent toxic effects. A solution containing one-third carbolic acid, repeated several times, will, according to this author, pro- duce a cure without slough. " A small, slightly protrud- ing, non-pedunculated tumor, merely felt as a prominence on the mucous membrane, may be cured by a single in- jection of a five per cent, solution, which will cause it to harden and shrink, while a fifty per cent, solution might give a good deal of trouble." With the weaker solutions the treatment will last from three to four months, the in- jections to be repeated twice weekly, unless sloughing is produced. One pile only should be treated at a sitting, but if very large, two or more injections may be used of the five per cent, solution, introduced some distance apart. No one method should be employed to the exclu- sion of others and, in our opinion, this method should be restricted to the soft, non-indurated, non-prolapsed piles. If a radical cure of indurated prolapsed piles can only be insured by producing a slough, often causing severe pain, we should prefer the clamp and cautery, when we are sure of removing the tumor at one operation, and can ex- actly determine the extent of our slough. As to the dan- gers, we cannot think that a charred, i.e., antiseptic, sur- face can be more dangerous than a slough produced by carbolic acid, since both must leave a granulating surface, and before that both are equally protected from the in- gress of micro-organisms. We have devoted so much space to this subject, because carbolic acid injection is now the fashionable method of treatment; but we are con- vinced that time will prove it to be only one of the methods adapted to a certain class of cases. Treatment of Strangulated and Irreducible Internal Piles.-As many authorities recommend im- mediate operation for strangulated piles, we shall now in- dicate the measures to be adopted when operation is either considered unadvisable or is rejected by the patient. In passing we must say that we have not become convinced of the propriety of operations upon inflamed piles, be- lieving that this condition is no real exception to the good surgical rule of not operating upon acutely inflamed tis- sues when avoidable, which is undeniably possible in strangulated piles. In reducing strangulated piles the prone position, with the hips well elevated by means of two or more pillow's placed beneath the pelvis, is essential, calling in, as it does, the aid of the gravitation of blood and of the intestines toward the chest. If reduction is attempted without general anaesthesia, the continuous ap- plication of a four per cent, solution of hydrochlorate of cocaine, for about fifteen minutes previous to the attempt, is advisable. All grease must be first carefully removed from the piles by gentle ablution w'ith soap and warm water, in order to obtain the full effect of the cocaine. The protruded mass, after being thoroughly anointed with some greasy substance, must be emptied of all superfluous blood by gentle pressure, and then returned within the bow'cl by the pressure of the fingers of one hand, while the forefinger of the other is introduced into the bowel, mani- pulations being used much resembling those employed in returning the gut after herniotomy. In many cases the protrusion will, in a few moments, slip up much as an inverted glove-finger is replaced. If the taxis fails, and general anaesthesia cannot be resorted to, the piles may be frozen by ether or rhigolene spray, or if these arc unat- tainable, ice may be kept continuously applied for an hour or so, the patient still retaining the position sug- gested, when a repetition of the efforts at reduction will usually prove successful. Should eventual failure re- sult, cocaine continuously applied, or moderate cold,* or both may be tried, or perhaps warm anodyne poultices will prove more comforting. The piles either gradually shrink or become reduced, or slough in part or wholly. Should the surgeon decide upon operation, he should be aware that if mortification is far advanced there may be much difficulty in making ligatures hold, so that haemor- rhage, difficult to arrest, may result from their cutting through the friable tissues. Operationby the Ligature.-Gentle, but forcible, stretch- ing of the sphincter should be a preliminary to either the ligature or cautery operation. This manoeuvre gives ready access to the parts, and saves the patient from the painful pinchings of an irritable sphincter. The best position for the patient is the Sims position for operation on the uterus or vagina, in which he should be placed after full anaesthesia has been induced. A preliminary evacuation of the bowels by means of a laxative given the night before, and a tepid enema a half-hour or so be- fore the operation, should not be omitted. After full dilatation of the sphincter each pile in turn should be seized with the vulsellum, toothed forceps, or tenaculum, and separated from the muscular and connective tissues by dissecting it up with the scissors parallel to the bowel. The incision is to be started in the sulcus-commonly in- dicated by a whitish line-where the mucous membrane and skin meet. As the vessels run parallel to and just beneath the mucous membrane, entering the pile at its upper part, the dissection can be carried on without dan- ger until the tumor is connected by a pedicle composed only of the vessels and mucous membrane. A strong, well-waxed ligature must now be carried well down to the bottom of the wound, the pile be firmly pulled out, and the thread tightly tied as high up the pedicle of the tumor as possible. The surgeon had better begin with the smallest piles first when a number are present, lest they be overlooked, and the most inferior ones should be attacked first, so that the flow of blood may not obscure the operator's view. After each pile has been tied the bulk of it must be re- moved by the scissors, leaving only enough to prevent the ligature from slipping ; the latter must be cut short, and when all the haemorrhoids have been thus dealt with, the stumps must be carefully returned into the bowel well within the sphincter. Any external tabs of skin requiring removal should now be snipped off with the scissors, bearing in mind that a too free removal of skin may cause undue contraction of the anus. Before recov- ery from anaesthesia, a rectal suppository containing a couple of grains of opium should be introduced, and a compress of lint or cotton firmly secured over the anus by a T- bandage ; this tends to obviate anal spasm and consequent pain. Operation by Clamp and Cautery.-Each tumor must be separately dealt with, being drawn firmly out by a vulsellum so that the clamp can be carefully applied to the base of the haemorrhoid. After screwing the clamp tight, the operator should remove, with a pair of curved scissors, all of the tumor which projects above the clamp, except about a "scant fourth of an inch ; " if the stump be cut too short the cautery cannot act effectively in sealing the vessels. The stump, after having been wiped dry, should be slowly and thoroughly cauterized with the iron at a dull red heat, destroying the stump down to the surface of the clamp.* Special attention should be paid to sealing the vessels at the upper end of the pile, where its chief vascular supply enters. A still better method of operating is to use cautery-irons like those of Mr. II. Smith, with either a dull chisel or a serrated edge, which must be made to travel along the upper surface of the clamp until the protruding portion of the pile is removed. Whichever method has been employed, after the cauteri- zation has been completed the clamp must be loosened turn by turn, and while this is being done, care must be taken to press it well down against the bowel, lest the stump slip out too soon ; if, during the loosening, any vessel bleeds, it must be cauterized anew with or without retightening the clamp. All the piles having been treated, the stumps are to be gently returned well up the bowel * Ice continuously applied where mortification is advanced may induce a most extensive destruction of tissue, and must, therefore, be used with caution. * We are aware that somewhat different advice has been given, but that above is the outcome of our own experience. 476 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Haemorrhoids. Hair. by the oiled finger, an opium suppository introduced, and an anal pad and T-bandage applied. The advantages of the cautery over the ligature arc said to be the immunity from tetanus, pyaemia, and haemor- rhage. the less chance of retention of urine, and the free- dom from pain. Our experience, so far as it goes, bears out these statements. Haemorrhage has occurred even in Mr. H. Smith's hands, whose experience of this method is greater than that of any other operator, and contraction of the anus may occur if the operation is an extensive one.* Pyaemia has occurred in a very few instances in the hands of other operators. Personally, while employ- ing no one method of treating piles to the exclusion of all others, we prefer the use of the clamp and cautery. After-treatment.-This is the same for either the ligature or clamp and cautery operation. The diet should be light and unstimulating, such as beef- or mutton-broth, beef-tea, milk, tea and toast, etc., until after the first mo- tion, when a more liberal diet may beinstituted. Unless there is some special condition demanding their use, wine, beer, or spirits should be strictly interdicted. If reten- tion of urine occurs, a warm hip-bath is indicated, and often suffices ; if not, the catheter must, of course, be used. The bowels had better be opened on the third or fourth day by castor-oil, aided perhaps by an olive-oil injection carefully thrown into the bowel just before the stool, which may be thus rendered painless, although the patient should be warned that he may experience severe pain and have a little bleeding. The bowels-kept quiet, if necessary, by paregoric-should be again relieved in two or three days, when-i.e., after the lapse of a week- if the patient has not previous to operation lost much blood, he may be allowed to exchange his bed for a sofa. At the end of ten days-better two weeks-although the cut surfaces are not usually entirely healed, they are in a condition to allow of moderate exercise or a return to light work. An enema should precede every motion for at least two weeks after operation, since a costive move- ment or hard straining at stool will sometimes, so late as ten days, induce rather smart bleeding from the con- gested granulating surface of the ulcers. Should the ul- cers fail to heal, or extend, after any method of operating, the granulating surfaces must be treated upon general principles.1 Charles B. Nancrede. 1 See articles on Diseases of the Rectum for treatment of chronic ul- ceration of this portion of the bowel. the condition. In former times venesection was much in vogue as a means of rapidly reducing the volume of the blood, and thus favoring coagulation at the mouths of the bleeding vessels. The same result may often be obtained by temporarily withdrawing a part of the blood from the general circulation by means of a moderately tight liga- ture applied around one or more of the limbs, near the trunk, in such a manner as to prevent the return of blood through the veins, but without obstructing the main ar- teries. Hot and stimulating pediluvia, sinapisms, dry cupping, etc., may be useful for the same purpose. Seda- tives are of advantage only in active haemorrhage, and are useless in the passive forms of bleeding. Of the internal remedies used to control haemorrhage the most important are ergot, digitalis, acetate of lead, and some of the astringents. Ergot and digitalis, and probably also the acetate of lead, exert their haemostatic action by causing a contraction of the arterioles. The principal astringent employed for this purpose is gallic acid, though it is a question as to how much value this substance really possesses when internally administered. If it have any action, it must be a remote one, and may be due to a general constriction of the tissues. Turpen- tine has also been extensively used in haemorrhages, es- pecially those from the lungs, stomach, and intestines. The astringents, when applied locally for the arrest of bleeding, are called styptics. The most commonly used are tannin and the substances containing it, the strong acids, alum, creosote, acetate of lead, and the chloride and subsulphate of iron. Styptics are often employed too recklessly in large open wounds when the ligature, press- ure, or ice would be much more effectual and would not inflict an injury on the parts, preventing primary union. The writer has seen extensive lacerations of the soft parts, and even scalp-wounds, which had been deluged with Monsel's solution, with results which can readily be im- agined. Styptics should never be used except in capil- lary bleeding from small wounds, such as leech-bites, epistaxis, and the like. The only exception to this is the case of haemorrhage from some of the large cavi- ties, as the uterus after delivery, or the stomach. Some substances occasionally used to stanch the oozing of blood do so mechanically by causing coagulation. Thus, cobweb and punk are often used in domestic practice to stop bleeding from cuts made with the razor or a penknife. Powdered rice, which is said to have marked haemostatic powers, probably acts in the same way. Among other sub- stances which have been recommended as good styptics and free from the objections urged against the iron salts are colophony (the resin left after distillation of turpen- tine), tincture of urtica dioica (or the common nettle), and antipyrin in solution. There yet remain to be mentioned heat and cold, both of which are haemostatics of considerable power. Hot- water injections within the uterus are one of the most effective means of controlling haemorrhage after delivery, and sometimes the alternation of hot and cold injections will'stop the bleeding when all other means have failed. A still greater degree of heat, in the form of the actual cautery, is often used to close bleeding vessels in opera- tions. Chemical cauteries, such as nitrate of silver and the undiluted mineral acids, are also frequently em- ployed. T. L. S. H/EMOSTATICS. Syn: Fr., Hemostatiques ; Ger., Blutstillungsmittel. By this term are designated all those means, mechanical, chemical, or physiological, by which the escape of blood from arteries, veins, or capillaries is arrested. The principal agents of this class are the lig- ature, pressure, posture, rest, revulsives, sedatives, heat, cold, ergot, digitalis, astringents, and styptics. In all cases in which the bleeding occurs from arteries of any but the smallest, calibre, if the vessels are acces- sible, the ligature is the most effective haemostatic. When the vessels are superficial and lie over bony prominences, as the head or face, the flow of blood may usually be easily arrested by simple pressure. This means, in the form of a tampon, is often employed when haemorrhage oc- curs from open vessels in the various cavities of the body. When it is not deemed advisable to apply a ligature, or when the tissues are in such a softened condition that this means is inapplicable, acupressure may often be ad- vantageously employed. Simple rest or elevation of the bleeding part may so reduce the force of the circulation that spontaneous haemostasis will occur. The same re- sult of reduction of the blood-pressure may be obtained by opium or chloral in large doses. Some writers recom- mend emetics in haemoptysis and other haemorrhages on account of their sedative action, but they are rather to be shunned, since vomiting will almost surely aggravate HAIR, DISEASES OF. Some of these have been, or are to be, treated under other heads. Thus, the thinning or diminution of the number of hairs below the normal will be found under the heading Alopecia. Abnormal increase in the number of hairs, or the profuse produc- tion of hairs in unusual situations, will be described under the heads of Hirsuties and Nmus pilosus. Premature loss of color-graying or whitening of the hair-will be found described under the title Canities, and the better known fungous diseases of the hair under Tinea tonsu- rans and Tinea farosa. The affections to be treated of here are those which involve the structure of the hair- shaft itself. Excepting for the fact that they are dis- figuring and annoying to those affected, the diseases here to be considered would scarcely merit attention, were it * When either the ligature or cautery is used for numerous piles, anal contraction may occur, especially if skin be injudiciously removed. After such operations the nightly or occasional use of a rectal bougie or the finger, for a few weeks, is advisable. 477 Hair. Hair. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. not that the careful study of such changes and diseases of the appendages to the skin are calculated to assist in the solution of the general problems of pathology. That disease of the hair which is most frequently ob- served is atrophy, " Atrophiapilorumpropria." Whether or not a true progressive and morbid diminution in bulk of the hairs takes place, it is certain that their physiolog- ical term of life may, under some circumstances, be di- minished. The hairs lose their normal condition, become dry, lustreless, rough, brittle, cleft, and fibrillated; they swell out and break off. These changes often take place as the result of morbid processes occurring in the parts from which the hairs arise-their follicles, the sebaceous glands, or the cutaneous structures immediately adjoin- ing. After fevers and other severe constitutional dis- turbances likewise the hair may become dry and lustre- less, and tend to fracture and splitting. In addition to these conditions which affect the hairs in general, there are several forms of atrophic structural alteration which must for the present be termed idio- pathic, because we cannot assign any cause for them. One of these is the well-known phenomenon known as scissura pilorum, in which the hairs become split up at their extremities. In some persons, particularly in fe- which Beigel gave the rather cumbersome name of " swelling and bursting of the hairs," but which Kaposi called tricorrhexis nodosa, the name by which this affec- tion is now generally known. (See Fig. 1531.) According to Kaposi, the affection is usually confined to the hairs of the beard and the eyebrows, though at least one case has been observed in which the hairs of the scalp were involved. The affected hairs show exceed- ingly small, somewhat transparent or glistening, conical swellings. There may be one, two, five, or more on the same hair-shaft; the little nodes being placed at various distances from one another, like pearls on a string. On a slight examination they might be taken for ova adherent to the hair, but on closer inspection they are found to belong to the hair itself, and do not consist of adherent masses. Some hairs have a conical, or fan- or brush-shaped en- largement at the end of each, and if this occurs on many hairs, on the mustache, for instance, the impression is conveyed that the hair has been singed by a flame, and has curled up at the burned end. The hairs thus affected are firmly fixed on their papillae, but break easily at the seat Fig. 1530.-Nodose Condition of Hair of Scalp. (Walter G. Smith.) Fig. 1531.-Tricorrhexis Nodosa : Beard. (Kohn.) males with long hair, or men with long beards, nearly all the hairs split up in this way. But this splitting is prob- ably without significance, and does not affect the growth of the hair. (See Fig. 1536.) Duhring has reported a single case of an " undescribed form of atrophy of the hair of the beard," characterized by atrophy of the hair-bulb and by splitting of the hair-sub- stance. To the naked eye the affected hairs varied in size and form, some having a uniform diameter several times greater than normal, while others throughout their length were unusually slender. The bulbs were in nearly all instances smaller than normal, and had a markedly contracted look. Not infrequently the diameter of the bulb and root were considerably less than that of the shaft. The majority of the hairs showed splitting into two, three, or more parts throughout their entire length. Under the microscope, atrophy of the bulbs and fission of the hair-substance were the conspicuous features. In the majority of the specimens the bulbs were distinctly shrunken and atrophied, appearing as small, contracted points or knobs. The hairs, as a rule, began to split within the bulb. (See Fig. 1535.) Another decidedly pathological condition is that to of the swellings. The stump of the hair which remains shows the lower half of a node as its extremity. Microscopic examination shows the nodes to consist of spindle-shaped swellings produced by a splitting asunder of the fibres of the hair-structure, so that the appearance presented is that of two besoms or birch-brooms rammed end-to-end together. The researches of Kohn seem to show that a separation or swelling takes place in the body of the hair, and that this produces a lighter color in the hair at the nodal points, as seen by reflected light, while the splitting takes place at a later stage of the disease. The cause of the disease is not known. Some observ- ers have considered it due to a parasite invading the hair, while others have thought the swelling and bursting of the hair to be due to the development of air in its tissues. The process itself is in reality in all probability an atro- phy, as has been recently suggested by Virchow, who suggests the name " intermittent atrophy," or " aplasia. " (See Fig. 1531.) This latter designation is particularly appropriate to the form of disease described by Walter G. Smith un- der the name of "A Rare Nodose Condition of the Hair," which, while presenting certain analogies with tricor- rhexis nodosa, differs from that disease in several impor- 478 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hair. Hair. of the nodes is two and a half times that of the narrow internodes. In tricorrhexis the diameter of the hair-shaft is not increased to any appre- ciable extent, and any enlarge- ment that is to be seen is due to the loosening and separa- tion of the fibres. The nodes are very numer- ous, and succeed each other like beads on a necklace. The condi- tion is very rare. (See Fig. 1530. Under the name tinea nodosa (see Fig. 1532) Cheadle and Morris have described a peculiar con- dition of the hairs of the mus- tache. To the naked eye the hair appears thickened and rough, with some incrusting material, and here and there nodular swellings. Numbers of hairs are broken off short, with brush-like ends. Under the microscope the roughness and thickening are seen to be due partly to an irregular in- crustation of granular-looking material around the shaft, and external to it, and partly to the swelling of the shaft itself by the incipient separation of the fibre-cells of the cortex. With a higher power the in- crustation is seen to be com- posed of an agglomeration of minute spherical light-refract- ing bodies of uniform size, having all the characters of the sporules of a vegetable para- site. The sporules are larger than those of tinea tonsurans. Piedra (Spanish for " stone ") is the name of a peculiar affection of the hairs of the head in women, occurring tant particulars. In Smith's cases there was the forma- tion of nodose swellings, or rather of atrophies with the production of a nodular appearance in the intervals, the altered hairs occurring in multitudes on the scalp, while tricorrhexis nodosa is almost invariably found in the beard and not on the scalp. When traction is made on the hair a break occurs invariably between the nodes, while in tricorrhexis nodosa the fracture occurs through the nodes. Another point of difference between this af- fection and tricorrhexis nodosa is that in the former the Fig. 1532.-Tinea Nodosa. (Cheadle and Morris.) Fig. 1534. - Concretions from Hair of Axilla. Fig. 1533.-Piedra. (Morris.) nodes are opaque, and constitute the darkest part of the hair, while in the latter they are invariably white. (See Figs. 1530 and 1531.) There is a great disproportion between the swollen and constricted portions of the hair. The average width Fig. 1535.-Fragilitas Crinium; Splitting at the Root. (Duhring.) only in certain parts of South America. It is character- ized by the formation of minute black nodes along the 479 Hair. Hallucinations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hairs which rattle like stones when the hair is combed, and which are so intensely hard that great difficulty is experienced in attempting to cut one, the knife slipping to one side or the other, and finally breaking the node if considerable force is used. Under the mi- croscope (see Fig. 1533) the appear- ance seen is that of a honeycomb mass, consisting of spore- like bodies deeply pigmented on the sur- face. The mass appears to originate from one cell that grows by budding, not only laterally, but in every direction, forming radiating columns of spore - like bodies. A s soon as the mass has grown to a certain size, the sur- face cells seem altered in shape, becoming darker in color, and forming a pseudo epidermis. Mr. Morris, who has made a care- ful study of the disease, considers it fungoid in character, probably due to some fungus of the genus ascomycetes. Knotting of the hair, due to some peculiar change in the con- dition of the shaft, has been ob- served by Bulkley and others. The knots may at times resemble the nits of pediculi. Occasionally a peculiar condi- tion of the hairs of the pubis and axilla is observed, when amor- phous yellowish, reddish, or brownish masses are found clinging to the hairs along a greater or lesser portion of their length. (See Fig. 1534.) These, in the opinion of the writer, are in all probability concretions of some of the sebaceous and sweat secretions, or their derivatives. The treatment of the various forms of hair-shaft dis- eases is unsatisfactory. Tricorrhexis nodosa, and prob- ably the other affections described, are best treated by frequently repeated shaving, though this often proves only a temporary relief. Schwimmer has used the fol- lowing ointment with success: R. Pulv. zinci oxidi, Gm. 0.5 (gr. viij.); flor, sulphuris, Gm. 1.0 (gr. xvj.); ung. simplicis, Gm. 10.0 (gr. clx.). M. Sig. : Rub in morning and evening. When fragilitas crinium is con- nected with a generally-debilitated condition of the hair, arsenic and cod-liver oil may sometimes be of use by im- proving the general nutrition. climate, like that of other Alpine regions, is healthful, and the air fresh and invigorating ; but the weather is rather cold and changeable until after the middle of May. All comforts are provided for visitors. The springs are situated a short distance from the vil- lage, and are of value chiefly on account of the consider- able amount of iodine and bromine which they contain. The most important of them are the Tassiloquelle, the Badquelle, and the Gunterquelle. The first of these is especially employed for drinking. One pint of the water contains 10.15 grains of solid matter, a partial analysis of which reveals: Grains. Sodium chloride 93.465 Magnesium iodide 0.448 Magnesium bromide 0.327 Ferrous carbonate 0.030 Free carbonic acid (in cubic inches) 3.46 A partial analysis of the Gunterquelle, which is also used for drink, shows it to contain -. Grains. Sodium chloride 18.201 Magnesium bromide 0.079 Magnesium iodide 0.037 Sodium carbonate 4.300 Calcium carbonate 0.076 The amount of these waters daily consumed by each patient at the drink-cures varies between four and twenty ounces. The baths are prepared with from ten to twenty per cent, of the water containing iodine. Indications.-The so-called scrofulous diathesis is the chief indication for the waters of Hall, whether the symp- toms be an infiltration of the lymphatic vessels or lesions of the bones or joints. They are recommended also for the treatment of granulated eyelids, eczema, lichen and lupus, nasal catarrh, ozena, and otorrhoea. The symp- toms of infantile syphilis rapidly disappear under their use. Many cases of ovaritis and chronic metritis are treated here, and the waters have gained so much reputa- tion in the treatment of goitre that the Tassiloquelle has been called the " goitre water." The Badquelle, as its name implies, is used almost ex- clusively for bathing, a well-fitted establishment having been erected for that purpose. Sitz-baths and inhalations are also administered. J. M. F. Fig. 1536.-Fragilitas Crini- um ; Splitting at the Tip. HALL. A city of about five thousand inhabitants, in Tyrolese Austria, on the Rosenheim-Innsbruck Railroad, about five miles from the latter terminus. It is of interest chiefly on account of its remarkably strong salt springs, the waters of which, diluted, are used for bathing. The principal establishments using the water are the Heilige Kreutz and the Baumkirche, the former a mile northwest, the latter four miles northeast, of the springs. Netwald's analysis of the water from the principal sources indicates the presence in one pint of Grains. Sodium chloride 112.044 Potassium chloride 0.049 Ammonium chloride 0.033 Calcium chloride 2.933 Magnesium chloride 2.622 Sodium iodide 0.061 Magnesium iodide 0.285 Magnesium bromide , 0.518 Calcium phosphate 0.026 Calcium carbonate 0.480 Magnesium carbonate 0.242 Ferrous carbonate 0.088 Silica 0.073 Duhring: Atrophy of the Hair of the Beard, Am. Jour. Med. Sci., July, 1878. Beigel: Heber Auftreibung und Bersten der Haare, Sitzungsb. der Wien. Akad. Math.-Natur KI., Bd. xvii., s. 612, 1855. Devergie: Tricoptilose, Ann. de Derm, et de Syph. i., iii., 1870-71, p. 5. Kohn, S.: Ueber Tricorrhexis Nodosa, Vierteljahrsch. f. Derm. u. Syph., viii., 1881, p. 581. Smith, Walter G. : A Rare Nodose Condition of the Hair, Brit. Med. Jour., v. i., 1880, p. 654. Desenne : Piedra, Bull. Gen. de Therap., i„ 95, 1878, p. 32. Pye-Smith, P. H. : Piedra, Trans. Path. Soc., Lond., v. xxx., 1879, p. 439. Cheadle and Morris: Tinea Nodosa, Lancet, v. i., 1879, p. 190. Bulkley: Curious Knotting of the Hair, Archives of Dermatology, vol. vii., 1881, p. 403. Michelsen: Ziemssen's Hautkr., v. ii., p. 144. Arthur Van Harlingen. Bibliography. Total 119.454 Carbonic acid gas 1.37 The baths, for the administration of which every facil- ity is afforded, are indicated in all cases requiring a strongly stimulating saline water. J. M. F. HALL. A town in Upper Austria noted for its mineral springs. It is beautifully situated at the foot of the north- ern slope of the Alps, about 1,230 feet above sea-level; six miles by carriage from the railroadst ation at Steyr, The HALL. A walled town in Wurtemberg, known also as Swabian Hall, situated in a deep valley on both sides of the Kocher River, thirty-five miles northeast of Stutt- gart, on the railroad from Heilbronn-to Krailsheim. The town is of interest on account of its rather weak saline 480 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hair. Halin dilations. spring, containing only 2.84 per cent, of solids. A partial analysis reveals ; most interesting on record. After a period of mental agitation and irritation he was visited by phantoms of persons both deceased and living, known and unknown, lie could distinguish these from realities. He endeavored to hallucinate acquaintances voluntarily, but, however vivid his imagination of them, never could succeed in seeing them externally; though hallucinations of these persons would appear when he did not seek them. On shutting the eyes they sometimes disappeared and some- times remained. In about four weeks they began to speak. Other means of relief failing, Nicolai was finally bled. During the operation the room swarmed with figures, which gradually became paler, moved more slowly, and finally dissolved. It is interesting to note that hallucinations may some- times be made to disappear by closing or covering the eye. On the other hand, they may persist when the eyes are closed, or occur in darkness. Persons who have lost their sight may still be subject to visual hallucinations. How long after the onset of blindness this liability re- mains can perhaps be inferred from Stricker's state- ments,3 that concepts of colors and forms occur in dreams of blind people for ten or twenty years, and that then auditory and tactual concepts predominate, till finally visual imaginings cease to occur. But no person born blind has hallucinations of sight, there having been no opportunity for such a person to accumulate visual mem- ories. Nicolai was unable to produce hallucinations voluntari- ly ; nevertheless many persons have possessed this power. Sir Isaac Newton, by going into a dark place and intently fixing the attention, could hallucinate the solar spectrum. Talma, the actor, could divest his audiences of their robes of flesh, and make them appear a host of skeletons. The artist who succeeded to Sir Joshua Reynolds's patronage could, after intent study of a face and figure, hallucinate the same at will. He was thus able to spare his patrons the annoyance of frequent posings, and so became a very popular portrait painter. After a time, however, this exercise led to confusion of the real and the phantom worlds, and finally to mental overthrow. In some cases the hallucination is perceived by one eye only. After a blow on the left side of the head, a young man had a left unilateral hallucination of a black cat. A lady saw the phantom of a man by her right, and of a woman by her left, eye. A young woman saw faces, one-half of which would disappear when either eye was closed, and the whole when both eyes were shut.4 In the Insane* The visual hallucinations of lunatics are vastly more complex, exaggerative, and bizarre, than those of sane persons. They are observed oftenest in acute cases, with heat of the head and great cerebral dis- turbance, though they may also occur in chronic insanity, and persist for years. They are agreeable or the reverse, according to the patient's dominant mental state. Usually he believes implicitly in their objective reality, and though occasionally recognizing their subjective character, he even then often illogically accepts them as real. It is im- possible to convince him of his error, as the other senses often do not correct, but rather substantiate, the mistaken perception. Hence these persons live in an unreal world of pleasing or terrifying visions. II. Of Hearing.-In the sane, auditory hallucinations are rather less common than those of sight. Voices are the most usual form. Socrates was guided by the warn- ings of his daemon; and under the assurances of her' hal- lucinations Joan of Arc faced the terrors of war and of mediaeval torture. Poems and music are sometimes heard. Hammond records some very fair verses which came as an auditory hallucination to one of his patients. Dr. Clarke relates that an elderly gentleman, a great opera-goer in his day, was visited by three phantom vocalists who sang with perfect distinctness and accuracy " Home, sweet Home," and selections from Beethoven and Mozart. Auditory hallucinations, when constant, are a source of unspeakable annoyance. One victim put a music-box Per cent. Sodium chloride 2.380 Magnesium chloride 0.003 Calcium sulphate 0.410 Calcium carbonate 0.031 Sodium sulphate 0.019 For stronger baths, the water is mixed with that of a very strong brine spring in the vicinity, containing more than twenty-five per cent, of salts. The principal bathing establishment is located on an island in the river. Vapor- and spray-baths are also administered. The brine is some- times administered internally for its cathartic effect, in the dose of a tablespoonful in a goblet of spring-water. J. M. F. HALLUCINATIONS AND ILLUSIONS. An halluci- nation is a sense-perception not excited by any external reality ; as when in darkness one sees apparitions of per- sons or animals. If, however, there is an objective real- ity, but its character is incorrectly perceived, as, for ex- ample, if a guide-post appears to be the attenuated form of a disembodied spirit, one is subject to an illusion. An hallucination, therefore, is " a creation out of nothing and entirely fictitious" (Spitzka); an illusion is a faulty inter- pretation of impressions made on the sense by some ex- ternal object. By external objects we mean not necessarily such as are outside of the body, but those which are external to the sensory mechanism subject to illusion. When a luna- tic hears voices speaking in his intestinal rumblings, he is rightly said to have an illusion ; since these sounds, though not outside of himself, are external to his hearing apparatus. But faulty interpretations of tinnitus from aural disease should be termed hallucinations. Much in- consistency may thus be avoided. Yet it will often be impossible to decide whether a given false perception is due to ab extra influences or to disturbances of the per- ceptive mechanism, whether it be an illusion or an hallu- cination. So that practically any hard and fast distinction between hallucinations and illusions fails in some cases. As has often been remarked, hallucinations and illu- sions reflect the dominant beliefs, and indicate the intel- lectual advance of the age. An ancient Greek had hallu- cinations of satyrs, nymphs, or gods; he never saw the Virgin or the saints who visited the early Christians. Nowadays the hallucinis hear voices through the tele- phone, and feel electric shocks. Visions of complex ma- chinery weary the seer. Some discover remarkable mi- croscopic organisms infesting their blood. All such facts show the power of preconceived ideas and expectant at- tention over perceptions. In studying hallucinations it will be convenient to take them up sense by sense. I. Of Sight.-In the Sane. Many illustrious per- sonages have been subject to visual hallucinations. Sir John Herschel had visions of angles, circles, and other geometrical figures. While riding, Goethe, on one occa- sion, saw himself approaching himself on the broad high- way. Sir Walter Scott relates how the figure of Lord Byron once appeared to him with the vividness of reality. Napoleon I. was troubled now and then by an hallucina- tion of crowding enemies, and would struggle, and fight, and fill the palace with his shouts. The literature of ap- paritions is full of other instances. Nor are visual hallucinations rare among people of the every-day type. The following will serve as illustrations • A young woman suffers some chagrin which preys upon her spirits. One evening she enters her room, drops the match, and, when stooping to recover it, sees a man's corpse out-stretched at her feet. The phantom disappears when a light is struck.1 Dr. Clarke4 narrates the case of a lady who at various times was visited by visions of animals, giants, etc. Dur- ing a sister's illness she had an hallucination of a female figure which she mistook for her mother, until it sud- denly fell to the floor and disappeared. Nicolai's report of his own case still remains one of the * De Boismont found in 1,146 cases of insanity 725 with hallucinations and illusions, those of sight being the most numerous. 481 Hallucinations. Hallucinations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. under his pillow in order to drown the noises which kept him awake ; and a lady who heard taunts issuing from the wall bought the adjoining premises, in the vain hope of thus ridding herself of disagreeable neighbors. Those who have been haunted by a tune or rhyming jingle have had a faint experience of this persecution. Mere tinnitus from aural disease has driven some sane persons to sui- cide.5 It is not difficult, therefore, to understand how a ceaselessly repeated command, especially when, as often happens, it comes clothed with divine authority, sooner or later forces the distracted victim to obedience. Many violent acts done by persons on the border-land of insan- ity, and by lunatics, are determined by the harassment of continued auditory hallucinations, or the irresistible au- thority of a heavenly mandate. Such hallucinations are often concealed, and first confessed as the motive of some crime of appalling suddenness. Very commonly the hallucination is of two or more voices arguing or giving contradictory commands, and the unhappy subject imagines himself persecuted by ene- mies or possessed by devils. The tinnitus of chronic oti- tis in persons of a neurotic temperament may be the deter- mining cause of hallucinations, and finally of delusions such as have just been mentioned.5 The insane describe a strange form of auditory hallu- cination which is inborne upon the soul without speech or sound. Commands or threats come in the midst of silence, and without their knowing whence. In some of these cases it has been observed that the patient uncon- sciously mutters in an almost inaudible voice, and takes the substance of his own words to be communications from without.6 To explain others, some have supposed that the cerebral hemispheres act independently, one de- termining ideas which the other cognizes and accounts for as of external origin. Auditory hallucinations may occur in deaf-mutes, pro- vided, of course, that they ever possessed the sense of hearing long enough to have acquired auditory memories. Cases of unilateral auditory hallucinations are reported, the patient hearing voices by only one ear, or different voices by either ear. III. Of Smell and Taste.-Hallucinations of these senses usually coexist, and are of a disagreeable character. They frequently depend on digestive or catarrhal troubles; and because of our inability to decide whether or no they have this external origin, the distinction between hallu- cinations and illusions is difficult to enforce. Subjective odors and tastes are the basis of delusions often harbored by the insane that their bodies are decomposing, or that their food is poisoned. IV. Of Touch.-The subject may feel himself seized, bound, struck, burnt, pinched, and variously tortured. Such persons often complain of the violence of their at- tendants. Anaesthesia is interpreted variously and curiously. Some who have lost all tactile sensations imagine them- selves disembodied spirits. Some infer their own non- existence. A soldier so afflicted declared that he had been killed in one of his many battles. Perverted sexual sensations in women may lead to illu- sions of sexual intercourse, or of pregnancy, and not rarely to accusations of rape. V. Of Muscular Sense.-Weights are estimated by the muscular effort put forth to sustain them and the fatigue thereon ensuing. The position of the limbs is made known largely by the perception of muscular con- tractions necessary to maintain the attitude. Hallucina- tions of musculation give rise to the sense of suspension in mid-air, and of flying. Some imagine themselves pos- sessed of gigantic strength, while others feel the weight of head or arms a burden beyond their powers.1 Illusions.8-There are many ways in which a sane mind forms faulty perceptions of external objects. If the perceptive organs are hyperaesthetic, their testimony suffers exaggeration. Ordinary lights may be dazzling, and ordinary sounds deafening. Hammond mentions a young lady to whom children seemed giants, and Sau- vage relates the case of another to whom a fly seemed as big as a fowl, and a fowl as big as an ox. The extraor- dinary acuity of all the senses in hysteria has not ceased even in modern times to be credited as supernatural. Anaesthesia and paraesthesia may induce illusions the reverse of those just described. Very familiar illusions of sight are those respecting the distance of objects. Perception of distance is entirely an inference which by long practice we form so rapidly as to be unconscious of our process of reasoning. Experi- ence has taught that any object between which and our- selves there are few intervening objects is near. One looks seaward and sees a ship. No objects are interposed by which the eye may pace the distance, and the vessel is judged to be one-half a mile away when perhaps it is two miles. We are now and then subject to illusions as to motion. When we are gliding silently over the water, a moored boat by which we pass appears the moving body. In the world of art many illusions meet us. The appear- ance of relief and perspective, especially in the stereo- scope, the confusion of the intaglio and the bas-relief, are common examples. Sensation may likewise prove deceptive, as when vio- lence done the ulnar nerve causes pain in the little linger ; or when irritation of the nerves in a contracting stump causes feelings which are referred to the amputated limb. Perception is swayed by anticipation of what is to be perceived. Tuke, Carpenter, and other writers on this topic furnish many illustrations.* The insane perception often completely metamorphoses its object. One patient declared: "The swine grunt names and stories, the dogs bark abuse and reproaches, the cocks and hens, and even the geese and turkeys, cackle names, words, and sentences." Just as under the influence of dominant ideas and expectancy sane persons now and then fall into errors of sense, so the perceptions of the insane are controlled by their delusions. Melancholia transforms natural objects into horrible and terrifying creations, loads ordinary conversation with abuse and threats, and makes usual bodily sensations tort- ures. If the delusion is of personal greatness, all nature sounds the praises of the delighted listener, all feelings promote his self-satisfaction. In a few cases the illusory perception has been unilat- eral, as when a gentleman heard with one ear the ticking of a clock to consist of articulate words. Causes of Hallucinations.-Children are more liable to hallucinations than are adults. Hallucinations may be caused by the use of alcohol, opium, belladonna, hyoscyamus, stramonium, hashish, quinine, digitalis, nux vomica, camphor, lead, nitrous oxide, ether, chloroform, and the bromides (in large doses). Gases and fluids absorbed from impacted and decomposing faeces have been known to determine hal- lucinations, along with other profound nervous disturb- ances.9 Disease of an organ or afferent nerve of special sense may be attended by hallucinations of that sense. A patient who from retinal disease had lost sight in the upper half of the left visual field had left unilateral hal lucinations of the upper half of objects.10 Dazzling vis- ions of angels with flaming swords, which afflicted an- other, were found to depend on compression of the optic nerve by cystic growths from the lateral ventricles.11 Horrible smells were prominent symptoms in a case of tumor at the base of the skull, which was found to have destroyed the olfactory tracts.12 A patient with right pur- ulent otitis heard coarse epithets uttered in the right ear alone. These disappeared when the otorrhoea was cured.13 Going higher, we find that disease of the sensory centres in the cortex may give rise to hallucinations. Those of meningitis are supposed to depend on irritation of these * The mirage and kindred deceptive appearances are often classed among illusions. But there is here no mistaken perception. The eye re- ports a landscape in the sky, and its testimony is correct. How the picture came there, science must explain. When to a multitude of ob- servers there appeared a golden angel hovering in the cloud above a church, there was no illusion. The form of the angel was there, and it remained for a philosopher to show that it was a reflection of a golden image on the spire. 482 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hallucinations. Hallucinations. cortical centres. In some cases of tumor of the occipital lobes visual hallucinations have been reported.* Irrita- tive lesions of the temporal lobes have been known to cause auditory hallucinations of the opposite side ; and le- sions of the uncinate gyrus and adjoining convolutions have produced hallucinations of smell.14 Epileptic seizures may be ushered in by hallucinations. One patient always saw an old woman with a red cloak, who rushed upon and struck him with her staff, where- upon he would fall in the fit. Others describe hallucina- tions of voices or bells, of noisome odors, or of foul tastes, as among the sensory aura of their attacks. Under the influence of prodromic hallucinations epileptics have been known to commit crimes. Hallucinations proceed oftenest, however, from less palpable morbid conditions, and especially from disturb- ances of the cerebral circulation. The somnolent state preceding sleep and the state of awaking are favorable to the appearance of phantoms, probably because of pro- found circulatory alterations then occurring in the brain. Cerebral hypersemia is a usual cause. We read15 of a gentleman who, by tying a handkerchief tightly about his neck, could cause an hallucination of Sir Walter Ra- leigh. Goethe declared: ' ' On lowering the head, I im- agine, when I close the eyes, that I see a flower in the middle of my visual organ. This is quickly decomposed, and from its interior are born other flowers, with colored and sometimes green petals." Change of posture, or any procedure emptying the surcharged vessels of the brain, dispels such hallucinations. Many cases of long standing have been relieved by bleeding. That cerebral anaemia may also cause hallucinations was shown experimentally by Hammond, in the case of a young woman whose carotids he compressed, whereupon she cried out in terror that a negro was rushing upon her with an axe. This vision ceased -when the pressure was intermitted, returned when it was resumed, and was more distinct the stronger the pressure. It is probable that phantoms of lowered vitality result from cerebral anae- mia ; as in the case of a lady who, whenever run down in health, was accustomed to see a black cat, which would leave her upon the exhibition of iron and stimu- lants. Hallucinations with starvation, fatigue, and ex- haustion from any cause fall naturally into this category. Strains of seraphic music, and visions of unspeakable brightness, attending the act and article of death, are suf- ficiently accounted for as a final phosphorescence of nerve-cells aflame with fever, and deprived of their sup- ply of blood by the failure of the circulatory powers. Theory of Hallucinations.-The existence in the brain cortex of separate centres governing movements of certain groups of muscles, and receiving special sense impressions, is now pretty generally admitted. Most writers accept also the corollary, that in each of these centres are stored the memories peculiar to its sensory or other function. If the middle of a dog's sight-centre be destroyed, he still sees, but for a time fails to recognize any familiar ob- ject. He knows it by the other senses, but not by sight. He cares nothing for the whip, unless he hears it snap ; nor for his food, unless he scents it. Similar facts are adduced in regard to the local preservation of other sense- memories. The brain, therefore, is not only the instru- ment of sense-perception, but it registers every sense-per- ception in its appropriate area. How this storing of impressions is accomplished, we do not know ; it is sup- posed to depend on nerve-cell modifications, analogous to, though more permanent than, retinal changes producing an after-image. As has been seen, pain from irritation of a nerve of common sensation is referred to its peripheral distribu- tion, and phantasms due to irritation of an organ or nerve of special sense are projected into the range of that sense. Similarly, when disease irritates cortical sensory areas, memories there stored are revivified, projected outward, and the patient has an hallucination. Hallucinations are therefore believed to be sense-memories morbidly revived. To this hypothesis cases like that of Bostock, the phys- iologist, seem opposed. He says of one vision which ap- peared after a fever: "I had constantly before me a human figure, the features and dress, of which were as distinctly visible as those of any real existence, and of which, after an interval of many years, I still retain the most lively impression ; yet neither then nor since have I been able to discover any person whom I had previously seen that resembled it." If, now, hallucinations be mem- ories, why are they not always remembered ? In memory we must distinguish three elements : 1st, The storing of impressions; 2d, their revival; and 3d, their recognition and location in time. They may be stored and revived, and yet pass unrecognized. Cole- ridge 16 relates that an illiterate peasant w oman recited during a fever long passages in Latin, Greek, and He- brew'. Investigation showed that she had in childhood lived with a clergyman who was wont to read aloud in these tongues, and many of her recitations wrere identi- fied with passages in his books. Here the brain had hoarded auditory memories incomprehensible, and there- fore, in all likelihood, unrecognizable by the individual. Similarly visual memories of faces seen in a crowd may stamp themselves on the cortex, to return some day as visual hallucinations-memories, but unrecognized. Are hallucinations of imaginary objects, dragons, etc., memories ? Such objects have never been seen ; how, then, can they be revived visual sensations ? It seems possible, however, that some of these creations have been seen in works of art. Luther must often have encoun- tered pictorial and sculptured representations of the devil, and thus that famous apparition may well have been a memory. Many hallucinations at first seeming too gro- tesque to be reminiscences of veritable sight-perceptions have thus been finally identified with forgotten pictures, or images, or masks. The extraordinarily whimsical hallucinations of lunatics do not support the objection ; for, if the insane mind utterly transforms actual objects of sense into fantastic forms and sounds, it were not too much to claim that it may similarly metamorphose mem- ories excited by cerebral irritation. Difficulty is found in making the theory fit certain cases of unilateral visual hallucination from cortical disease. To correspond to our received scheme of optic nerve decussation (cf. Vol. I., p. 644; Vol. II., Figs. 609 and 767) the hallucination should be to the right or left of the middle line in both eyes. Perhaps these cases, like those of hysterical amblyopia, suggest the existence of high cortical centres where the percepts and memories of each eye are collected and combined, and whose inhibi- tion or irritation may produce unilateral blindness or a unilateral visual hallucination. Photopsia and tinnitus are the only hallucinations di- rectly resulting from eye or ear disease ; it is, therefore, difficult to account for complex hallucinations, as of men, or of voices, proceeding from such diseases. We may, perhaps, suppose that prolonged irritation of an organ of sense is propagated upw'ard, and excites a sympathetic central disturbance, which then begets the hallucination ; but this is a mere guess. Why closing or covering the eye causes some hallucinations to vanish is also a fact as yet unaccounted for. Pathological findings in cases of general paresis and other cerebral diseases accompanied by hallucinations seem not to lend much aid to the doctrine of their local origin. The pathological side of the argument is as yet, however, far from closed. Medico-Legal Bearings of Hallucinations.-Of what value are hallucinations as evidences of insanity ? On this topic much has been written, but it is impossible to formulate an answer not liable to exception. If, say some, a person see false visions or hear false sounds, and yet, in spite of sufficient evidence to the contrary, believes them to be real, he is insane ; whereas, if he realizes their subjective character, he is sane. But it would have gone hard to convince Mohammed that he did not see and hear the angel Gabriel on the mountain of Hira, or Martin * Nevertheless, tumors, even when implicating the sensory centres, do not cause hallucinations as often as we might expect; a fact to be ac- counted for, probably, in the same way that we explain occasional ab- sence of motor symptoms, irritative or paralytic, when a tumor occupies the cortical motor region. 483 Hallucinations. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Luther that he threw his inkstand at anything less than the very devil himself ; albeit few physicians would care to give a certificate of lunacy for either of these person- ages. On the other hand, there are lunatics who recog- nize the fletitiousness of their hallucinations. But these instances are, after all, exceptional, and in the great ma- jority of cases Maudsley's statement holds, viz.: " When a person has hallucinations that are utterly inconsistent with the observation and common-sense of the rest of mankind ; when he cannot correct the mistakes of one sense by the evidence of another; when he believes them in spite of confuting evidence, and when he suffers them to govern his conduct-then he must certainly be ac- counted insane."11 It is usually held that responsibility does not attach to crimes committed under the influence of hallucinations. The possibility of such hallucinations being concealed must be borne in mind, and in all cases of apparently motiveless homicide searching inquiry should be made, and if hereditary influences, previous eccentricities, or changes in disposition or demeanor, indicate the possibil- ity of mental unsoundness, the criminal should be ques- tioned as to hallucinations; if none be confessed, he should be isolated and watched. When voices command a person to dissipate his prop- erty, recourse may be had to interdiction ; but depri- vation of civil rights is not to be enforced unless the hallucination plainly leads to acts injurious to the sub- ject or his family. Hallucinations do not deprive of testamentary capacity, provided they exercise no influence upon the general conduct, and have not weakened the natural affections.18 William S. Cheesman. 1 Geo. Sigmund: On Hallucinations. Winslow's Psychological Jour- nal, October, 1848. 2 Visions; a Study of False Sight. 3 Wiener Med. Blat., 1878. 4 Hammond : Paper on Unilateral Hallucinations, read before New York Neurological Society, December, 1885. 5 D. B. St. John Roosa: Treatise on Diseases of the Ear, pp. 265-266. 0 Dr. Max Simon: The Invisibles and the Voices. Lyon Medical, December 5. 1880. 7 Eugene Semerie: On Muscular Hallucinations. Gazette Hebdom., February 6, 1863. 8 James Sully : Illusions. 6 Pepper: System of Medicine, vol. ii., p. 647. 10 Pick. 11 Forbes Winslow: On Obscure Diseases of the Brain, and Disorders of the Mind. 1868. 12 Julius Althaus, M.D.: Lecture on Physiology and Pathology of the Olfactory Nerve. Lancet, May 21, 1881. *'E. Regis: Unilateral Hallucinations. L. Encephale, No. I. 14 M. Allen Starr; Cortical Lesions of the Brain. Am. Jour. Med. Sci., April, 1884. 15 Hammond : Nervous Derangements. Biographia Literaria. 17 Dr. Henry Maudsley : Hallucinations of the Senses. Pop. Sci. Mo., October, 1878. 18 A. Brierre de Boismont: Des Hallucinations. wedge-shaped piece from the inner side of the shaft of the first metacarpal bone just above the head, as practised by Barker (see report in The Lancet, No. 15, 1884) would seem, theoretically at least, to be a much more desirable operation. The joint is thereby not interfered with, the deformity is reduced, and the function of the toe as a spring in walking is restored. Thomas L. Stedman. HAMMOCK SUSPENSION. In 1880 Mr. Richard Davy published an account of the method adopted by him, at the Westminster Hospital, in the application of the plaster-of-Paris jacket in cases of spinal caries, under the title of "Hammock Suspension." The advantages claimed at the time have been fully confirmed by extended experience since. These advantages are the avoidance of the pain and discomfort always experienced by the pa- tient, and entire freedom from the dangers of syncope and fracture of the spine sometimes met with in the method of suspension originally suggested and employed by Sayre. In addition to these decided advantages the surgeon is able to proceed deliberately in the application of the jacket, as the patient is not at all incommoded by his position, which can be maintained until the jacket has hardened and become firm, so that there is no danger that the plaster will be broken in changing from the suspended to the horizontal position, as sometimes happened in the earlier method. The hammock can be made of muslin, or, if greater strength is required, burlap or stout drill- ing can be employed. It should be slightly wider than the patient's chest, and one end is to be securely sewed around a sufficiently strong rod, about two feet and a half long ; the other end is to be simply knotted. When ready for suspension the hammock is spread over a table and the knotted end secured to a hook in the wall and the cross-rod at the other attached by two straps to a curved iron suspension-bar of Sayre's apparatus, which has been connected by rope and compound pulley to a fixed point opposite. The patient now draws on a seam- less jacket, which is secured over the shoulders and reaches half way to the knees. Suitable jackets can be made upon an ordinary machine for knitting stocking- legs, and can be made of wool or cotton. These jackets are so elastic that they readily adapt themselves to pa- tients of almost any size. All the bony prominences are now covered with pads placed beneath the shirt. The points usually needing protection are the crests and ante- rior superior spinous processes of the ilia, and the boss on the back. Where great emaciation exists the depression on either side of the spinous processes can be tilled out by long pads of cotton wadding rolled up in thin muslin. It is usually better to place a " dinner pad" over the abdo- men, as the sense of constriction often complained of by the patient is quickly relieved by removing it after the jacket has set. • The patient is now placed on the ham- mock, face downward, the chin reaching over the cross- bar, and the hands grasping it on either side, and is then gently swung clear of the table and the rope secured around the pulley (see Fig. 1537). In order to support the head the forehead may rest upon a cross-piece which extends from one strap to the other. The table is now removed but left within easy reach so that the patient can rest his hands on it if he desires. This gives a sense of support and prevents swinging from side to side. The plaster rollers are now applied, commencing at the nar- row part of the waist and carried downward to a little below the anterior superior spine and then upward as high as the axillae. The first turns should be firmly ap- plied and each should overlap the preceding one by about two-thirds its width, and this should be continued through- out the application in order that an even thickness may be obtained. The bandage, made of crinoline, into which the best quality of plaster has been rubbed, should be about three inches wide and four yards long, and just before using should be placed in water to which salt or alum has been added, as in this way the setting occurs much more rapidly. The patient is to remain suspended until the jacket is firm, and can then be lowered gently upon the table, which has been replaced. HALLUX VALGUS. By this term is understood a de- formity of the great toe, of not infrequent occurrence, in which the digit is strongly abducted and sometimes lies across the other toes. It is in the majority of cases caused by badly constructed shoes, in which room is wanting for the toes to lie evenly and without squeezing. The de- formity may begin at any age, usually in young adult life, and affects either sex, females rather more frequently than males. The great toe being abducted, the inner half of the head of the first metacarpal bone meets with no opposing pressure and consequently, as is the case in other articulations, it hypertrophies. The plane of the joint looks now forward and outward, instead of directly forward, and the abduction of the phalanx is thus ren- dered permanent. If pressure from the boot is continued, a bursa soon forms over this enlarged half of the articu- lar surface of the bone, and this may in time become in flamed, and result in the production of a painful bunion. After these osseous changes have taken place the restora- tion of the toe to its normal position becomes very diffi- cult, if not impossible. Various forms of apparatus for this purpose have been constructed, which are intended to act by means of springs or elastic traction in a direction of adduction. They are of little value, however, in con- firmed cases, and resort must usually be had to operative measures. Resection of the metacarpo-phalangeal articu- lation has been performed by L. II. Sayre, and even am- putation has been resorted to. But the removal of a 484 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hallucinations. Hand. The hammock is now cut off above and below the plaster, and the latter is trimmed so as not to rub against the axillary folds when the arms are by the side, and the "dinner pad " is then removed. During the suspension the patient suffers very little inconvenience, and often at once experiences decided relief on resuming the standing posi- tion, In children and male adults the "hammock sus- pension " answers admirably. When the patient, how- ever, is a female with large mammary developments, the prone position in the hammock flattens out the breasts, and the plaster often causes uncomfortable pressure. This can, however, be obviated by placing pads of proper size and shape outside the hammock (not between ham- mock and body), and having them held in place until the bandage is applied. The pressure can thus be regulated and ample room obtained for the breast by removing the pads. Thus placed, the pads are more efficiently man- aged then if they are placed next to the skin. Experience has more than confirmed the advantages of hammock suspension. It meets fully all the indications in spinal the skilled musician, artist, or handicraftsman is a very different organ from that of the untrained and inexpert novice. The very word "handy" expresses this idea. As to the second notion, it appears to be founded upon the extraordinary degree of tactile sensibility which the hand possesses. The laying on of hands has been a favor- ite method of healing from the very earliest historical period, and is still prevalent, not only where the royal touch is believed to be a sovereign remedy for • ' king's evil," but also among the so-called healing mediums. The mesmeric passes were believed to be efficacious only when performed with the ends of the fingers, in order that the "force''might be drawn off into the patient's body. Von Reichenbach's patients saw flames of " od " force issuing from the ends of the fingers ; many worthy people have no doubt that a nervous headache can be cured by some transfer of this force by means of passes over the brow of the sufferer ; and we have lately had a revival of the old astrological theory of an " astral fluid" which is more transmissible from those with pointed fin- gers. Obscure nervous sensations felt in the fin- gers and along the nerve- tracts are believed to be caused by this force or fluid. Owing probably to this superstitious rev- erence, we find that the physicians of the middle ages used the de- tached hand of a corpse for the scattering of tumors and the reduction of swellings. The use of this strange remedy still sur- vives. The author has recently found sev- eral authentic cases of such application. In one it was used for cure of a white swelling, and in another for a protracted intermittent fever, a female homoeopathic phy- sician vouching for its efficacy. She explained this to the writer by stating that the "morbid processes going on in the dead hand attracted the disease and removed il"(!). Sometimes the virtue of the deceased is believed to have a marked influence. This was shown in the case of a well-known Catholic priest who died recently in Wash- ington, and that of a Carmelite nun in Baltimore. Many applications of the dead hand were made in both cases for the cure of the sick and afflicted, showing that the old belief is still active. Another superstition which had a prominent place in the black art of the middle ages was that of the ' ' hand of glory. " This was a dead right hand of a murderer prepared with appropriate conjurations, in which was placed a magic candle made of murderer's fat and the hair of the dead. This was believed to prevent sleepers from awakening and to open locks and bars. As late as 1831, such a hand was left by thieves in a house in Loughcrew, Ire- land. Thieves in Mexico use the left hand and arm of a woman dying in her first childbed for a similar purpose, and in 1875 a Mobile negro carried around with him the hand of his murdered victim to insure himself against detection. During the past winter, 1885-86, a hand was stolen from a dissecting-room in Washington, to be kept by a woman "for luck."* The left forefoot of a rab- bit is said to possess magical powers, and is frequently carried by negroes for averting evil-a belief shared, it is said, by at least one United States Senator. Such a foot was sent to President Cleveland shortly after his inaugu- ration. Sir Charles Bell, the author of the celebrated " Bridge- water Treatise on the Hand," 1 says : " We ought to define the hand as belonging exclusively to man, corresponding in sensibility and motion with that intelligence which converts the being who is weakest in natural defence, to a ruler over animate and inanimate nature." However flattering to our pride this statement of the great physiol- ogist may be, modern investigation has shown it is not anatomically correct, as there is nothing in the structure Fig. 1537.-Hammock Suspension. caries, and secures the patient from the danger, pain, and discomfort of the " tripod," and enables the surgeon to avoid haste and precipitancy in the application. In cer- vical caries the method permits of the easy- adoption of the " jury-mast." In lateral curvature, in the rare cases in which a plaster jacket is indicated, the hammock suspen- sion does not always answer as well as the usual method; here the weight of the body is desirable to correct the deformity as far as possible. In spinal caries the prone position and the sway of the hammock afford exactly the kind of extension desired, namely, a separation of the bodies of the vertebrae. It is also occasionally useful in fracture of the ribs, and can be advantageously employed in fracture of the spine. N. P. Dandridge. HAMPSTEAD. A suburb of London, England, in the county of Middlesex, four miles northwest of the city. The village is irregularly built, on the side of the Hamp- stead hill, and is composed for the most part of narrow, tortuous streets and lanes ; yet it is the most noted of London suburbs for its beautiful groves and avenues. The mineral springs, for which it is of interest in this place, issue from the side of the hill, and were discovered in the seventeenth century. In the early part of the last century they rivalled in popularity the Epsom springs and Tunbridge wells, but later their popularity began to de- cline, and they are now but little resorted to. The water- supply has also been much reduced by the cutting of rail- road tunnels and sewer-drains. J. M. F. HAND. Cresollius calls the hand "the minister of reason and wisdom." As the active servant of the brain, adjusted for the most delicate and varied uses, it has al- ways been held in peculiar honor. The coat of arms of the surgeons' guild of the middle ages was a hand, with outspread lingers and an eye in their midst, typifying thus the noble art of chirurgie, which name was itself derived from xeip, the hand, and epyov, work. Respect for this important member has even been carried so farthat it has been supposed to contain a force within itself capable not only of intelligent action, but of transmission beyond the body. When we regard the high degree of muscular co- ordination which it possesses we readily see whence orig- inates the tirst of these popular fancies, for the hand of * These superstitions have not failed to attract the notice of literary men, tide Scott's Antiquary. Harriscn Ainsworth's Rookwood, and the Ingoldsby Legends. One of the ingredients of the witches' broth of Macbeth was "finger of birth-strangled babe." 485 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the human hand that distinguishes it, except in degree, from that of anthropoid apes. Even Huxley's statement, that the apes do not possess an extensor of the metacarpal bone of the thumb, is open to question. Comparative an- atomy shows us in fact that a general typical form for the thoracic limb and hand pervades the entire vertebrate series. This is especially marked in the mammalia, and backward in a marked degree. There is, therefore, a complete homology believed to exist between the thoracic and the pelvic limbs. The opposing view, which has recently been rapidly gaining ground, is that the shoulder and pelvic girdles are formed from coalesced vertebral elements. It is held that the most primitive form of limb is simply a lateral skin fold extending along the whole body, and that into this certain cartilaginous process- es, or rays, (actino- phores of Ryder, pt cry go p bores of Parker) extend. Each of these may bear sev- eral others extending radially through the fin. When necessary for more special forms of locomotion, the actinophores become united into solid bars constituting the shoulder and pelvic girdles, and the other skeletal elements are distally situated rays. Fig. 1538 shows va- rious forms of tins found in primitive fishes ; and it will be seen that there is a certain general resem- blance to a hand with a large number of digits. According to this view there is no absolute homology between the thoracic and pelvic limbs, but only a homodynamy. Between fishes with fins and amphibia with feet there is a gap which has not yet been filled up by the discovery of intermediate forms, but it appears probable that the limb in its reduced state is the result of adaptation to walking instead of swim- ming. In swimming it is necessary only to propel the body forward, in walking it must be also supported and raised ; hence the necessity of the strong proximal bones and the Fig. 1538.-Skeletons of the Thoracic Limb of Lower Vertebrates, showing the Gradual Development of the Hand. in many cases the student of human anatomy has no diffi- culty in determining at once the different bones of the forefeet of an animal which he has never before seen. In one case within the author's experience, a professor of ob- stetrics, who was not an anatomist, was obliged to exam- ine a class in anatomy, and procured from the cabinet the skeleton of a bear's forepaw, which he passed around as belonging to the human skeleton. As the functions of the member vary, the different parts become reduced or increased either in size or in number, but a general plan pervades the whole, and the tin of a fish, the wing of a bird or a bat, the paw of an animal, are all constructed on a single type. While the differences be- tween the human hand and that of the higher apes are not essential, being only those of degree, yet the rela- tive proportions of the dif- ferent parts distinguish it markedly. The following table from Humphry shows the size of the hand and the foot relative to the stature taken as 100 : I. II. III. IV. V. VI. . Hand. Foot. Man 11.82 16.96 Gorilla 14.54 20.69 Chimpanzee. 18.0(1 21.00 Orang 20.83 25.00 This superior length is due mainly to the metacarpal bones and phalanges. With regard to the primi- tive origin of limbs two dis- tinct views have been ad- vanced by anatomists. Ac- cording to the first the proximal part of the limb, which we are accustomed to call the shoulder or pelvic girdle (scapula and clavicle for the arm, innominate bone for the leg), arises from visceral arches of the vertebrae, and' upon these radial bars of cartilage are set for the support of the fins. The pelvic girdle is thought to have become shifted Fig. 1539.-Skeleton of Hand or Forefoot of Six Mammals. I., man ; II., dog ; III., pig; IV., ox ; V., tapir ; VI., horse, p, Radius; u, ulna; a, scaphoid; b, semilunar; c, cuneiform; d, trapezium; e, trapezoid;/, oh magnum; g, unciform; p, pisiform; 1, thumb; 2, index-finger; 3, middle-finger; 4, ring-finger; 5, little- finger. (Gegenbaur.) bending at the shoulder, elbow, and wrist, and at the hip, knee, and ankle. Fig. 1538, IV., shows how closely the plan of the hand and arm of amphibian corresponds with that of man. From this point up through mammals there are many modifications, produced by the peculiar functions 486 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. which the limbs are called upon to perform. When of use for prehension, digging, etc., the five-fingered type remains, and it is in fact the most persistent of all; but occasionally the occurrence of extra digits in the human species reminds us of a far-off ancestry, in whom the rays were more numerous. When the anterior limbs are used more for locomotion they become variously modified by stress and impact, and lose unnecessary digits. The reduction always takes place laterally. First the thumb becomes rudimentary or disappears, then the little finger, next the second finger, then the fourth, and so on. The discussion of the various causes for this is of extreme in- terest, but would exceed the proper limits of this article. The principal typical forms are shown in Fig. 1539. Embryological evidence as to the development of the hand agrees, as far as it can at present be understood, with the facts observed in the animal series. The first rudiment appears as a thickening and crescen- tic protuberance (see Fig. 1540, A), which grows laterally from the body wall. Further outgrowth may be arrested at this point, and in that case we have a child born with a hand springing directly from the shoulder, a species of monstrosity reminding one of the flipper of a seal, and hence called phoco- melus. Normally, however, other seg- ments are developed between the first bud and the body wall (Fig. 1540, B), and in these the bones of the arm develop. The for- mation of the fin- gers is first indi- cated by notches along the edge of the distal bud from which converging grooves run, indi- cating the future interdigital spaces (Fig. 1540, C). The first groove that ap- pears is that between the thumb and the forefinger. The terminal phalanges soon become free, but the remaining portions of the fingers are united until the third month. If development is arrested here, we have the fingers re- maining with a web between them, as in the amphibian paddle, and in some quadrupeds. The thumbs become free first. The varied structures of connective tissue, cartilage, bone, muscles, nerves, and vessels all develop gradually within this rudimentary bud, as they do in other parts of the body, by a differentiation of mesoblastic cells. Some interesting problems are connected with the time and order of ossification of the various parts. The typi- cal plan of the hand is shown in Fig. 1538, IV. In the wrist there are originally nine bones, which are ar- ranged in two rows ; those of the first are named syste- matically, the intermedium, between ulna and radius, ulnare, radiale, and correspond to the scaphoid, semilunar, and cuneiform bones of man. There is then a centrale (sometimes two, as shown in the figure) found in many apes and rodents, represented in the second month of foe- tal life by a small independent cartilage ; and then, in a second row, carpales I., II., III., IV., and V., each bear- ing a metacarpal bone. The first three of these corre- spond to the trapezium, trapezoid, and os magnum, the fourth and fifth uniting to form the unciform. The pisi- form bone is generally held not to be an essential carpal element, but a sesamoid developed in the tendon of the extensor carpi ulnaris. A radial sesamoid occurs in some apes, and is occasionally found in man. . At birth all the carpal bones are cartilaginous. Ossifi- cation begins in the os magnum (first year), then follow the unciform, cuneiform, semilunar, scaphoid, trapezoid, and trapezium in about that order, and at intervals of from nine months to a year, so that the carpus proper is complete during the eighth year. The pisiform is some- what later, not ossifying until from the tenth to the twelfth year. The metacarpals follow the rule of long bones and ossify much earlier, commencing in the shaft at about the ninth week of foetal life, an epiphysis remaining cartila- ginous. In the metacarpal bone of the thumb this epiphysis is at the proximal end, but in the others it is distal. The epiphysis begins to ossify about the third year. The phalanges ossify in a similar manner, but the epiphyses in them are always at the proximal end. The agreement in ossification between the first metacarpal and the phalanges has given rise to much speculation. It has been supposed to indicate that the missing bone of the thumb is not a phalanx, but a true metacarpal. Sap- pey2 believes the metacarpal epiphysis to be the metacar- pal proper, the remaining part being a phalanx, which would make the thumb agree with the other digits as to the number of segments, as is the case with some other mammals, the sloth, for example. The metacarpal bone proper has, he supposes, atrophied so as to allow the thumb to be set farther back and obtain more perfect op- posability. It appears doubtful whether we ought to accept this interpretation, as a proximal epiphysis occa- sionally appears in the second metacarpal, and some animals have both proximal and distal. It is suggested that too much weight should not be given by osteologists to epiphysial ossifications, as it appears probable that their presence or absence depends very much upon the activities of the animal in producing strains upon the skeletal elements. The hand is considered as divided topographically into three regions : the wrist, middle hand, and fingers-cor- responding to the skeletal divisions of carpus, metacarpus, and phalanges. Region of the Wrist.-Externally this region is not very precisely defined. Its upper limits are generally considered as marked in front by the upper transverse crease which runs across the forearm, always quite well marked even in extreme extension. Its lower limits are marked by another furrow which curves around the base of the thumb. Behind, the marks of limitation are by no means as clear. Upon strongly extending the hand (dorsal flexion) there appear three or more furrows which correspond in a general way to the joints of the wrist, viz., the radio-carpal, medio-carpal, and carpo-metacar- pal. Although described as such by Malgaigne, they are not practically good guides to the joints in question. The muscles of the arm as they reach the wrist all be- come reduced to comparatively small tendons, which pass down over this region to be inserted below, the flexors lying on the anterior surface, and the extensors on the posterior and external. The wrist is, therefore, the nar- rowest part of the limb, and this affords an increased facility of motion to the hand as a whole. The bony parts are so arranged as to form an arch with the concav- ity forward, filled with the descending flexor tendons, and the great vessels and nerves. Under the skin of the anterior surface, which is smooth and without hairs, can easily be felt the prominent points of this arch, viz., on the radial side the tubercle of the scaphoid, on the ulnar the pisiform. These vary in prominence in different in- dividuals. It is not uncommon for uninstructed persons to suppose that they have " a bone out," and unscrupul- ous quacks take advantage of this notion to work sup- posed cures. Upon flexing the hand a tendon starts up. This be- longs to the palmaris longus, and in a lean wrist it can be plainly seen to spread out and become continuous with the palmar fascia. On the radial side of the palmaris ten- don, and close to it, can be easily felt the tendon of the flexor carpi radialis. Behind and between these two lies the median nerve. When the superticialis vola? artery is large, it may be seen to pulsate where it lies alongside of the tubercle of the scaphoid. The radial artery usually does not appear here, having already passed outward under the extensor tendons of the thumb to reach the back of the hand. The point where the pulse is usually felt is not, strictly speaking, within the anatomical region Fig. 1540.-Outlines of the Anterior Extremi- ties of Human Embryos at Different Ages. (Allen Thompson, after His.) A, at four weeks ; B, at five weeks; C, at seven weeks; D, at nine or ten weeks. 487 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the wrist, but upon the lower end of the radius. It is admirably adapted for the purpose, as the artery here lies upon a bony bed, may be easily compressed, and is about to make a sudden and abrupt curve. Hence a careful palpation shows at once the amount of tension of the ar- terial wall. By extending the wrist, the artery may be slightly stretched and the structures above it rendered tense, so that it may be still more easily felt. Occasion- ally the superficialis vote is given off higher than usual, and makes a secondary pulsation, the ''pulsus duplex" of old authors (not the pulsus dicrotus). In this case it is easy to control it by pressing it against the scaphoid. On the ulnar side, the flexor carpi ulnaris tendon shows prom- inently in flexion of the wrist, as it passes down to its in- sertion in the pisiform bone, and externally to this the pulsation of the ulnar artery may be felt. The tendons of the flexors of the fingers lie deeper. The skin upon the anterior of the wrist is firmly bound to the deeper structures by a very thin layer of subcutan- eous tissue, and it is therefore difficult to make a flap from it in amputating the forearm. Flexion has produced a number of transverse markings. These are the rasceta of the chiromants, a word derived from the Arabic, signify- ing wrist. There are usually three of these, and they are not only prominent in all states of the hand, but are found in foetal life. An attempt has therefore been made to eminences-first, the round head of the ulna, second, the more obscure, pointed styloid process of the radius. From this latter, running toward the thumb, the tendon of the extensor of the metacarpal bone of the thumb appears on extension, and a short distance from it the extensor of the first phalanx. The triangular space between these has been called la tabatiere anatomique, or anatomist's snuff- box, because it -was formerly the custom, when snuff-taking was fashionable, to carry snuff to the nose in this little hol- low (Hyrtl). By pressing deeply on this space, the beat- ing of the radial artery may be felt as it passes under the tendons to reach the first metacarpal interspace, where it passes into the palm. It here rests on the scaphoid and trapezium. Over the back of the wrist and hand the tendons which come down from above, and are at first closely pressed together, begin to spread out to go to their respective insertions. These tendons are, from within outward, those of the extensor carpi ulnaris, extensor minimi digiti, extensor communis digitorum, extensor indicis, and the extensors of the thumb. These tendons are also confined by an annular ligament, and are fur- nished with synovial sheaths, as shown in Fig. 1542. The affection popularly known as weeping sinew (gan- glion) is rather common in connection with these sheaths. .B. v. ext. longi pollicis. B. v. flex, carpi radialis. B. v. extens. carpi ulnaris. B. v. ext. carpi radial- orum. B. subtend, flex, carpi ulnaris. Post annular lig. B. tendinosa radialis. .Ant. annular ligt. B. v. abd. long, et ext. brev. pollicis. B.tendinosa ulnaris. B. v. ext. min. dig.. B. v. ext. com munis et indicia. B. v. flexorum propriorum. give them significance as characteristic signs, but when we reflect that the hand of the foetus is also movable and actively used, and that its condition is one of pronounced flexion of all the joints, it is not surprising that, in view of the peculiar relations of the skin and subdermal tissue, that these as well as the lines of the palms should be formed. Across the front of the wrist passes a thick band of fas- cia, called the anterior annular ligament. This being at- tached to the bony prominences on either side, confines the tendons in the deep carpal furrow or canal. The continual friction of the tendons along this furrow has caused exten- sive synovial sacs or sheaths to be formed. Occasionally but a single one occurs, enclosing all the tendons. The usual arrangement is, however, for two sheaths (Fig. 1541), one ,(bursa tendinosa ulnaris) surrounding the tendons of both superficial and deep flexors, the other {bursa tendinosa ra- dialis) surrounding the tendon of the flexor longus polli- cis. The ulnar sheath is almost always continuous with the sheath of the little finger, and amputation of that digit is therefore more apt to be followed by extensive suppuration than that of the index, middle, or ring fin- gers. These extensive synovial sacs are very troublesome when inflamed, as they may lead to extensive suppura- tion of the forearm and, indeed, death has been known to follow. An amputation of the hand is much less serious. Upon the dorsal surface of the wrist the skin is much more movable, somewhat hairy, and without prominent furrows. Under it may be seen two prominent, bony Fig. 1541.-Synovial Sheaths of the Palmar Surface of the Hand. The small bones of the skeleton of the wrist are undoubtedly of considerable value in breaking and dis- persing the shocks transmitted from the lower hand. The general plan of its construction has been already alluded to. We may consider the radius as bearing, first, the scaphoid (radiale), which in turn bears the trapezium and trapezoid (carpales I. and II.), the sup- porters of the first and second metacarpals; second, the semilunar (intermedium), which bears the os magnum (carpale III.) and the third metacarpal. The ulna does not directly joint with the wrist, its carpal bone, the cuneiform (ulnare), being separated from it by the tri- angular fibro-cartilage. This bears the unciform (car- pales IV. and V. united) and the fourth and fifth meta- carpals. The joints and ligaments of the wrist will be treated in a separate article. Region of the Middle Hand.-The muscles which belong to the hand proper are arranged in two groups, one upon the radial side, making an elevation called the thenar eminence ; another on the ulnar side, called by correspondence the hypothenar eminence. The upper part, where these two join, is called the ball of the hand, or by French anatomists le talon de la main. The central portion between the eminences is the hollow of the hand, and it can be contracted and deepened by the action of the muscles on either side. Because of this, it was called by the old anatomists poculum Diogenis, or Diogenes' cup, in allusion to the story that the cynic philosopher, on seeing a shepherd drink from his hand, vowed to hence- Fig. 1542.-Synovial Sheaths of the Dorsal Surface of the Hand. 488 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. forth use this, as the simplest possible utensil, instead of the rude wooden cup which he had heretofore deemed the acme of simplicity. Around this hollow are set the so-called "mounts" of chiromancy, governed, as is as- serted, by the seven planets. The thenar eminence is styled the mount of Venus, and we may see a survival of the old notion in the fact that among the vulgar a titilla- tion of this surface is believed to excite amatory pas- sion.* It is possible that there may be an anatomical basis for this belief. An inspection of Fig. 1550 will show that the region in question lies in the boundary between the distribution of the ulnar and the median nerves, and is somewhat less fully supplied than are other parts of the hand. It is therefore, like other regions with the same character of nerve distribution, susceptible to that obscure form of nervous excitement called "tick- ling," which is known to cause a variety of reflex acts. We are as yet hardly sufficiently versed in the laws of transmission of impulses to decide absolutely that this may not have a reflex effect connected with the genital apparatus, especially if aided by an association of ideas. The lower part of the hypothenar eminence is called by palmisters the mount of the Moon, its upper the mount of Mars.* At the root of the four fingers are the other mounts, which anatomical peculiarities are caused by the insertion into the roots of the fingers of the strong pal- mar fascia, by slips between which the tissues bulge. The mount of Jupiter belongs to the index, Saturn to the medius, the Sun to the ring-finger, and Mercury to the little finger.' That this absurd farrago is not entirely obsolete the author has had ample evidence, as several intelligent people have assured him that they believe that these eminences have power to attract the seven different qualities of "astral fluid," and the doctrine has been fully set forth in more than one serious treatise within the last ten years.3, 4, 6, 6, ', 8. Indeed, it would seem as if the advances of science within the present cen- tury, instead of extinguishing ignorant pretension, had caused pseudo-sciences to spring up by the score. Daz- zled and bewildered by the evidences seen on every hand of the power of science, those untrained in the exact methods of scientific research are unable to distinguish between the true and the false, and a vast field is left open for charlatans and visionaries. The old astrologists believed not only that the hand was governed by the in- fluence of the stars, but that certain signs were fixed upon it before birth, and became a basis from which to interpret the individual's character and constitution. Since this character and constitution have their limita- tions, signs for these also were found in the hand ; and they further assumed that future events, such as sickness, death, and other matters of fortune or misfortune, could be foretold. There were many who went much farther than this into all the excesses of charlatanry. The hand, being the servant of the mind, is modified and changed according to the use to which it is put; hence, say the palmisters, this organ is the appropriate index of character, and the lines of the hand, caused by •he nervous influences actuating different muscles, and the tension and stress exerted on the skin, must be, if truly interpreted, a most significant guide. A little re- flection will show that the modern disciples of palmistry have fallen into the same error as have the physiogno- mists and phrenologists, in that they expect to obtain exact and detailed particulars by examining physical characters which are highly generalized, being the result of a great number of separate physiological processes and acts. Certain general notions as to bodily constitution, use, and adaptability can undoubtedly be made out upon the inspection of the hand ; but there appears to be no war- rant for any exact details. The principal lines are shown upon Fig. 1543. It will be seen that they form, rudely, the letter The one running around the ball of the thumb and marking off the thenar eminence was known to the old chiromants as the linea vitalis, or line of life. Measurements along this, made by describing arcs of circles from the sever- al mounts, were believed to represent different periods of life, and any break in the line at the points where these crossed were said to indicate sickness or death at that period. This, gravely set forth in all recent works on palmistry, also appears in books of the sixteenth cen- tury, and probably farther back.9 This fold, with an- other which occasionally occurs running from the wrist toward the finger, centrally through the palm, and called the saturnine line, or linea fortume, indicates to an anato- mist only the action of the adductor pollicis in drawing the thumb over, and is deep or almost entirely absent as the thumb has great or little flexion. The statement is made by Langer,10 that the saturnine line is not found in any but those of pure Caucasian race. As it is well marked in the chimpanzee, this seemed open to doubt, and the author has examined the hands of several negroes Fig. 1543.-Surface-markings on the Palm of the Hand. The thick black lines represent the chief creases on the skin. (Altered from Treves.) to ascertain if the statement had any foundation. In all those examined it showed with great clearness, even better than in whites. From the radial border of the hand, near the upper end of the linea vitalis, arises the linea cephalica, or head line, which passes obliquely across the palm, disappearing near the ulnar edge. The value of this line to a surgeon is considerable, as, where it crosses the fourth metacarpal bone, it marks the superficial palmar arch (see Fig. 1543). The arch may in some individuals be seen to pulsate strongly at this point. The commencement of the line indicates the metacarpo-phalangeal joint of the index- finger. It appears to be caused by the flexion of the four fingers, and corresponds rather closely to the origin of the lumbricales from the flexor tendons. Another line, not so extensive, is the linea mensalis, or heart line, which extends across under the mounts at the bases of the third, fourth, and fifth fingers. It is a little behind the metacarpo-phalangeal joints, and expresses flexion there of the three outer fingers, which usually act * Iago says of Desdemona: "Didst thou not see her paddle with the palm of his hand * Lechery by this hand, an index and obscure pro- logue to the history of lust and foul thoughts." 489 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. together. The name mensalis was given it because the names of the mounts were also names of months. Besides the lines described, a number of others are men- tioned by the chiromants, and in some hands there is a complete network. These might be of value for the purpose of proving personal identity in medico-legal cases. The occupation of the individual may occasion marks, callosities, and discolorations of the skin, alterations of the nails and hairs, formation of special bursse, and even changes in the articulations, muscles, and bones, which are of importance in determining identity. The limits of this article will not permit of a full treatment of this subject, which has been very carefully examined by Vernois.11 The shape of the hand may be permanently altered by the use of tools. The epidermis of the horny hand of a laborer may be so thick as to prevent the eruption of an abscess. The subcutaneous connective tissue of the palm is composed of short and thickly set fibrous bands, which firmly unite the skin with the deep fascia, forming parti- tion-walls, of little chambers which contain fat. When the tissue is cut through, these little adipose masses, released from their confinement, extend beyond the edges of the wound. This arrangement secures a considerable degree of elasticity and protection. Abscesses do not usually point under thicker parts of the subcutaneous tissue, but seek the ball of the thumb and the hypothenar emi- nence. The deep fascia is a strong and firm sheet, triangular in shape, the palmaris longus, its tensor, being inserted at the point of the triangle. Indeed, so continuously are the two united, that we may properly consider the fascia as an expansion of the tendon. It occurs, however, when the muscle is wanting. Opposite the fingers it splits into four processes, which are inserted by these slips at the bases of the fingers and into the sheath of the flexor ten- dons and the first finger-joint. Acting through these slips, the palmaris acts therefore as a flexor of the fin- gers. A chronic shortening of this sheet is known as Du- puytren's contraction, and is always accompanied by a permanent bending of fingers. The little finger and ring- finger are most affected; the thumb never, as it receives only a very insignificant slip of the palmar fascia. A band of fascial fibres stretches across the roots of the fingers, and is known as the superficial transverse liga- ment. A thin fascia also separates the interosseous mus- cles from the rest of the palm. The metacarpal bones of all the fingers except the thumb are bound together at their lower ends by a strong strip called the transverse metacarpal ligament, and processes extend between this and the palmar fascia, making thus distinct chambers through which pass the flexor tendons as they go down to the lingers. It is through this passage that suppura- tion extends from the lingers into the palm. Another series of orifices at the sides of the fingers per- mits the collateral vessels and nerves and the tendons of the lumbricales to reach the fingers. The structures beneath the palmar fascia are contained in three compartments, which are separated by intermus- cular septa ; one (see Fig. 1544), external, separates the Fig. 1544.-Horizontal Section of the Hand through the Middle of the Thenar and Hypothenar Eminences. (Tillaux.) a, Metacarpal bone ; b, first dorsal interosseus; c, palmaris brevis; d, abductor min. digiti; e, flexor brevis min. dig.; f, opponens min. dig.; g, flexor brevis poll.; h, abductor poll.; i, opponens poll. ; J, adductor poll. ; k, flexor long, pol.; I, dorsal interossei; m, palmar interossei; n, flexor sublimis ; o, flexor profundus; p, superfic. voice ; q, median nerve, and (on inner side) ulnar artery and nerve ; r, deep palmar arch ; 1, palmar fascia; 2, outer septum; 3, inner septum ; 4, deep fascia of palm. muscles of the thenar eminence and becomes continuous below with the sheath of the adductor pollicis, passing with it to be inserted into the third metacarpal; the other, internal, is attached to the anterior border of the fifth metacarpal, separating off the muscles of the hypothenar eminence. The middle compartment is the most impor- tant, as it contains, besides the flexor tendons and their accessory muscles, the vessels and nerves of the palm. The following table gives the principal facts regarding the muscles of the palm, as stated by the best authori- ties : Origin. Insertion. Innervation. Action. Thenar Muscles. Abductor pollicis. Opponens pollicis. Flexor brevis pollicis. Adductor pollicis. Htpothenak Muscles. Trapezium and annular Base first phalanx of ligament. thumb. Trapezium and annular Metacarpale I. along ligament. whole length. Trapezoid, os magnum. Base first phalanx of and metacarpales II. thumb, with sesamoids, and III. Shaft of metacarpale III. Base first phalanx thumb. Median. Median. Outer head median. Inner head ulnar. Ulnar. Abducts and rotates thumb and extends second phalanx. Brings first metacarpal forward and rotates it in- ward. Flexes and rotates first phalanx of thumb. Adducts thumb. Abductor minimi digiti. Opponens minimi digiti. Flexor brevis minimi digiti. Palmaris brevis. Median Muscles. Pisiform and tendon flex- Base first phalanx digit or carpi ulnaris. V., with slip to extensor tendon. Annular ligament and Ulnar border metacar- unciform. pale V. Annular ligament and Base first phalanx digit unciform. V. Palmar fascia and annu- Skin of inner border of lar ligament. palm. Ulnar. Ulnar. Ulnar. Ulnar. Draws little finger away from others. Draws little finger forward, narrows hand, and deepens hollow. Keeps phalanx firmly down in grasping. Draws up integument on inner side. Lumbricales. Palmar interossei. Dorsal interossei. Radial sides of tendon of Radial sides of tendons of flexor profundus digi- extensor communis dig- torum. itoruin and first pha- langes. Metacarpales II., IV., Bases of first phalanges and V. . digit. II., IV., and V. Adjacent sides of meta- Base of first phalanges carpals, more particu- digit. II., HI.,and IV., larly upon those of the and to extensor tendon, finger where insertion * occurs. First two by median, last two by ulnar. Ulnar. Ulnar. Extensors of last two phalanges, flexors of first pha- langes when these are semiflexed by the dorsal interossei. The first and second are abductors and rotators, the third and fourth adductors and rotators. Extensors of last two phalanges, adductors and ro- tators, flexors of first phalanges. Flexors and abductors of first phalanges, and in slight degree rotators. The third extends last two phalanges. 490 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. It should be noted that between the two heads of the flexor brevis pollicis the tendon of the long flexor of the thumb passes, lying in the groove of the trapezium. The deep head of this muscle (supplied by the ulnar nerve), as usually described, should rather be called a por- tion of the adductor pollicis, with which it is somewhat closely allied. The palmaris brevis probably, by its con- traction, assists to protect the ulnar artery and nerve, which pass directly under it. When the list is firmly clenched, this muscle assists in tightening the palmar aponeurosis, and its situation is marked by a little hollow on the ulnar side of the hand. It is not usually capable of independent action, but the author has found some persons who had the power to move it at will, thus wrinkling the skin. It appears to be a muscle derived from the panniculus carnosus, like the small muscles of the face. The lumbricales are so called because of their round, worm-like appearance. The old anatomists, because of their use in flexing and extending the fingers, called them fiducinales, or fiddler's muscles. Duchenne12 noticed that in persons who were suffering from lead paralysis, and had therefore no control over the extensor muscles supplied from the musculo-spiral nerve, there was still some power of extension in the sec- ond and third phalanges. The statement made in the ta- ble as to the action of the lumbricales is that of Adam,13 where it becomes free from the first dorsal interosseous muscle, which covers it in the upper part of the inter- space. As the skin and fascia on the dorsal surface of the web are thinner than on the palmar, abscesses of the palm which reach the base of the fingers usually dis- charge behind. The skin of the dorsum is in many respects the oppo- site of that of the palm, being thin, easily movable, hairy, especially toward the ulnar side, and but slightly sensitive. (Edema is much more quickly shown here, the subcutaneous tissue being loose and numerous veins course through it. Some idea can be obtained of the to- nicity of the vascular walls by noting their visibility through the skin. They vary much, however, in differ- ent individuals. The deep fascia forms the sheaths of the tendons as Fig. 1545.-Bones of Two Fingers, with the Insertions of the Tendons. (R. Quain.) In A, the tendons of the flexor muscles are bound to the bones by the fibrous sheath. In B, the sheath has been removed, as well as the vincula accessoria; 1, metacarpal bone ; 2, tendon of the flexor sublimis; 3, tendon of the flexor profundus; *, perforation of the sublimis by the profundus tendon ; 4, tendon of the extensor com- munis digitorum ; 5, lumbricalis muscle; 6, one of the interosseous muscles. founded upon observations made on the cadaver, and with electrical excitation with special instruments. Fig. 1545 shows the manner of insertion of the lumbri- cales, as well as that of the interossei and the flexor ten- dons. Besides the muscles mentioned in the table, the tendons shown in Fig. 1545 lie in the hollow of the hand. As they approach the fingers, the tendons of the superficial flexor lie immediately upon those of the deep, and in fact embrace them in a groove upon their under surface, this groove deepening until it at last becomes a slit through which the tendons of the deep flexor pass. It is there- fore impossible to cut the tendons of the superficial flexor without at the same time cutting those of the deep flexor. The back of the hand is convex, and shows plainly the metacarpal bones. When laid upon a flat surface, it is comparatively flat, but when the flexor tendons act they pull the bones together in such a way as to increase the convexity. The adaptability of this for the purpose of firmly seizing objects may be seen by reference to Fig. 1548. When the fingers are extended and spread apart, the extensor tendons shown in Fig. 1546 are well dis- played. Shallow furrows appear between the tendons, and at the lower part of the dorsum the heads of the metacarpal bones become prominent. At the base of the fingers the skin becomes thinned out into an interdigital web semi- lunar in shape. The web between the thumb and the in- dex-finger is thicker and more marked than elsewhere, because it contains in front the adductor of the thumb Fig. 1546.-Superficial Musclesand Tendons on the Back of the Wrist and Hand. (After Bourgery.) The posterior annular ligament of the wrist isreprcsented. 1, Extensor ossis metacarpi pollicis ; 1', its inser- tion ; 2, extensor primi internodii pollicis; 2Z, its insertion; 3, tendon of extensor secundi internodii pollicis; 4, extensor communis digito- rum: 4', tendon to the middle finger receiving the insertion of the second and third dorsal interosseous muscles; 4", division of the tendon into three portions, of which the median is inserted into the second phalanx, the two lateral passing on to be inserted at 4/,z into the ter- minal phalanx; 5, extensor minimi digiti; 5', its junction with the slip of the common extensor; 6, placed on the lower end of the ulna, points to the extensor carpi ulnaris; 6^ insertion of this muscle into the base of the fifth metacarpal bone : 7, part of the flexor carpi ul- naris ; 8, placed on the os magnum, points to the insertion of the ex- tensor carpi radialis brevior ; 8', placed on the base of the second met- acarpal bone, points to the insertion of the extensor carpi radialis longior; 9, tendon of extensor indicis; 10, small part of the adductor pollicis, and inner head of the flexor brevis pollicis; 11, first dorsal interosseous or abductor indicis; m the other three interosseous spaces are seen in succession, from the radial side inward, the insertion of the first palmar, second dorsal, third dorsal, second palmar, fourth dorsal, and third palmar interosseous muscles; 12, abductor minimi digiti. they pass down. These tendons are arranged in two sets, which may be said to represent a superficial and a deep extensor similar to the arrangement of the flexors. To the superficial extensor belong the tendons of the exten- sor communis and the extensor minimi digiti, which pass down under the annular ligament almost vertically, di- verging to their respective insertions after reaching the dorsum. The tendons of the communis, which go to the last three fingers, are united by oblique bands. This re- stricts the motion of the ring-finger to a considerable de- gree, and it cannot be fully extended when the third or fifth digit is held firmly flexed. Subcutaneous section of 491 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. these bands is sometimes resorted to for the purpose of giving pianists more independent movement of the ring- finger. To the deep extensor set belong those muscles which, arising lower down upon the forearm, run some- what obliquely across the others to be inserted into the index-finger and the thumb. These are the three exten- sors of the thumb and the extensor indicis. Many vari- eties occur which confirm this view. In apes the extensor indicis also supplies the middle-finger, and sometimes the ring-finger as well. The extensor secundi internodii pol- licis (which should be called extensor longus pollicis) also sends a tendon to the index, and sometimes to the medius. Similar variations occur in man. Koster14 found the tendon of the indicis and the long extensor of the thumb united by a cross band like those which appear on the tendons of the common extensor. The bones of the middle hand are the five metacarpals, each concave toward the palm, and having a somewhat prismatic shaft with two enlarged extremities. Closely applied at the bases they spread along the shaft so that they never touch there, while again at the lower end they can be brought together. There is thus left room for the interossei muscles. The first metacarpal is an exception, as, in order to preserve the independence and opposability of the thumb, the base is set over and in front of the line of the others, and its distal end is not confined by liga- ments. Since it is shaped more like a phalanx than like the others, anatomists have not failed to add this to other evidence which has been adduced to prove that the thumb has no true metacarpal. The joint by which it articu- lates with the trapezium is a saddle-joint, the movement being free in two planes, viz., that of flexion and exten- sion, and that of adduction and abduction. It is not, however, limited to these, as circumduc- tion can take place quite easily. There is no rotation. The cap- sule is thick and strong, and dis- location is very rare. The situation of the joint is easily made out by running the linger upward along the shaft of the bone until it reaches the pro- cess at the base, immediately above which is the articulation. The process is made more promi- nent by strongly flexing and adducting the thumb, and the interarticular line can then be easily made out in most individuals. The other metacarpals are united to the wrist-bones and to each other by articulations which are fixed by means of interosseous ligaments, which make their disarticulation very difficult. The fifth joint has the most movement. The rounded lower ends of the metacarpals are of im- portance in forming an arch which strengthens the hand. For this reason they should be preserved in amputat- ing the fingers, when it is possible to do so. The articu- lar surfaces here are directed in such a manner as to have the planes of movement converge toward the middle of the hand. This greatly increases the power of grasp of the phalanges, as the tighter the lingers close the more strenuous becomes the lateral pressure. The convergence of the flexor tendons assists this. The extensor tendons pass over the most prominent part of the metacarpal heads behind. The third metacarpal, though not the longest, has its head more prominent, and is usually the one which receives injury from striking heavy blows. The Fingers.-The anatomical names of the five digits or fingers are the pollexor thumb, indicis or index, medius or middle finger, annularis or ring-finger, and auricularis or little finger, the latter presumably so-called because of its use in cleaning the meatus auditorius. They are of notably different length, but somewhat nicely adjusted to the functions of grasping, as will be seen on holding a ball in the hand, as shown in Fig. 1548. The middle finger is the longest and has, therefore, the longest circumference to span, and the others are so ad- justed, as to length, that they come very nearly to the same level at their tips. For this reason all tools which are to be grasped by the hand should have a swelling in the handle opposite the middle, so as to insure a good grip The usual arrangement as to length of the fingers is that in the extended hand the thumb does not quite reach the second phalanx of the index, the medius is longer than the annularis by half a nail, and the auricularis reaches only to the last phalanx. There is considerable variation in the length of the index. In about two-thirds of the cases (Mantegazza15) the index is shorter than the annularis, reaching only to the root of the nail of the medius. In others the two fingers are nearly of the same length, and rarely the index exceeds the annularis in length. Ecker16 considers the shortness of the index to be a characteristic of apes, and thinks that when relatively longer it is an attribute of a higher form of hand. He finds it longer in women, who show in this, as in many anatomical features, signs of a purer morphological form. Carns4 does not mention the length of the fingers, but figures what he calls, after d'Arpentigny,3 the idealistic hand (seelische hand, main psvchique), which shows a long index. It is noticed by Hyrtln that the apparent length of the ring and index fingers may be influenced by the posture of the hand. If the hand is laid flat, so that the axis of the medius corresponds with that of the entire arm, the index usually appears a little shorter than the ring, but abduct the hand, and the ring-finger will appear a whole nail's length longer. Griming18 has recently given the results of two hundred observations very care- fully taken. He finds that the ring-finger is usually the longer, yet the reverse is not uncommon, and more frequent in females. In the foot the second toe is usually the long- est, but a greater length of the big toe is not rare, also more frequent in females. This lends some support to the the- ory that the foot has no digit homologous with the thumb. The general relation of the middle finger to the rest of the hand is expressed by Langer 10 as follows : If a measurement be taken from the os magnum to the end of the finger, the various parts, as measured from the angles at the joints made by flexion, will be in the proportion of 8 : 5 : 3 : 2, that is to say, the middle hand is as long as the three other portions, and the basal phalanx is as long as the middle and ungual together. The length of the entire hand has been used by artists as a canon of proportion for the whole body, being set at one-ninth of the whole height. The Egyptian canon seems to have been based upon the length of the index, which was reckoned as one-nine- teenth of the height. Many measures used as rough esti- mates are taken from the hand ; the length of the middle finger from knuckle to point is reckoned as one-eighth of a yard, and from the tip of the thumb-nail to the second joint as about half of that, and is called one nail. The breadth of the hand is used as a measure for horses, and is reckoned at four inches. The breadth of the thumb is the pouce or inch of the old French measures. Of course all these are liable to vary because of individual peculi- arity.19 It should be noted that the proportions of the hand to the entire height are attained very early, at least by the fifth year (Quetelet20). The member appears to have the same early physical development that the brain has, and the hand of the new-born child is structurally that of the adult, differing only in size. The thumb has from very early times held the place of honor among the digits, as the loss of it deprived the hand of much of its power. It is especially by the su- periority of the thumb that man's hand is distinguished from that of the higher apes. There are no less than eight muscles attached to it, and this gives a freedom and variety of motion which is not possessed by any other .Trapezium. .Capsule. First meta- carpal. Fig. 1547.-Carpo-metacarpal Joint of the Thumb. Fig. 1548.-The Length of the Fingers as Adapted in Grasp- ing. (Humphry.) 492 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. digit. To cut off the thumb was an old method of dis- abling an enemy, by preventing him from properly using his weapons, and soldiers sometimes resorted to this muti- lation to exempt themselves from military duty-as those of our own time have been known to amputate the ter- minal phalanx of the index to unfit themselves for pulling the trigger of a gun. It is from this custom that the word poltroon is said to have arisen, being a corruption of pollice truncus. The palmisters exalt the thumb far above the other digits. D'Arpeutigny says: "I'animal superieur est dans la main, Vhomme est dans le ponce." The ungual phalanx represents the will, the other the intellect, and according as these are relatively prominent they judge of character. The Eskimo tradition is that woman was originally formed from the thumb of man. The thumb was used by the spectators of Roman gladia- torial combats to indicate whether the conquered party should die or live. Those who have felt the brutal force of Gerome's painting, " Pollices Verti," will not forget it. In La Vendee a large thumb indicates a predilection for the black art, and to bite the thumb is a grave insult in Scotland and Italy * The unusual strength of the muscles which are attached to the thumb, making it an efficient portion of a pair of forceps when applied to the other fingers, leads also to its being affected by convulsive action. In almost all cases of this kind the thumb is firmly clenched and drawn into the palm (see Fig. 1549). This may be of service as a medico- legal sign, as it isalmost always found in those who have The middle folds are double and exactly opposite the joints, the lower folds are all single and a trifle above the joints Upon the thumb there are also three folds, the upper and lower folds correspond to the joints very nearly, the middle one having no topographical signifi- cance. The skin on the fingers is remarkably rich in pa- pillae ; the number of these containing nerves increases as we proceed toward the finger-tips. These papillae, both on the fingers and palm, are arranged in lines form- ing characteristic curvilinear ridges. Upon the eminences formed by the pulps of the fingers and the eminences of the palm these are arranged in elliptical or spiral patterns, and it has been seriously proposed to use these as a means of identifying individuals. In certain cases they have Fig. 1549.-The Convulsive Hand. (Warner.21) died a violent death, and consequently suffered spasmodic contraction of the muscles during the last agony. The index or pointing finger has been called the gynae- cologist's eye. It is somewhat more sensitive to tactile impression than the others, and, being supplied with special muscles, it is particularly serviceable as the an- tagonist of the thumb. It is always best to preserve this finger and the thumb, if possible, in injuries to the hand, as by themselves they make quite a serviceable organ. The ring-finger, or annularis, is so called from the fact that it has been customary, since the time of the Romans, to carry rings upon it. This has been said to originate in the fact that they supposed it to be especially connected with the heart, either because it is supplied by two nerves (see Fig. 1550). or more probably because the vena salva- tella runs prominently from it up the arm. Owing to the connection of the tendons this finger is somewhat pro- tected by those beside it, and consequently is less liable than the others to injury, and this affords ample reason why it, as well as the left hand, should be chosen to wear the ring. The old anatomists called it the digitus medicus, because they were accustomed to mix medicines with it. Upon the palmar face of the fingers are seen certain transverse furrows, well marked. These are important guides to the jointsand should be well noted (see Fig. 1543). They are not correctly given in any of the books on palmistry which the author has consulted, which shows that in point of accuracy their "science" leaves something to be desired. The folds nearest the palm are single for the index and little fingers, double for the others. They do not correspond exactly to the metacarpo- phalangeal joints, but are three-fourths of an inch below. Fig. 1550.-Distribution of Nerves to the Palm of the Hand. (Tillaux.) if, median nerve ; U, ulnar nerve; «, a, a, a, a, a. collateral branches of the median nerve; b, dorsal branch of the ulnar nerve; c, muscular branches ; d, superficial branch ; e. deep branch ; /, anastomotic branch. been of service. Faulds22 mentions that by means of fin- ger-marks upon a greasy glass it was ascertained who, among a number of servants, had been drinking some rectified spirit ; and another case, where a criminal was detected by an impression of sooty finger-marks on a white wall. He considers that the Mongolian races have a special and characteristic pattern. The city authorities of San Francisco recently considered the propriety of registering all the Chinese who arrived at the port by taking an impression of the thumb. It is said that the legal expression " my hand and seal," arose from the cus- tom of sealing papers with the thumb. It is somewhat open to doubt whether a marked individuality exists, and, if so, whether it could be made practically useful. Beneath the skin the subcutaneous tissue is like that of the palm-a series of little cushions of fat On the last phalanx this is called the pulp of the finger. Still deeper is found the canal for the flexor tendons The fibres of this sheath are less thick opposite the joints, so as not to impede flexion. They are continuous above with the * Vide Romeo and Juliet, Act I., sc. 2. "I will bite my thumb at them, which is a disgrace 11 they bear it." 493 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. palmar fascia. The canal contains in the thumb only the tendon of the long flexor, in the other fingers the tendons into the second phalanx (see Fig. 1545, B). The deep flexor is inserted into the terminal phalanges. Some persons have power to use it independently. Fig. 1551.-Results of Section of the Median Nerve. (L6ti6vant.23) of the superficial and deep flexors. They are united to the sheath by small bands termed retinacula. Opposite On the dorsal surface of the fingers the skin forms elliptical folds at the articulations of the first and sec- ond phalanges, and simply a few transverse folds at the Fig. 1553.-Deformity from Injury to Ulnar Nerve. (L6ti6vant.) Fig. 1552.-Zones of Anaesthesia after Section of the Median Nerve. (Letievant.) the first phalanx the flexor sublimis splits and the two halves fold around the deep flexor, again uniting behind it by their margins. They then separate and are inserted Fig. 1554.-Zone of Anaesthesia from Injury to Ulnar Nerve. (L^tievant.) articulations of the second and third. Under the skin the extensor tendons form a broad aponeurotic sheet into 494 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand* Hand. which the expanded tendons of the lumbricales and inter- ossei are inserted. This sheet terminates with the inser- tion of the extensor into the last phalanx. The nails which terminate the digits are, as is well known, really epidermal elements. They are found in the embryo at about the third month of pregnancy. Their growth is always from the root, and the rate at which they grow can frequently be noted by the spots which occur upon them, and thus a general notion may be obtained of the vigor of the processes of nutrition. The joints of the lingers have a general resemblance to each other, the metacarpo-phalangeal being merely a little broader. The ends of the phalanges broaden out somewhat at their extremities, and when the body becomes emaciated, as in a wasting disease, these ends become very prominent, and the disorder known as clubbed fingers results. At the metacarpo-phalangeal joint of the thumb there are two sesamoid bones, which are believed to be radial. The ulnar supplies the flexor carpi ulnaris and the principal part of the deep flexor, leaving to the median that portion which goes to the index-finger, which might, therefore, properly be classed as a separate muscle. After section of the median nerve the hand and arm present the appearance shown in Fig. 1551. This condition arises from paralysis and atro- phy of the muscles supplied by the nerve. There is, however, a considerable movement left to the fingers, pro- nation being effected by the shoulder muscles acting on the arm, flex- ion of the wrist by the flexor carpi ulnaris, the first phalanges flexed by the interossei, the others by the deep flexor. The thumb suffers most, and we may, accordingly, say that the median nerve especially presides over the move- ments of that digit. In the same way as motility is not entirely lost, so also is sensi- bility retained to some extent. Fig. 1552 shows the area upon which anaesthesia occurs, the darkest spots being those that are most affected, the lighter shades succes- sively less intense modifications. It will be seen in com- paring this with Fig. 1550, that the anaesthesia does not correspond with the distribution of the nerve. The rea- son for this is believed to be found in the collateral branches which run from the ulnar to anastomose with the median. There is no doubt that the anaesthesia after section continues to grow less, and it has been suggested that when certain parts are disabled, other nerves may send out filaments from the fine plexus into which the nerves break up before going to supply the papillae, in order to supply the need. The deformity and loss of sensibility from injury to the ulnar nerve are shown in Figs. 1553 and 1554, and the same for the radial in Fig. 1555. The correlative action of the muscles and nerves has a very marked result upon what may be called the physiog- nomy of the hand. War- ner 21 has care- fully studied this subject, and describes, among others, the following types, which relate to the ex- pression of the emotions: The convulsive hand (Fig. 1549), in which the thumb is for- cibly and violently adducted, the fingers pressed closely together and semiflexed on the thumb, the hand assum- ing a conical shape. The op- posite of this is the hand in fright (Fig. 1556), the pha- langes and the wrist being extended. The whole atti- tude is that of repelling an abhorrent object. In pure horror, not accompanied by fear, the hands are thrown widely back, the arms up- lifted, the fingers open. A passenger upon a train that ran over a man, told me her first intimation of an accident was seeing through the window a person assume this atti- tude as the train shot past. The convulsive wringing of the hands is an expression of quite an opposite order, indi- Fig. 1556.-The Hand in Fright. (Warner.) Fig. 1555.-Deformity and Anaesthetic Arna Resulting from Section of Radial Nerve. (L6tievant.) one of the causes of the difficulty of reducing a disloca- tion at that joint. Similar structures, usually cartilagi- nous, however, are found on the palmar surfaces of each of the phalangeal joints. In negroes, or in those laborers who use the hands much for heavy work, they may all be ossified, as they are in the forefoot of a bear. The artic- ulations are all imperfect hinge-joints, having lateral ligaments and a thickening of the capsule on the palmar surface. It should be remembered that the articular line is always found beyond the angle formed by the flexion of the phalanges. The nerves of the hand are three in number. Their distribution to the palmar surface is shown in Fig. 1550, and the muscles they supply are mentioned in the table on page 490. To those mentioned there should be added those which come down from above. Of these the flexors are sup- plied by the median and ulnar, the extensors by the Fig. 1557.-The Feeble Hand. (Warner.) 495 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. eating intense and continued painful emotion, and instead of the hand-washing motion performed by tragic actors, is, when genuine, a passing of one hand down the other, with a convulsive twist at the ends of the lingers. The feeble hand (Fig 1557) is indicated by a dropping of the thumb and a bending of the phalanges. The tonic hand in rest (Fig. 1558) is like this, but differs in the degree of the action. The nervous hand (Fig. 1559) has the wrist slightly bent, and the me- tacarpo-phafangeal joints hy- per-extended, and the first and third internodes slightly flexed. T h e energetic hand (Fig. 1560) is theoppositeof this, the wrist being extended and the small joints in flexion. The vessels of the hand have re- cently been the subject of careful study by Bourceret,24 and he has arrived at some conclusions which seem impor- tant and new. By a very ingenious process, and using a series of injections, he has been able not only to fill the entire arterial and capillary system, but the venous sys- tem as well, injecting from the heart outward, notwith- standing the valves. The arrangement of the arteries has already been alluded to. The radial and ulnar form, as shown in Fig. 1543, two arterial arcades known ds the superficial and deep palmar arches, the first of them being made by the radial and the deep branch of the ulnar. To these may be added a third arch over the back of the wrist, formed by collateral branches of the two trunks. From these arches pass branches which supply the fingers, being of considerable size throughout their length, even to the last phalanges, and not accompanied by venas comites. The object of this excessive vascular supply is not only the nutrition of the fingers, but also to maintain the bodily warmth there. They communicate by two sets of capil- laries, one small and intended for nutrition only, the other large and intended for increasing the heat. literature. It appears, however, that there is reason to suppose that we have, in dextral preference, merely a further differentiation like that which has resulted in the development of the feet and hands from four originally similar organs. The left hemisphere of the brain appears to be assuming control of the more complicated motor functions performed by the right side of the body, while the right hemisphere attends more especially to the nutri- tive functions through the sympathetic system. It is noted that the senses of temperature and of weight are usually more acute in the left hand. Perhaps this is in some degree due to its less frequent use. Granting this, we have to search for the origination of the tendency. Hyrtl17 supposes it to arise from the fact that the in- nominate artery carries more blood to the right side. Dwight and others 28, 29, 30 think it depends upon the situation of the left carotid at the top of the arch, surmis- ing that it receives a swifter current of blood, which goes to the left brain, controlling the left side. Blumen- bach supposed that it was due to a deviation of the in- nominate artery to the left. Breschet thought that there was an innate tendency to a predominance of nutrition on the right side in foetal life. The right side of the spine develops first and so throws the heart to the left. Comte31 suggests that it is due to the fact that the foetus in utero lies usually on the left side, owing to the obliquity of the pelvis, and that this occasions a precocity of develop- Fig. 1558.-The Tonic Hand. (Warner.) Fig. 1560.-The Energetic Hand. (Warner.) ment of the right side. The percentage of left-handed persons is about that of presentations where the foetus lies on its right side. An ingenious explanation is offered by Buchanan,32 who holds that the centre of gravity lies on the right side owing to the weight of the liver, and that this causes a greater development of the muscles there. It is possible that several of these causes may have had an effect upon the matter. Not liking to have so much good speculation go by without adding a stone to the heap, the author sug- gests that an efficient cause may be found in the situation of the heart upon the left side. A savage soon learns that his enemy is vulnerable there, and takes pains to pro- tect himself by withdrawing the left side and using the weapon with the right. The constant persistence of this use of the right arm as the weapon-bearing member has probably resulted in organic dextral preference, and left- handedness may be considered as an atavism. Frank Baker. Fig. 1559.-The Nervous Hand. (Warner.) These capillaries are arranged in very complicated tortuosities, like little balls of tangled thread. They open immediately into the veins, which are also remark- able for their flexuosities. Any consideration of the hand would be incomplete without some remark con- cerning the separate use of the two hands. Right-hand- edness, or rather right-sidedness, for the matter is not by any means confined to the hand, is the rule among all races of men, and some traces of it may be seen in the animal creation. The elephant, for example, is said to use the right tusk more than the left, and this is accord- ingly called the servant tusk.25 Left-handedness is the ex- ception, occurring in about nine per cent, of individuals. Many attempts have been made to explain this, and Franklin's26 plea for the left hand, and Charles Reade's essay27 upon the injury mankind inflicts upon itself by the continuous use of the right, are well-known curiosities of 1 Bell, Sir Charles: The Hand, its Mechanism and Vital Endowments, as Evincing Design. London, 1852. 2 Sappey, Ph. C.: Anatomic Descriptive, vol. i. 3 D'Arpentigny, S.: La Chirognomie, ou 1'Art de reconnaitre les Ten- dances de 1'Intelligence d'apres les Formes de la Main. Paris, 1843. 4 Carns. C. G.: Ueber Grund und Bedentung der verschiedenen For- men der Hand in verschiedenen Personen. Stuttgart, 1846. 5 The Hand Phrenologically Considered : being a Glimpse at the Rela- tion of the Mind with the Organization of the Body. London, 1848. (Mainly a reproduction of Carns and d'Arpentigny.) 6 Desbarrolles, Ad.: Les Mysteres de la Main, rev61cs et expliques. Paris, 1859. (All recent works on palmistry copy largely from this.) 7 De Metz. V.: Handbook of Modern Palmistry. New York, 1884. 8 Frith, H.. and Allen, E. H.: The Language of the Hand. London and New York (Routledge), n. d. " La Grande Chyromance Naturelie, ou 1'Art parfait de se Connoitre soy-mestne, tireee de tons les plus graves Autheurs anciens et modernes qui ont traitte de cette matiere. Paris, 1577. 10 Langer, C.: Anatomie des ausseren Formen des menschl. Korpers. Wien, 1884. 496 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. 11 Vemois, M.: De la Main des Ouvriers et des Artisans an point de vue de 1'Hygiene et de la Medecine legale. Paris, 1862. 13 Duchenne : Physiologic des Mouvements. is Adam, C.: On the Anatomy and Physiology of the Small Muscles of the Hand, Arch. Med., New York, 1883, ix., 59, p. 260. it Koster, W.: Sur la Signification Genetique des Muscles Extenseurs des Doigts, Arch. Neerland. d. Sc. exactes. 1879, xiv., 320. Ibid., Affen und Menschenhand, same journal, 1880, xv., 313. 75 Mantegazza, P.: Antropologia della Lunghezza relativa dell' Indice e dell' Annulare nella Mano humana, R. Inst. Lomb. di sc. e lett. Rendie. Milano, 1877. 2 s., x., 303. ia Ecker, A.: Ueber einen schwankenden Charakter in der Hand des Menschen, Arch. f. Anthrop. Braunschw., 1875-6, viii., 67. 17 Hyrtl, J.: Topographische Anat., 7th ed. Wien, 1882. 18 Gruning, J.: Ueber die Lange der Finger und Zehen bei einigen Volkerstiimmern, same journal, 1885-6, xvi„ 511. n» Fletcher, Robert: Human Proportion in Art, and Anthropometry. Cambridge. Mass., 1883. 20 Quetelet, L. A. J.: Anthropometrie, ou Mesure des diff erentes Fac- ultes de 1'Homme. Bruxelles, 1870. 21 Warner, F.: Physical Expression. New York, 1886. 22 Faulds, H.: On the Skin Furrows of the Hand, Nature, London, 1880, xxii., 605. 23 L6tievant: Traiti des Sections nerveuses. Paris, 1873. 24 Bourceret, P.: Circulations locales: la Main. Paris, 1885. 26 Shaw: On Right-handedness, J. Anth. Inst., London, 1877-8, vii., 94. 29 A Petition of the Left Hand. Sparks' Edition of Franklin's Works, ii., 183. 27 Reade, Charles : The Coming Man. 28 Dwight, J. : Right- and Left-handedness, Quar. Jour. Psychol. Med., 1870, iv„ 535. 29 Wyeth, J. A.: The Anatomical Reason for Dextral Preference in Man, Ann. Anat, and Surg, Brooklyn, N. Y., 1880, ii., 121. 30 Cahall, W. C.: Why are we Right-handed ? Pop. Sci. Mo, New York, 1883, xxiii., 86. 31 Comte, J. A.: Recherches anatomico-physiologiques relatives a la Predominance du Bras droit sur le Bras gauche, Jour, de Physiol. Ex- periment. et Pathol, Paris, 1828, viii., 41. 32 Buchanan. A.: Mechanical Theory of the Predominance of the Right Hand over the Left, or. more generally, of the Limbs of the Right Side over those of the Left Side of the Body. Glasgow, 1862. Ibid., Theory of the Right Hand, Ed. Med. Jour., August, 1863. when a polydactylic weds a person with normal mem- bers, the deformity is rarely encountered in their chil- dren. Various theories have been advanced to account for this malformation, but none of them is satisfactory. It has been supposed to be due to a primitive abnor- mality in the germ, or to the fusion of the twin germs within the womb-a fusion coming, as it were, within a finger's breadth of being complete. Another theory is that of Serres, cpioted by Saint-Germain, who supposes a primitive duality of all the organs. According to this view a bifid thumb would be but the expression of an ar- rest of coalescence of the two primary thumbs from some disturbance in the course of intra-uterine growth ; and so of any of the other organs. There is an almost infinite variety in the possible forms of polydactylism. In some cases the phalanges of two fingers articulate with one metacarpal bone, or there may also be a supernumerary metacarpal. Any one of the digits may be duplicated, and the extra member may be of normal appearance and in the same line with the others, or it may be atrophied, deficient in phalanges, or entirely devoid of skeleton, and either entirely distinct from, or partially fused with, its neighbor. Sometimes a finger is found growing out from the border of the palm, at right angles to it, unprovided with either nerves or bones, and resembling a mere fleshy tumor. The double thumb is a very common form of polydactylism. It may be a simple bifurcation, or there may be two distinct thumbs, or one may grow from the other, and the second may be simply a pediculated tumor. Another, and rare, variety is that of the bifurcated hand. In this form the thumbs are absent, and we have two opposed hands articulated with the carpus, each of which has four fingers with the metacarpal bones complete. One instance of this kind has been recorded in which there were twelve digits on each hand and foot. The muscular apparatus is suffici- ently developed to afford free movement of the fingers of the opposed halves of the hand, so that, except for the deformity, the bifid hand would seem to be almost an improvement on the normal member. Another condi- tion, allied to polydactylism, is that known as macrodac- tylism, in which the tally of digits is correct, but in which the fingers are of abnormal length, owing to an increase in the number of phalanges. This deformity is of ex- ceedingly rare occurrence, there being but very few well authenticated cases on record. There is a diversity of opinion as to the advisability of operation in polydactylism. Many authorities counsel abstention when the extra finger is well-formed and capa- ble of independent movement. But the danger of an operation of this sort is so slight that it would seem bet- ter, for aesthetic reasons, to remove the digit in all cases. There might be some question when the two fingers ar- ticulate with one metacarpal bone, owing to the danger involved in opening the joint, but the recent advances in antiseptic surgery have made us much less apprehensive of interference even with the largest articulations, and the mental distress occasioned by the malformation is often so great that the risk of a stiff finger seems trivial by comparison. If there is an extra metacarpal bone it should be removed, leaving, however, the carpal extrem- ity and thus avoiding injury to the wrist-joint. In the case of a bifid hand the question is somewhat different, as the member would be deprived of much of its usefulness if one- half were removed, for, owing to the absence of thumbs, there would remain no opposing digit, and the hand would consequently lose much of its grasping power. If the patient will consent to the deformity for the sake of utility, abstention should be our rule in these cases. Syndactylism.-This is the deformity occasioned by the fusion, more or less complete, of two or more fingers. The union may be effected by simple folds of integument (webbed fingers), or it may be more intimate, so as to leave scarcely a trace of the line of division, the bones as well as the soft parts being sometimes fused together. In such extreme cases the nails are often also adherent, so that the member presents the appearance of a hoof. When the union is tegumentary, it is often only partial in extent, seeming to be merely a prolongation of the HAND, DEFORMITIES OF. It is not proposed, under this heading, to present an exhaustive treatise upon all the deformities and malpositions of the hand and fingers, but only to describe briefly those deviations from the nor- mal which are of interest from either the frequency of their occurrence, their amenability to treatment, or their semeiological signification. For convenience of descrip- tion the following classification has been adopted, and the different deformities of the hand and fingers will be considered as far as possible in the order here given : I. Congenital Deformities. - 1. Polydactylism (Macrodactylism). 2. Syndactylism. 3. Ectrodactylism (Didactylism, Brachydactylism). 4. Club-hand. II. Acquired Deformities. - 1. Deformities from Paralysis: (a) Progressive Muscular Atrophy ; (J) Infan- tile Paralysis ; (c) Cervical Paraplegia ; (d) Hypertrophic Cervical Pachymeningitis; (e) Disease or Injury of the Peripheral Nerves ; (/) Plumbism. 2. Deformities from Muscular Spasm : (a) Hemiplegic Contractures ; (5) In- fantile Hemiplegia ; (c) Athetosis ; (d) Amyotrophic Lat- eral Spinal Sclerosis ; (e) Paralysis Agitans; (f) Tetanus ; (g) Hysterical Contractures ; (A) Wrist-joint Disease. 3. Deformities of Miscellaneous Origin: («) Dupuytren's Contraction ; (b) Scleroderma ; (c) Ainhum ; (d) Leprosy ; (e) Syphilis ; (/) Arthritis Deformans ; (g) Gout; (h) Os- teomalacia ; (0 Rachitis ; (k) Occupation ; (I) Cicatricial Contractions ; (m) Hippocratic Fingers. Congenital Deformities.-Polydactylism.-This is one of the least infrequent of the congenital deformities of the hand. It was known to the Romans, as the sur- name Sedigitus testifies, and we read in the Holy Script- ures of a Philistine who had six fingers on each hand, and six toes on each foot (II. Kings xxi. 20). The num- ber of supernumerary digits varies ; there are more com- monly but six fingers, but there may be eight or more. The deformity may be confined to one hand, but it is more often double, and not infrequently all four of the extremities are similarly affected. Some remarkable in- stances are on record in which the condition existed in several members of the same family, and even occurred in several successive generations ; but the number of such cases is too small to establish with any degree of positive- ness the existence of an hereditary influence. Possibly, if alliances were made of sedigiti with sedigita, the offspring might also be provided with supernumerary digits, but 497 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. commissure. The condition may exist as a congenital affection, or it may occur after extensive burns or ulcer- ations when two raw surfaces on contiguous fingers are in apposition. The etiology of congenital syndactylism is doubtful. The deformity does not appear to be due to an arrest in the normal fissure of the fingers, although at first sight this would present itself as the most proba- ble explanation, since, as pointed out by Saint-Germain, in the embryo the fingers are united two by two, the lit- tle with the ring-finger, while in syndactylism it is most frequently the ring and middle fingers that are adherent. When the fingers are united at their tips but separated at their metacarpal extremities, as sometimes happens, it is certainly not due to arrest of development, and is in all probability the result of ulcerations occurring in intra- uterine life. Operative measures for the relief of this deformity should not be undertaken too early, before the fingers are of sufficient size to allow of the application and retention of the dressings ; yet they should not be too long de- ferred, because of the retarded growth which occurs in deformed digits. When the circumstances permit of a choice as to the time of operating, it is better to select some period between the ages of five and eight years, and nearer the former age than the latter if possible. There are two points in the treatment which are of equal impor- tance : 1, to effect a separation of the adherent fingers ; and, 2, to prevent reunion of the opposed raw surfaces. Various methods have been proposed and practised to fulfil the indications, but the limits of this article permit us to describe only those which experience has proved to be the best adapted to meet the ends in view. In simple webbed fingers, where the connection is by a loose fold part of the dorsum of the first digit. A few sutures are then inserted to retain the flaps in their new position, and the operation is complete. The dorsal incision should be prolonged a little farther than the one on the palmar aspect of the fin- ger, so as to imitate as nearly as may be the normal commissure. Fig. 1562 represents the three steps of the operation seen in cross sec- tion. If more than two fingers are adherent it will be better to perform two operations. If, for example, the four fingers are united, the ring and middle fingers may be separated from each other first, leaving the index and little fingers to be freed by a subsequent operation. The accidents to be guarded against are sloughing of the flaps and exposure of the articulations. Movements of the fingers are to be prevented until union has taken place between the skin and the underlying tissues. Ectrodactylism. - Congenital ab- sence of one or more fingers is a very rare condition, and when present is usually associated with deficiencies of other organs. It is sometimes seen with hare-lip, and is not uncommon in monsters. When the thumb is wanting, there is usually an absence of the radius also. Any one or several of the fingers may be absent, but perhaps the most common form is that in which the three middle dig- its are missing, leaving only the thumb and little finger (pince de homard, didactylism). The defect exists usually in the phalanges alone, though sometimes the correspond- ing metacarpal bones are also absent. A few cases have been recorded in which there was a loss of one or two phalanges only (brachydactylism). Portions of one or more fingers, or even the entire hand, may undergo an amputation in utero. When this occurs the deformed digits are usually adherent throughout a greater or less extent; sometimes the stumps are completely welded to gether, and sometimes they are united only at their tips. Club-hand.-Syn.: Fr., Main bote ; Ger., Klumphand. Club-hand may be either congenital or acquired, the lat- ter being by far the more frequently met with. The con- genital affection only ■will be considered in this section, as the club-hand resulting from paralysis, wrist-joint dis- ease, etc., will be discussed under the head of Acquired De- formities. As in club-foot, so in club-hand, we distinguish four principal varieties, called respectively palmar, dorsal, radial, and ulnar, corresponding to the four positions of flexion, extension, abduction, and adduction. We have also, and more frequently, the intermediate or compound forms of dorso-radial, dorso-ulnar, palmo-ulnar, and pal- mo-radial, the last named being the more usual variety. Club-hand may be unilateral or double, and is commonly, though not always, associated with club-foot. The osse- ous framework of the hand and arm may be perfect in every way, or it may be deformed or even in part want- ing. In perhaps the greater number of cases there is an absence of some portion of the skeleton combined with a deformity of the remaining parts. When the radius is wanting the thumb is also absent. Associated -with club- hand we may have any of the malformations of deficiency or of excess which have just been considered. The mus- cular system participates in varying degree in the general malformation of the member. There is sometimes paraly- sis, and we occasionally find the muscles of one or another group of the forearm so matted together as to be indis- tinguishable ; or they may even be reduced to mere apo- neurotic structures, with scarcely a trace of muscular tissue present. In such cases there are usually also ab- normalities of the vessels and nerves of the parts. Atro- phy of both bones and soft parts of the affected member almost invariably occurs, if the malposition is allowed to remain uncorrected, even when the hand and arm are otherwise normally formed. The accompanying illus- trations are from photographs of a case presenting at the New York Orthopaedic Dispensary. The question of the Fig. 1502.-Didot's Opera- tion for Syndactylism, represented in Cross Section. Fig. 1561.-Didot's Operation for Syndactylism. of integument, this may be divided by the knife or scis- sors, and the dressings are then to be applied in such a manner as to prevent any contact between the separated fingers until cicatrization is complete. This may be ac- complished by dressing each finger separately, or better, by bandaging the hand to a light metallic splint with gut- tered digitations. The gutters should be deep enough to retain each finger securely, and the splint should be a lit- tle curved to permit of slight flexion of the fingers. When the fold of skin is rather scant, it may be necessary to insert a few sutures in order to approximate the edges of the wound. When the union between the fingers is more dense, involving the fleshy parts, the separation is in most cases best accomplished by the anaplastic method devised by Didot, of Liege. This operation is performed as follows (see Fig. 1561); A longitudinal incision is made through the integument in the median line, along the dor- sum of one finger and the palmar surface of the other. The skin is now dissected away from the line of incision toward the septum and just a little beyond this point, and then the remaining connection between the fingers is severed. The flaps of integument are now folded over in such a way that the portion removed from the dorsum of one finger fills the gap left by that taken from the pal- mar surface of the other, and this latter portion becomes 498 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. etiology of club-hand is, as yet, in common with that of most congenital deformities, without any satisfactory explanation. Some of the more simple forms of club- hand seem to have been caused by the retention of the member in a constrained position in utero, but in other cases where there is absence of a portion of the skeleton, an inert member of normal appearance and in normal position. It is often surprising to see with what dex- terity these deformed limbs are endowed. The patient pictured above was able to write neatly and legibly, and could also sew and use her hands in a variety of ways with ease. Acquired Deformities.-Dupuytren's Contraction.- Contraction of the palmar fascia being the most impor- tant of the non-congenital deformities of the hand, it is thought best to depart from the order given in the classi- fication, and to treat of it first among the deformities of this class. It has received its name from the eminent French surgeon who first described it, and proved by dissection that the condition was one of contraction of the palmar fascia, and not of the flexor tendons. Men are more frequently affected than women, and adults than children; indeed, the affection occurs with exceeding rarity ih individuals under twenty years of age, although a few cases have been reported in which a similar condi- tion existed at birth. The contraction begins usually in the ring-finger, and may be confined to this one alone, though more often the other fingers are successively im- plicated. Any one of the other fingers may be primarily contracted, and sometimes, though rarely, the thumb alone is affected. Flexion of the metacarpo-phalangeal joint occurs first, and the two terminal phalanges become flexed only after a varying interval. Increased flexion of the fingers is possible, though the action of grasping is painful; but any attempts at extension are resisted by the contracted bands of fascia, and if persisted in cause severe pain. In the early stages the skin of the palm is movable, and the contraction of the fascia becomes evi- dent only on forcible extension of the fingers ; but as the disease progresses the integument be- comes adherent to the deeper tissues, is puckered and thrown into nu- merous creases, and is raised up in lon- gitudinal ridges by tense bands of the thickened and con- tracted fascia lying beneath it. As first shown by Dupuytren, and confirmed since by dissections made by other observers, as well as by the results of treatment, the pathological changes are confined strictly to the palmar fascia, the flexor tendons and the articulations being rarely, if ever, implicated. Malgaigne believed the disease to reside in the deeper layers of the corium, and Goyraud locates it in the liga- mentous bands extending from the sheaths of the flexor tendons to the skin ; but the contraction begins first in the palmar aponeurosis, and the integument is involved only secondarily. Many writers have sought to establish an etiological relationship between this affection and gout, but though the latter may act in certain cases as a predisposing cause, the contraction is undoubtedly refer- able to traumatism as the exciting cause. This may be inflicted in a variety of ways, as in repeated slight shocks from the handle of a tool resting in the palm, or from the head of a cane, or it may be by a strain in lifting heavy weights, or by contusion from a blow, or even from an apparently insignificant wound of the integu- ment. Dr. Abbe, of New York, has recently advanced the theory of reflex action, starting from the peripheral irritation and returning from the nervous centres to the part originally injured, and there inducing nutritive dis- turbances which are manifested by thickening and con- traction of the aponeurotic bands. A case is related by Lange, in Virchow's Archiv, 1, 1885, of a woman who had Dupuytren's contraction affecting the ring-finger of both hands, dating back several years, of such a degree that the tip of the finger lay against the palm. She had an attack of apoplexy followed by hemiplegia of the left side, and almost immediately the contractibn of the left hand disappeared, that on the right side remaining un- changed. The writer argued that this would point to a Fig. 1563.-Club-hand. Dorsal aspect. or where the deformity is associated with that of club- foot, we must seek farther for a rational theory of its causation. The aim of therapeutics in club-hand is to place the member as nearly as possible in the normal position and there to maintain it, as long as may be necessary, by mechanical supports ; taking care, however, not to sacri- fice the utility of the limb to mere symmetry. The res- toration is to be accomplished gradually, the employment of great force being seldom necessary or even justifiable, Fig. 1566.-Dupuytren's Contraction of the Palmai- Fascia. (Richer.) and tenotomy is, as a rule, not advisable. In most cases, especially in infants, manipulation alone is usually suffi- cient, the hand being maintained in its acquired position by a retention splint. The latter should be so constructed as to permit of adjustment from time to time, as the limb becomes straighter. This may be accomplished by a specially constructed apparatus, similar to that shown in Fig. 1565 ; or plaster-of-Paris, felt, or leather may be used, a new splint being applied every few weeks as the case progresses toward a cure. Electrization of all the Fig. 1564.-Club-hand. Palmar aspect. Fig. 1565.-Apparatus for the Correction of Club-hand. (After Du- breuil.) At the wrist is a universal joint, allowing for movement or fixation of the hand in any required position. muscles of the forearm is useful, especially in cases of long standing where there is atrophy of the limb. If, as sometimes is the case in older children, the useful- ness of the hand is impaired by attempts at correction of the deformity, all such efforts should be abandoned, for a hand capable of movements and possessing grasp- ing power, even though it be deformed, is far better than 499 Hand. Hand. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. central nervous lesion as the cause of the contraction, since an affection of the tendons or fascia, or even of the peripheral nerve endings, could not disappear so rapidly on the occurrence of central paralysis. M. Cayla and other French physicians regard this affection as one among the many dystrophic troubles associated with diabetes. The only effective treatment consists in division of the contracted bands, and any attempts to overcome the flexion of the fingers by elastic extension, massage, poultices, etc., are merely a waste of time.* Several methods of operation are in vogue at the present time. Dupuytren practised transverse incisions directly through the integument and fascia, thus making a number of small open wounds which were allowed to heal by granu- lation. Goyraud, in order to avoid the gaping of the wounds, advised longitudinal incisions through the in- tegument, dividing the aponeurotic cords by transverse cuts. Adams' operation consists in the subcutaneous division of the palmar fascia and its digital prolongations. A very small tenotome is introduced between the skin and the fascia, and the latter is then divided by a down- ward cut. The incisions are repeated at a number of points until all the contracted bands are divided and complete extension of the fingers is possible. It is often necessary to divide the same cord in several places before the finger is completely freed. A central incision in front of the first or second phalanx is to be avoided if possible, because of the danger of wounding the tendon. Immediate extension is now to be made,.and the fingers are to be bandaged firmly to a digitated splint. The bandage is not to be removed until the fourth day, and should then be immediately reapplied. The pain follow- ing the operation is sometimes very severe, and it may on this account be necessary to loosen the bandages some- what. This should be done very cautiously, however, for if extension be not thoroughly maintained a recon- traction will almost certainly take place. The splint should be worn continuously, night and day, for three or four weeks, and then at night only, for three or four weeks longer. Passive motion is necessary to restore free motion to the fingers, especially if the contraction have existed for a considerable length of time. Another mode of operation is that employed by Busch, of Bonn. It consists in the dissection of a triangular tongue of skin from the palm, the base of the triangle resting in the crease which separates the finger from the hollow of the hand, and the apex terminating at the point of greatest prominence when the finger is forcibly extended. The base of the triangle is left attached, while the rest of the flap is dissected up, as much of the connective tissue as possible being raised with the skin. All the contracted bands are now divided until free extension of the finger is obtained, and the edges of the ■wound are then approxi- mated as nearly as possible, the gap resulting from re- traction of the skin being left to heal by granulation. By this method the danger of wounding the sheaths of the tendons is reduced to a minimum. Whatever plan of operation be adopted, the wounds should be dressed antiseptically, and the after-treatment by extension be faithfully pursued. Paralytic Deformities.-The study of the varied and characteristic positions assumed by the hand in the differ- ent affections of the nervous system is one of exceeding interest from a semeiological point of view, but the limits of the present article will allow only of a brief review of the more important deformities of this class. For a more extended description of these conditions the reader is re- ferred to the excellent monographs of Amidon and Meil- let. It is only intended in this paper to describe the deformities of the hand, the diseases of which these de- formities are symptomatic being treated of elsewhere un- der their appropriate titles. Many of the illustrations are from the admirable drawings of Richer in Meillet's thesis. Progressive Muscular Atrophy. In the earlier stages of this disease, when the atrophy is confined chiefly to the muscles of the thenar and hypothenar eminences, we find the deformity represented in Fig. 1567, known as the "monkey hand," main de singe. Owing to the atrophy at either side, the hand presents an appearance of great length ; the thumb approaches the index, is on a line with, the other fingers instead of being placed anteriorly to them, and at the same time is rotated in such a way that the palmar surface looks directly forward, and all power Fig. 1567.-Main de Singe. (Richer.) of opposition is lost. When the atrophy invades the in- terossei and lumhricales while the muscles of the forearm are still unaffected, the resulting position is that of the " claw hand," main en griffe (Fig. 1568). The rounded ful- ness of the hand is now gone, the metacarpal hones stand out prominently on the dorsum, while the skiu sinks down between them into the deep grooves left by the dis- appearance of the interossei. The palm is fiat, and the tendons stand out as tightly stretched cords diverging from the wrist to the roots of the fingers. The latter are flexed and so wasted that they literally consist of nothing but skin and bones. The typical main en griffe is not very common in wasting palsy, for it is seldom that such extensive changes occur in the muscles of the hand while those of the forearm are still intact, and if the latter are weakened the claw-hand cannot be produced. Free pas- sive motion of the fingers is possible, except in advanced stages of the disease, when, owing to long maintenance of the hand in this vicious position, it becomes fixed there by reason of changes iu the fibrous and bony tis- sues. In addition to the deformity, there is sometimes in progressive muscu- lar atrophy a circumscribed elastic swelling on the dor- sum of the hand, similar to that frequently occurring in lead paralysis. As long as any muscular tissue remains the fibrillary contractions are usually observable. Infantile Paralysis. The muscles of the upper ex- tremity are comparatively rarely affected, at least perma- nently, in anterior poliomyelitis, but when paralysis does occur in this region the deltoid and the posterior mus- cles of the forearm are those usually invaded. The supi- nator and extensor groups are affected simultaneously, hence the resulting deformity consists in flexion and pro- nation of the hand. The flexion is at first passive, and is readily overcome by manipulation (wrist-drop), but later the antagonistic 'muscles become shortened, the bones of the wrist become altered in shape from pressure, and the deformity is permanent (club-hand). Cervical Paraplegia. In myelitis of the upper portion of the spinal cord there is complete paralysis, with atro- phy, of the muscles of the arm. The hand is thin and apparently lengthened, and what remains of the muscular tissue is soft and flabby. The fingers are usually in slight flexion, but there are no contractures, the hand is simply an inert and useless paw. Hypertrophic Cervical Pachymeningitis. In this disease the interossei and lumhricales are first affected, but the involvement of the flexor and pronator groups speedily follows. When the atrophy and paresis of these muscles are accompanied by contraction of their antagonists, the resulting deformity is one of extension and supination of the hand, with flexion of the fingers. The flexion most frequently occurs only at the two terminal phalanges, the proximal phalanges being usually, though not invariably, in a position of hyperextension. Charcot has applied to Fig. 1568.-Main en Griffie. (Richer.) * Costilhes (These de Paris, 1885) claims to have cured several cases of the affection by application of an ointment composed of tincture of iodine, 2; iodide of potassium, 10 ; vaseline, 20. The ointment is re- newed every twenty-four hours, and its use persevered in until the epi- dermis of the palm is completely exfoliated. 500 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Hand. this deformity (see Fig. 1569) the term main du predica- teur emphatique, from its resemblance to the gesture com- monly used by public speakers in emphatic discourse. This position is habitual, but, except in cases of very long standing, is not permanent; the fingers can be passively straightened, frequently also by voluntary action of the patient, but the weakened muscles contract very slowly, and the normal position cannot be maintained for any great length of time. The atrophy of the hand is always very marked. The de- formity may begin as a unilateral condition, but more commonly both hands are simultaneously affected. Disease or Injury of the Pe- ripheral Nerves.-Paralysis of the ulnar nerve (Fig. 1570), from whatever cause, results in exten- sion of the wrist and of the prox- imal phalanges of all the digits, with strong flexion of the two terminal articulations of the little and ring fingers. There is also atrophy of the thenar and hypo- thenar eminences. Section or injury of the median nerve is manifested by slight extension of the first, and flexion of the last two phalanges of the index and middle fingers. The thumb is adducted and rotated so that the palmar surface looks anteriorly, and its power of opposi- tion is lost. When the musculo-spiral nerve is the seat of degenera- tion, there is complete paralysis of all the extensor mus- cles, and we have the deformity known as wrist-drop. It differs from that due to lead-poisoning in being com- plete, none of the extensors nor the supinator longus escapes. Furthermore, in plumbism the wrist-drop is bilateral, while that following paralysis of the musculo- spiral nerve is, of course, confined to the side of the injured nerve. Plumbism. Wrist-drop, the deform- ity of the hand associated with sat- urnine poisoning, is too well known to require any detailed description in this place. Lead paralysis may at- tack any of the extremities, but more commonly begins in the forearms, and exhibits a marked preference for the extensors and for all the muscles supplied by the musculo-spiral nerve, the supinator longus excepted. The patient is unable to raise the hand or extend the fingers, though in some cases the extensores indicis et minimi digiti are not implicated, so that a partial extension of these fingers is possible. The thumb is flexed and directed toward the palm. The fin- gers are also slightly bent, and are in- capable of being abducted while the hand hangs down, but if it be placed flat on a table, then a voluntary sep- aration of the fingers becomes possible. The grasping power is almost abolished while the hand is in the prone position, but if it be placed in supination the ability to flex the fingers is restored. There is more or less atrophy of the muscles, causing a flattening of the hand ; there is atrophy also of the posterior muscles of the forearm, while the flexor surface of the limb preserves its normal fulness. The degree of paralysis varies greatly; some- times the extensors of the fingers alone are involved, those of the hand itself being unaffected. We frequently find tense, elastic, oval swellings (ganglia) over the exten- sor tendons at the wrist ; they are usually painless, and are filled with a gelatinous semi liquid material. They may exist, of course, independently of lead-poisoning, but are of very common occurrence in this affection. Spasmodic Deformities.-Some of the deformities to be described under this heading arise in conditions more properly regarded as paralytic, but as the malpositions are referred to spasm as the direct cause, their considera- tion falls more naturally in this division. Hemiplegic contractures are the expression of a second- ary sclerosis of the lateral columns of the cord, following the cerebral injury. They commence at a variable time, usually within a few months after the apoplectic seizure, and are met with in the upper extremities more often than in the lower. The onset of the affection is gradual; at first a certain stiffness only is noticed in the muscles, which little by little becomes developed into a strong spas- modic contracture, persistent during the waking hours, but usually somewhat re- laxed during sleep. Both the extensors and flexors are affected, but owing to the greater strength of the latter the deformity is one of flexion, as a rule. The muscles may be atrophied and cord-like, or they may present but little change other than that consequent upon disuse. There are three principal types of the deformity: there may be flexion of the digital articulations alone, of both the fin- gers and the wrist, or finally, the wrist alone may be flexed while the fingers are in a position of hyperexten- sion. Fig. 1571 represents the deformity of the first type. • Infantile Hemiplegia (cerebral atrophy). When the hemiplegia dates from early life, the normal growth of the affected member is interfered with, there is atrophy of the limb, and the hand and arm being kept in a state of flexion, the osseous and ligamentous structures are forced to accommodate themselves in their growth to this false position, and the bones having now been, so to speak, moulded into abnormal shapes, the deformity be- comes permanent, independent of the muscular contract- ures. We find, therefore, in these cases, a true club-hand of the palmo-ulnar variety. The position of the hand and arm sometimes designated as the " swan's neck," cou de cygne, is represented in Fig. 1572. One often encounters the un- fortunate subjects of this deformity in the streets of any large city. They walk with a hemiparetic gait, limping, and swinging the leg (wrhich is decidedly " pigeon-toed ") in an outward curve. The arm rests against the side, the forearm is flexed nearly to a right angle and pronated, and lies across the body, while the hand is fixed in a position of more or less flexion, with a slight incli nation to the ulnar side. In addition to the limp and the de- formity of the hand, there is frequently also a somew'hat va cant expression in the counte- nance. In some cases of infan- tile hemiplegia, there is simply a condition of retarded devel- opment. The hand is well formed, or at the most there is but a feeble contracture of the fingers, but it is smaller and weaker than its fellow7. Athetosis. This peculiar con- dition, allied in its clinical feat- ures to chorea, was first clearly described and named by Hammond in 1871. It is characterized by a series of constant slow movements of extension, flexion, abduc- tion and adduction of the fingers and toes. In the hand the movements occur chiefly at the metacarpo phalangeal articulations. They are partially under the influence of the will in so far that they can be controlled for a short time by a strong effort, but the period of rest is very brief, and the movements soon recommence in spite of all that Fig. 1569.-Main du Predica- teur Emphatique. (Richer.) Fig. 1571.-Hemiplegic Contracture, (Richer.) Fig. 1570. - Paralysis from Injury of Ul- nar Nerve. (Richer.) Fig. 1572. - Infantile Hemi- plegia, " Con de Cygne." (Richer.) 501 Hand. Harbin Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the patient can do to restrain them. The usual position which the hand assumes during the interval of enforced quiet is one in which the thumb is extended, and the ring and little fingers are abducted and flexed, while the remaining lingers are slightly separated, but otherwise in a nearly normal position. The hand and forearm in ad- vanced cases are somewhat hypertrophied from contin- ued muscular action. One member only may be affected, or the deformity may be bilateral. Amyotrophic Lateral Spinal Sclerosis. In this affection the contractions are chiefly spasmodic in character, al- though the deformity is due partly also to the disturb- ance of equilibrium between the antagonistic muscles from paralysis. The hand is thin and atrophied, and both the wrist and the fingers are in a state of moderate flexion. In the later stages of the disease the spasm is relaxed, the wrist is straight, but the fingers, especially the two terminal phalanges, are firmly flexed (main en griffe\ Fibrillary contractions are usually present, or may be readily excited by a slight tap on the muscle. Paralysis Agitans. Shaking palsy occurs in individuals past the middle age. In these subjects the arm is rotated slightly inward, and the elbow and wrist are partially flexed, so that, as in infantile hemiplegia, the hand lies near the pubis, or rests in the lap when the patient sits. The fingers are semiflexed, chiefly at the metacarpo-pha- langeal joints, and have a slight ulnar inclination, while the thumb rests opposed to the pulp of the index. The posi- tion of the hand is thus very like that assumed in writing. Sometimes, instead of flexion, there is a slight degree of hyperextension of the second phalanges on the first. Notwithstanding the continual movements of the arm, hand, and fingers, there is a certain rigidity of the mus- cles which prevents a perfect correction of the deform- ity. The movements usually cease during sleep, and may often be controlled temporarily by a strong effort of the will. Tetanus. The thumb is drawn into the palm and en- closed by the strongly flexed fingers. The two borders of the hand are approximated, thus increasing the vault of the palm. Sometimes the fingers are not flexed, but their tips are drawn together, forming a cone, as Trous- seau expressed it, like that made by the accoucheur when about to introduce his hand into the vagina. The wrist is flexed, and the hand rotated inward. Hysterical Contractures. The more common position of the hand in this most unstable of all affections is one of flexion ; sometimes the thumb alone is flexed, but more often it is covered by the tightly-clinched fingers ; the wrist may be extended, but is more usually flexed, sometimes simulating osteitis of this joint. The contrac- ture is permanent even during sleep, but yields when the patient is profoundly anaesthetized, returning only very gradually after the influence of the antesthetic has passed away. It may be overcome by a strong faradic current, and sometimes disappears entirely and permanently after a few applications, or the same result may be observed as the effect of any sudden mental shock. It often, how- ever, resists every form of treatment. As a rule there is no marked atrophy, nor any organic change in the mus- cles, and the electrical contractility is retained. The diagnosis is usually rendered more certain by the pres- ence of other hysterical manifestations in the patient. Wrist-joint Disease. In simple, chronic, or fungous syn- ovitis of the wrist-joint the position of the hand is normal, the only change being a swelling about the articulation. But when the disease invades the bony structures reflex muscular spasm is induced and, as a rule, flexion occurs. The contraction exists at the wrist only, the phalangeal articulations being unaffected. The spasm is relaxed under profound anaesthesia, but returns immediately as the patient begins to pass from under its influence, even before consciousness is regained, thus differing from the neuromimetic contracture. Miscellaneous Deformities. - Scleroderma. When the hand is involved in this disease it presents a most peculiar appearance. The skin is thick, hard and smooth, and seems to be tightly stretched over the bones. The fingers are usually more or less flexed, and are often twisted to- gether in a curious fashion (Fig. 1573). The phalanges, especially the terminal ones, are generally atrophied, giv- ing to the fingers a resemblance to elongated cones. The nails are shortened and abnormally curved, or they may be flattened and projecting so as to form an obtuse angle with the back of the finger. There is some- times apparent ankylosis of the articulations, in other cases slight movements of the fingers are pos- sible. Cicatrices may be present, giving evidence of former ulcera- tions. In some cases the pha- langes have almost entirely disap- peared. In Ainhum, a disease supposed to be of the nature of scleroderma, the connective tissue hypertrophy is localized in rings or semi-rings embracing, it may be, one finger or several, or encircling the fore- arm. In advanced cases there is atrophy of all the parts lying to the distal side of the constricting bands. In the congenital form of the disease the fingers involved are often found adherent at their extremities, though sepa- rated at their roots. This is probably the result of ulcera- tions and subsequent adhesions of the opposing surfaces occurring in intra-uterine life ; it cannot be due to arrest of development, since the separation of the fingers pro- ceeds from the periphery toward the centre. The pres- ence of a constricting band is marked by a deep depres- sion partially or entirely surrounding the digit. Leprosy. In this disease, elephantiasis Graecorum, the leprosy spoken of in the Holy Scriptures, the hand often presents the deformity called by French writers main en griffe. All the muscles are atrophied and the skin seems to be drawn tightly over the bare skele- ton. The proximal pha- langes are extended, but the two terminal ones are in a condition of extreme flexion ; the thumb is ro- tated outward and not, as in the griffe of progressive muscular atrophy, on a line with the fingers, and with the palmar surface directed forward. The contracture is permanent, and a passive straightening of the fingers is not possible. There are frequently ulcerations on the hand and fingers, and the ulcerative process may extend so far that the phalanges become denuded of their soft parts, and then they not uncommonly fall off. Syphilis. In syphilitic dactylitis, one of the later man- ifestations of the disease, we find a fusiform enlargement of the fingers, sometimes of one finger only, but fre- quently of several. This swelling may be confined to one of the phalanges, or it may surround the articulation. In the latter case motion is restricted by direct injury to the joint; in the former, it is impeded mechanically by the size of the finger. The tumor is hard and red, but usually little, if at all, painful. The skin is at times ul- cerated. The course of the disease is usu ally very slow. Arthritis Defor- mans. This affection, called also chronic rheumatic arthritis, very frequently manifests itself first in the hand and finger joints. The distortions produced are varied, yet usually sufficiently characteristic to per- mit of easy recognition (Figs. 1574, 1575, and 1576). The terminal phalanges may be hyperextended, flexed, or bent laterally. The joints are enlarged, and studded with little nodosities. A very pathognomonic deformity is that Fig. 1573.-Scleroderma. Fig. 1574.-Arthritis Deformans. Fig. 1575.-Arthritis Deformans. 502 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hand. Harbin Springs. caused by adduction at the metacarpo-phalangeal articu- lations, giving an ulnar deviation to the fingers. This is often one of the earliest symptoms of the disease. We sometimes meet with cases in which the hand is tightly clenched, with the in- dex-finger adducted across the medius. There is a sinking in of the interarticular spaces in the fingers, partly real from atro- phy of the soft parts, and partly apparent from enlarge- ment of the joints. Gout. The distortion of the hand occurring in chronic gout often bears a resemblance to that just described, but need never be confounded with it. The tophaceous de- posits are larger than the nodosities of arthritis deform- ans, and the ulnar deviation of the fingersis seldom seen. Fig. 1577, from Meillet, represents well the deformity of the hand and the tophi. The onset of gout is less insidious than that of chronic rheumatic arthritis, and the patient usu- ally gives the history of a number of pre- ceding acute attacks recurring at contin- ually shortening in- tervals, until finally the disease becomes permanent. Osteomalacia. In osteomalacia the hand is short and flattened. There is usually also in bedridden patients a hyperextension, or, to speak more correctly, a backward curve of the phalanges, caused probably by the efforts of the patients to raise themselves up by pressing with the fingers on the bed. Rachitis. One of the most constant and characteristic of the manifestations of rickets is the enlargement of the epiphysial ends of the long bones, so-called "double joints." This enlargement is very evident at the wrist, and sometimes constitutes an unsightly deformity. In some rare instances the phalanges may participate in the general bony softening and consequent deformity. Occupation. Sometimes a contraction of the fingers is said to follow from the habitual and long-continued flex- ion necessitated in certain occupations, as in the case of car-drivers, lace-makers, and others. In view, however, of the comparatively small number of such persons who suffer from any digital distortions, it seems more reason able to refer the contractions, in most cases at least, to some other cause, as chronic rheumatism or traumatism (Dupuytren's contraction).. Cicatricial Contractions. The distortions of the fingers caused by the contraction of cicatrices differ in no way from those occurring in other regions. The fingers may be dislocated backward or laterally, or deformed in any way, depending upon the direction in which the con- tracting force is exerted. Hippocratic Fingers. This terpi is applied to the en- largement of the finger-tips met with in chronic diseases in which there is a consid erable degree of disturb- ance of hsematosis, such as phthisis, asthma, and other pulmonary troubles, organic heart disease, cy- anosis from persistence of the foramen of Botal, etc. It has likewise been ob- served in myxoedema. The terminal phalanx of the finger is enlarged and pre- sents a bulbous appearance, the pulp seems hypertro- phied, and the nail is thickened and abnormally convex, curving forward toward the palm and laterally. The other phalanges present no change. A similar condition, though in a Vess marked degree, may exist in the toes. Although this defor- mity occurs very fre- quently in the diseases mentioned, it is yet by no means an absolute indication of their ex- istence, for many indi- viduals have clubbed fingers who are per- fectly free from the suspicion of any chronic disease. Little remains to be said concerning the management of these distortions of the hand and fingers which we have just been considering, their treatment being in the main that Of the conditions to which they owe their origin. Yet massage, poultices, or the application of suitable me- chanical support may be very efficient aids in restoring the utility of the limb. The consideration of the special treatment best adapted to assist in the correction of each deformity would demand too great space, and would, moreover, be of little practical value, since each individ- ual case must be managed according to the special indica- tions, for which no general rules can be formulated. Tenot- omy is seldom re- quired, although it may at times be of great service. In wrist-drop the function of the paralyzed extensors may be well imitated by elastic bands passing from the wrist to each finger in the manner shown in Fig. 1580. Electricity, of course, is indicated in many of these affections, and should be applied according to the rules laid down in the articles upon these subjects. The following works may be consulted by the reader who desires a more detailed description of the individual deformities of the hand treated of in this article : Abbe, Robert: On Dupuytren's Finger-contraction; its Nervous Origin, N. Y. Medical Journal, April 19 and 26, 1884. Amidon, R. W.: Deformity of the Hand as a Symptom, Am. Journ. of Nervous and Mental Diseases, December, 1881. Annandale, Thomas: The Malformations, Diseases, and Injuries of the Fingers and Toes, and their Surgical Treatment. Philadelphia, 1866. Adams, William : Observations on Contraction of the Fingers (Dupuy- tren's Contraction) and its Successful Treatment by Subcutaneous Di- vision of the Palmar Fascia, and Immediate Extension. London, 1879. Dupuytren : Lejons Orales de Clinique Chirurgicale. Bruxelles, 1832 ; also translation of the same, Philadelphia, 1833. Didot, A.: Note sur la Separation des Doigts Palmes et sur un Nouveau Procede Anaplastique destind a Pr6venir la Reproduction de la Dif- formite, Bulletin de 1'Academic de Medecine de Belgique, 1850, t. lix., p. 351. Fort, J. A.: Des Difformites Congenitales et Acquises des Doigts. These de Paris, 1869. Esbach, G.: Modifications de la Phalangette dans la Sueur, le Rachi- tisme et 1'Hippocratisme. Paris, 1876. Forster, A.: Missbildungen des Menschen. Jena, 1861. Meillet, H. : Des Deformations Permanentes de la Main au Point de Vue de la Semeiologie. These de Paris, 1874. De Saint-Germain, L. A.: Chirurgie Orthopedique. Paris, 1883. Verneuil: Syndactylie et Cicatrices Vicieuses des Doigts, Revue de Therapeutique M6dico-Chirurgicale, Paris, 1856. Thomas L. Stedman. Fig. 1576.-Arthritis Deformans. (Richer.) Fig. 1579.-Clubbed Fingers in Cyanosis. (Richer.) Fig. 1577.-G-out. (Richer.) Fig. 1580.-Apparatus for the Relief of Wrist- drop. HARBIN SPRINGS. Location, Harbin, Lake County, Cal. ; Post-office, Calistoga, Napa County, Cal. Access.-By Central Pacific Railroad, California Pa- cific & Nor. Railroad Division, to Calistoga; thence by stage to springs, twenty miles. Analysis. -None has been made. These springs are situated in a canon of the coast range, at an elevation of seventeen hundred feet above the sea, amid beautiful and picturesque scenery. The springs are numerous, and possess substantially the same chemical properties. The baths are supplied from the principal spring, which has a temperature of 118° F. The hotel and cottages will accommodate two hundred. Deer and smaller game are plentiful in the mountains, and the streams afford good trout-fishing. G. B. F. Fig. 1578.-Clubbed Fingers in Phthi- sis. (Richer.) 503 Hardback. Harelip. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. HARDHACK : Steeple-bush ; Spiraea tomentosa Linn. Order, Rosaceae (Spiraea). A shrub, two or three feet high, with a thick-branched, woody root and slender, simple, or nearly so, upright stems. The leaves are small, alternate, erect, or spreading, rather crowded ; they are ovate, serrate, thick, very woolly, and rusty-gray beneath, smoother and dark green above. Flowers small, numer- ous, in dense terminal panicles. Calyx and corolla regular, of five segments ; petals rose-purple. Stamens several times as many as the petals. Pistils generally five ; fruit of five or so, several-seeded ; woody follicles ; persistent. This is an American plant, growing in the Northern and Middle States, especially in the rocky, poor soil of New England. Its employment in medicine is also American and local, and, like most others of our family remedies, reputed to have been learned from the In- dians. It was dropped from the secondary list of the Pharmacopoeia at its last revision. The root was the au- thorized part, but the leaves and flowers are generally employed and better. Tannic and gallic acids are the principal constituents ; it is also slightly bitter. Spiraea has been used as a tonic astringent in the diar- rhoeas of summer, and of children. It may also be used as an astringent gargle or lotion, but has no special ad- vantage over other tannin-containing drugs. Dose, from half a gram to a gram (gr. viii. ad gr. xv.). Decoction and fluid extract are suitable forms. Allied Plants.-The genus is large, and furnishes a number of pretty garden flowers, mostly shrubs. One or two species supply an essential oil of the wintergreen type (Oil of Spiraea), containing salicylic acid in combina- tion. For the order, see Roses. Allied Drugs.-See Nutgalls. IE P. Bolles. lip. Thus, if the two lateral portions do not unite to the incisive portions, we have a double, or bilateral, harelip ; if only one of these sides fails to unite, then we have a single, or unilateral, harelip. I have, in a few of my earlier operations, removed the intermaxillary bone, and on examination of it, noted an absence of the lateral incisors. This, I believe, has been the experience of most surgeons who have given careful thought to the question whether this island contained all of the upper incisors or not. In two cases that I ex- amined a few years after the operation for cleft palate, in which I had saved the intermaxillary bones, I found an irregular lateral incisor on the right side, back of the reg- ular rowr of teeth, in each. Fergusson, Demarquay, Gurdon Buck, and others re- port a large number of cases to show' that harelip ap- pears in some families through many generations, and I have observed this in the record of my own cases. Like webbed fingers and toes, it often is seen without any evidence of consanguinity being present. * I fancy there are few surgeons w ho have examined cases of harelip care- fully that have not been impressed with the effort so often made by mother or nurse to prove that the deformity is entirely due to some fright given the parent, which has produced its effect upon the child in utero. Maternal impressions may be one of the factors in the production of harelip, and yet evidence of such cause is so often wanting as to lead us to doubt. Acting early upon the suggestion of the late Sir Wm. Fer- gusson, I have examined many lips and jaws for fissure, and frequently found slight notching or partial defects in the mouths of one or the other of the parents. I have frequently had occasion to call the attention of my class to this point in the study of these cases. This is very well showm in Figs. 1581 and 1582, from Mason. Some cases are not so well defined, the amount of depression in the vermilion border of the lip being much less. I have noticed that close pregnancies form a factor in causing this deformity. In connection w'ith these cases it is not unusual to see in the Fig. 1581. HARELIP, unlike cleft palate, may be regarded as a strictly congenital malformation. It is a deformity that, from its peculiar prominence, has brought more sorrow to the hearts of parents than perhaps any other of nature's defects. To the surgeon it has been the source of more thought and care in the operation for its relief than many surgical problems of far greater importance. Like cleft palate, it may be looked upon as an arrest in foetal development, confined, with very rare exceptions, to the upper lip. When situated in the lower lip, there are many deformities that may coexist with it, such as combined fissure of the lower jaw and tongue, and a variety of other like complications. Sir William Fer- gusson, in the fifth edition of his "Surgery," p. 506, speaks of several cases of this kind observed by himself and others in their practice. Associated with upper harelip are sometimes remark- able deformities about the face ; for instance, the fissure may extend up along the nose on one or both sides to, or into, the eyelids, or it may extend out. on one or both sides from the angle of the mouth, and may implicate Steno's duct, a very unpleasant complication. Mason speaks of a cyanotic condition of the child which I have also observed in one case. This condition of cyanosis is, at times, cured by the operation for clos- ure of the fissure. Mr. George Lawson gives the ex- planation {Lancet, June 7, 1862, p. 599) that during the lull in the circulation, in cases in which faintness occurs, the foramen ovale becomes closed and thus the double current is established. The limits of a paper of this nat- ure must necessarily make remarks upon the pathology of harelip somewhat brief. M. Coste 1 states that the mouth is formed between the twenty-fifth and the twenty-eighth day of fcetal life. The frontal lobe becomes much enlarged, and shows a great hollow which divides into two smaller lobes, called by him the incisive centres, and from which the incisive bones and the middle portion of the upper lip are de- veloped. The centres for the superior maxillae, which form the lateral parts of the upper lip, converge one to- ward the other, and come nearer to each side of the cor- responding incisive centre. At the fortieth day the two incisive centres, in the substance of which the incisive teeth are developed, unite one to the other in the middle line and thus complete the central portion of the upper Fig. 1582. Fig. 1583. same patient extra thumbs or fingers, spina bifida, and the like. The late Professor Alden March had a child brought to his clinic for relief of harelip who had cleft 504 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hardback. Harelip. palate, an extra toe and finger upon each foot and hand, double hernia, and club-foot. He thought the child hardly in a proper condition for operation, and quietly said to the poor mother, " My good woman, you had bet- ter try it over again." Accidents, bites of dogs and other animals, treatment of naevi, and other surgical conditions may result in a tem- porary form of harelip, which may be said to be cured generally in the final treatment given to such lesions. In the case of Miss C , aged six, suffering from naevus on the upper lip, whom I had treated in various ways without complete success, the final injection of a solution of tincture of iron produced a slough resulting in a fis- sure such as is seen in Fig. 1583, but which was closed with scarcely any scar by means of two silver harelip pins. A considerable number of cases is met with in which the kind of harelip is of the double variety, as seen in Fig. 1584, from Mason. In this variety the fissure may be very slight on one side and yet complete on the other, or, in cases in which there is a double fissure of the alveolar arch, as in cleft palate, we may have the horrid horn-like projection as seen in Fig. 1585, from Mason, and in one of my own cases, Fig. 666, of vol. ii. Cases of median harelip have been recorded by surgeons, but they are exceedingly rare, and their ex- istence has even been doubted by some. A case was brought to my clinic in the fall of 1883, that of Miss P , aged two years and six months, with cystic tumor at the tip of the nose, in which there was a complete me- dian fissure of the upper lip. Fig. 1586 (from a sketch of the little patient) shows the case very well. Sir Wm. Fergusson has very justly remarked that one cannot judge of a case, after the operation has been completed, as to whether it was originally a median fis- sure, for very many cases of double harelip, when operated on, show a decided tendency to the formation of a cicatrix in the middle line. Fig. 1587, one of my own cases, and quite as bad a case of double harelip as I have ever operated upon, shows this condition clearly. It is a singular fact that in these various kinds of fissure in the upper lip there is really very little loss of substance. One finds this to be true by merely approximating the soft parts temporarily. Regarding the time of life for operating in cases of harelip, much has been said by the older operators, but with little unanimity of opinion, some advising interference in in- fancy, others preferring to wait until advanced childhood. At the present time, I am of the opinion that modern surgeons prefer the early operation. My own experience teaches that a good time for the operation is when the infant is about six weeks old, especially if the child be healthy. In a case of double fissure perhaps it is well to wait until the child is six or seven months old. Of one thing I am certain, that in the latter complication we should perform the operation as early as possible, in order to secure good ef- fect of the soft parts in bringing together the cleft in the hard palate, which amounts to a great deal in a period of two years. In cases of double harelip I prefer to operate on one side at a time (see Fig. 669, vol. ii.) and to save all that is possible of the island. As I stated in my paper on Cleft Palate, I believe it is always best to save the intermaxil- lary bone, or island, if we can. In operating upon one side at a time, the first should be allowed to become firm before undertaking the second operation, which generally would not come under two months. I sometimes shape the skin covering the island in these cases in the form of a square, and then, making flaps from the upper lip and cheeks on each side, secure a good, full lip, not appearing at all constricted. I am convinced that in doing the operation we should pare the edges of the fissure freely, but not throw the pieces away-that is, not finally detach them ; therefore, I think the operation that embodies this principle is the best. Operations upon the adult are exceedingly rare, and then chiefly for the purpose of improving an imperfect result following an early operation, as I have done in a few instances. In operating for harelip we should in all cases be sure to loosen well the at- tachment of the cheek to the alveolar pro- cess ; there should be perfect freedom of movement, and no re- straint put upon the parts when the pins or sutures-whatever they may be-have been introduced. This is generally best done with a long, blunt - pointed teno- tome. The position of the infant at the time of operating is a point of much importance. If the child is strong, I believe it safe and wise to give chloroform, or such an anaesthetic as the surgeon considers best. Having the child held by a good nurse or competent assistant-as is spoken of by so many writers-is often the easiest and best for the operator ; but I am much in favor of placing the little one on a narrow, firm table of proper height, around which the assistants can work more at ease and not be in the way of each other. Standing on the right side of the table and patient, the operator pro- ceeds to free or loosen the fissure on each side, as I have stated. When this is thoroughly done, he directs an as- Fig. 1584. Fig. 1586. Fig. 15S5. Fig. 1587. sistant, opposite to him and at the head of the child, to grasp the left side of the fissure between the forefinger and thumb of his left hand, and then, with his right fore- finger and thumb, to hold the right side in the same manner. The surgeon may now, with the so-called hare- lip-forceps, or simple forceps, grasp the edge of the fis- sure, and, introducing a sharp-pointed narrow knife at the point of cleft nearest the nose, and on whichever side 505 Harelip. Harelip. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seems best to him, carry the knife from above downward toward the vermilion border of the lip, executing the same movement on each side, and removing sufficient tissue to give good, broad surfaces for mutual contact. In a simple harelip I often pare the edges of the fissure with a pair of good curved scissors (Fig. 685, vol. ii.). Thus far, if the assistant's thumbs and fingers are not too large, and if he performs his part well, but little blood will be lost. I consider the compressors of the upper lip for controlling haemorrhage, spoken of by some authors, as really not necessary, but if they are to be employed I would recommend an instrument like that shown in Fig. 1588 (copied from Mason). Now, after having decided upon the kind of material to be employed for closing the fissure, is the time for quick and careful work. It must ever be borne in mind that the vermilion border of the lip should be wrell pre- served, with no sliding upward or downward on either side, and also that there ought not to be any notching. As to the kind of suture, I must say my preference is for the silver hare- lip pins. In intro- ducing them, I pre- fer that the first should be nearest the vermilion border, and passed from the left to the right side of the fissure, raising or depressing the pin before passing it into the right lip, as may be necessary to bring the parts into good apposition. Of course, these steps may be modified or reversed if operating upon a single right- sided fissure, or if standing in front of the child. Fig. 1589 (from Mason) illustrates my point. The pin should be introduced at least a quarter of an inch back from the freshened edge of the fissure, passing obliquely through the edge of the lip, but not including the mucous mem- brane ; it should then enter the opposite side and emerge in the same manner. Now, around this pin put a figure- of-eight silk ligature, not too tight, as some allowance must be made for swelling. Then, next above this first pin, introduce in a similar manner one or two more, as may be needed. If two are used, it is well to bring them together by one ligature, crossing from one pin to the other, as you are not then likely to get so much of a slough-that, with ulceration, being the great danger in the employment of silver pins. Sometimes it is necessary to introduce between the pins a few fine superficial silk sutures, and also to place two or three in the mucous membrane (I prefer the latter of fine catgut, and do not disturb them), and one in the ver- milion border of the lip, not leaving them in more than twenty-four or thirty-six hours. After the pins have been introduced the points should be cut off with bone forceps, and a small portion of ab- sorbent cotton put under each end. They are not to be left in longer than three days, as a rule, and should al- ways be watched with care to prevent ulceration or sloughing. It is better to take them out too soon than to leave them in too long. Some surgeons prefer simple silk, some silver wire, and many other devices have been suggested. I take it that few surgeons rely upon the rubber or adhesive plaster to hold the parts in apposition while the healing process goes on ; but after the pins and sutures have been re- moved, in order to prevent too much tension on the newly formed tissue, I hold the parts well in apposition by plac- ing narrow strips of plaster across from ear to ear, thus holding the cheeks quiet and restraining the movements of the lips. Mr. Mason speaks of the use of collodion over pins and sutures. After the operation the child should be kept quiet by the use of anodynes, if necessary. He should be fed first with a spoon, and, when all is going well, after a few hours, or perhaps one, two, or three clays, allowed to nurse or take the bottle. Crying should be prevented as far as possible, and yet it is surprising to note how little harm it does. It is clear that no one special kind of operation can be made to apply to every variety of harelip. Fortunately, we have a choice among numerous modes of procedure that practice has demonstrated to be successful. In the operation known as Malgaigne's, the incision is commenced at the superior part of the lip, and performed from above downward (Fig. 1390, left side, b, b'). Scissors are used as in ordinary operations, except that, when the operator has reached the lowest point possible without detaching the cut piece, he stops (Fig. 1590, left side, a, a ). The other side of the labial fissure is treated in the same way. There are then two small flaps adhe- rent to the lip by a pedicle. After having reunited, by the aid of pins, the two margins of the cleft in their whole extent, except toward their free border (that is, toward the bottom), these flaps are brought from above downward and approximated face to face (Fig. 1590, right side, b, b ). The point now is to finish and shorten them so as to prevent the furrow so much dreaded at this stage of the operation, preserving a piece varying in size according, to the extent of vacuum to be filled (Fig. 1590, right side, a, a'). Union is afterward effected by approximating them with one or two inter- rupted sutures or with a fine harelip pin. If care is taken to place these uniting agents very near the free margin of the lip, the cicatrices will be scarcely visible. M. Mirault, of Angers, employed one flap only. A flap is taken from above downward, but left attached to the prolabium (Fig. 1591, left side, a); on the other side of the cleft the margin is completely re- moved (Fig. 1591, left side, b). The flap, a, is now turned down, and from being perpendicular becomes horizontal, and forms the margin of the lip (Fig. 1591, right side, a and b). For double harelip Sedillot suggested a cheilo-plastic operation. The sides of the central tubercles being pared, a flap of soft tissue is taken from each side, as shown in Fig. 1592. The flaps, a a, are brought down to form the red margin of the lip, and the raw surfaces, b, b, come in contact with the raw surfaces on the sides of the central tubercle, b', b'. Dr. A. M. Phelps, of Chateaugay, N. Y., in a paper read before the Medical Society of the State of New York, February, 1885 (see " Transactions," p. 255), pre- sented an operation for single harelip containing some original and striking features. The steps of the operation are these : '4 After first passing a loop through each angle of the lip for the forefinger of the left hand to hold the parts perfectly, with a pair of curved scissors separate the lip from its attachment to the jaw sufficiently to freely re- lieve the nostril and make all parts easily movable. The mucous membrane should be freely divided in both di- rections. With an ordinary cataract knife, or a slender, sharp tenotome, puncture the lip at 1 (Fig. 1593), follow- ing the dotted lines describing a curve to 2, and from thence to 3. Withdraw the knife after going freely through each nostril at 3, and with a scalpel cut from 3 to 4 through the entire thickness of the lip. The pieces, B and B, will now turn downward, leaving the V-shaped piece as seen in Fig. 1594. Fig. 1590.-Malgaigne's Operation. Fig. 1588. Fig. 1591.-Mirault's Operation. Fig. 1589. Fig. 1592.-Sedillot's Op- eration. 506 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Harelip, Harelip. "Now introduce the silk sutures as shown in Fig. 1594, after which cut away the pieces B and B, and the result will be shown in Fig. 1595. Before cutting away should be an equal distance from each corner of the mouth. The curves should be similar, and both enter the nostril at the same point on each side. On the nor- mal side the incision should enter the nostril near the co- lumna, and but little or none of the nostril be cut away. When the deformed nostril is drawn to a normal position the incisions will then correspond. Fig. 1593 w ill con- vey the idea. " 3. The incisions from 3 to 4, making the V, should extend to fully one-half the breadth of the lip. If the V is made too short, difficulty will be experienced in get- ting the lip together. This would necessitate a more ex- tensive division of the mucous membrane, or possibly the addition of transverse incisions extending outward into the cheeks under the corners of the nose. " A fatal mistake would be to get the centre piece too long, as it -would make a deformity. Cut it away to just the length to admit of the lip being stretched together, varying it according to the tension in each case, making it as short as possible. It would be much better to make the transverse incisions to relieve tension than to leave it too long, should a case not suitable for the operation be selected. " The steps as followed in single harelip should also be followed in double, using the double curved incisions already described. " The advantage of the double curved incision is this : When the pieces B and B, Fig. 1593, are turned down- ward, the curve at a, a, becomes straight, and when joined to its fellow of the opposite side, adds just so much to the width of the lip, at a point where it is desired, as the distance is from 1 to 2, Fig. 1593. The widening of the lip at this point, and the curving downward of the white line above the vermilion border of the lip into the point, is what lends the artistic appearance to the lip." An artistic lip and a scar in the median line are the strong points in this operation. Dr. M. H. Collis,2 of Dublin, says : " I never throw away a particle of the parings. My incisions are made so as to make every fragment of them useful. On one side they are preserved to make the lip thick, and on the other to increase its depth. The method is somewhat complex, but a reference to the accompanying figures Fig. 1593. the pieces B and B, pull the lip up with them and stitch the mucous membrane together with catgut as far under- neath as possible. Enough tissue should be left in the median line to compensate for retraction. The tempta- tion is to cut the pieces B and B too short. It is better to cut them long, and, if necessary, trim them a little. " The following are a few rules well to observe : "1. Select only those cases in which one-fourth of Fig. 1594. Fig. 1596.-Collis's Operation. will make it intelligible (Fig. 1596). When dealing with single harelip, I take the larger portion, that which includes the middle bit, and pare it freely from the nostril round the margin from a to b, until the point of the knife comes opposite the fraenum. The in- cision goes through all the tissues of the lip except the mucous membrane. It follows the curved line of the margin of the fissure, and leaves a long wound, which is curved toward the fissure. The flap is left loose and at- tached only by mucous membrane. On the other or smaller side of the lip, where wre generally find the tis- sues thin, especially as we approach the nostril, the treat- ment is quite different. I transfix the lip at d, close to the nostril, and carrying the knife along parallel to the mar- gin as far as/, I detach a moderately broad flap, which I leave adherent above to the ala nasi, and below to the free margin of the lip, well beyond or external to the rounded angle at the fissure. This flap, which (unlike the one at the opposite side) comprises all the tissues of the lip, is now divided into two at its centre (c, e). I thus get two loose flaps, a superior (c, d), attached to the ala nasi, and an inferior {e, f), hanging on to the free mar- gin of the lip. The loose end of the upper flap is turned up so that its raw surface faces the wound in the opposite side of the fissure, and the lower end of the lower flap is Fig. 1595. the lip, at least, remains between the fissure and the cor- ner of the mouth. "2. Each curved incision, 1, 2, and 3 (Fig. 1593), 507 Harelip. Hay Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Analysis.-One pint contains : similarly turned down. The point c is brought up to a, and fastened there. The point e is brought down to b, and fastened there. 1 have thus got on the small side of the lip a wound as extensive as that on the larger side. The upper flap completes the outline of the nostril. The lower one supplements the outline of the free margin of the lip. I thus get a lip nearly double in depth any which I could possibly have got by the ordinary inci- sions." Mr. Thomas Smith recommends an operation useful in suitable cases of double harelip, in which the lateral sides are pared in the manner shown in Fig. 1597, a' a, and two flaps are taken from the central tubercle, but are not to be detached at their lower margins. " The wound is closed by drawing down the flaps from the side of the central tubercle, and at- taching them to the raw surface on the lower margin of the lip." The condition of the infant before operating should be as good as possible. There should be no unfortunate surroundings regarding diphtheria and allied conditions, nor should the operation be done in hot weather, or at any time in the year when epidemics of any kind peculiar to children are prevailing. As a general rule, one operation is all that is needed, but sometimes failure occurs, and in this we ought not to be discouraged, but, as soon as the child has sufficiently improved, try again. Regarding Hainsby's truss, I have had but little experi- ence in its use, and must say that it requires great care, and is apt to annoy the child. As to a second operation, years after the first, to relieve an unsightly scar or depression in the vermilion border of the lip, I am much in favor of its performance, espe- cially in females. Albert Vander Veer. 1 Mason. 8 Ibid. Greenville Spring Saloon Spring (Raymond). (Raymond). Grains. Grains. Carbonate of magnesia... 2.87 0.26 Carbonate of iron 0 36 Carbonate of lime 0.60 2.99 Chloride of sodium trace. 1.24 Sulphate of magnesia 16.16 27.92 Sulphate of lime 11.06 10.24 Total 30.69 43.01 Therapeutical Properties.-The chief constituents of these springs are the sulphates of magnesia and lime. The former salt acts as a purgative, but here its effect is modified by the astringent lime, and the result is laxa- tive. Cases of congestion of the abdominal viscera, and chronic inflammations of the mucous and serous mem- branes, are benefited by these waters. These springs, four in number, issue from the lower sihirian rock. The " Greenville," situated in the grounds of Daughters College, is the only one kept in order. They are all essentially similar in composition. The ordi- nary drinking-water of the surrounding region is lime- stone; in some cases slightly chalybeate. Harrodsburg is situated in a beautiful blue-grass country, which affords drives over good roads. Near by are the Kentucky and Dix Rivers, with beautiful scenery and good fishing. Hotels.-At the springs, " Daughters College " is open for guests during the summer season, and there are also several hotels in Harrodsburg. There are churches of various denominations and good schools in the village. Geo. B. Fowler. Fig. 1597.-T. Smith's Operation. HARROGATE. The principal inland watering-place of England, situated in the Northwest Riding of Yorkshire, on a beautiful plateau near the river Nidd, eighteen miles from York. The town consists of two rather loosely built townships, known respectively as High and Low Harrogate, which have become united by a range of handsome houses and villas. Immediately in front of the principal line of houses is a common of two hundred acres, secured by act of Parliament so that it cannot be built upon, giving the place a charmingly rural appear- ance. Harrogate owes its celebrity mainly to its mineral springs, although certain claims are laid to its healthful- ness of climate, based chiefly upon the fact of its being situated about equidistant from either coast of the island. High Harrogate is more exposed to the winds than the lower town, and its climate is, therefore, considered more exhilarating than that of the latter, which is warm and sheltered. The springs yield chalybeate and sulphur waters. The principal chalybeate springs are the English Spa, or Tewitt's Well, discovered in 1570 ; the Royal Chalybeate Spa, or St. John's Well, discovered in 1631; Muspratt's Chalybeate, discovered in 1819 ; and the Starbeck Springs, midway between High Harrogate and Knaresborough. The principal sulphur springs are the Old Sulphur Well, in the centre of Low Harrogate, discovered in 1656; the Montpellier, discovered in 1822; and the Harlow Car Springs, in a wood about a mile west of the lower town. The chief of the Montpellier Springs arises within the Crown Hotel, where bathing facilities are provided. The chief bathing establishments are the New Victoria Baths and the Bath Hospital, the latter for the poor. The following analysis of the Old Sulphur Well and the Montpellier spring, by Hofmann, indicates the solid constituents of one pint: HARKANY, in the southern part of Hungary, six miles from the railroad station Fiinfkirchen, is of interest for its drilled sulphur thermal well. The well yields an abundant supply of water at a temperature of 144° F., which is used both for drink and for bathing. Analysis.-One pint contains : Grains. Sodium chloride (1.368 Sodium carbonate 1.582 Sodium sulphate 0.076 Potassium chloride 0.560 Lithium chloride 0.015 Calcium chloride 0.330 Calcium carbonate 0.739 Strontium carbonate 0.061 Magnesium chloride 0.261 Magnesium bromide 0.007 Magnesium iodide 0.061 Magnesium carbonate 0.005 Manganese carbonate 0.023 Silicic acid 0.989 Organic matter 0.115 Total 5.192 Per cent. Carbon oxy-sulphide 0.68 Carbonic-acid gas 19.17 Especial importance is attached to the presence of car- bon oxy-sulphide, consisting of one atom each of carbon, oxygen, and sulphur, and burning, when ignited, with a clear blue flame. Indications.-The water of Harkany is recommended chiefly in scrofula and rickets, mercurialism, cutaneous affections, chronic rheumatism, and paralysis. The water has also an aperient action. A large and well- equipped bathing establishment has been erected. J. M. F. Old Sulphur Well. Montpellier. Grains. Grains. Sodium sulphide 1.548 1.441 Calcium sulphate 0.013 0.059 Calcium carbonate 1.237 2.418 Calcium chloride 8.174 6.191 Magnesium chloride 5.569 5.467 Potassium chloride 5.470 0.575 Sodium chloride 86.018 80.309 Silica 0.025 0.184 Total 108.054 96.644 HARRODSBURG SPRINGS. Location and Post-office, Harrodsburg, Mercer County, Ky. Access.-By Cincinnati Southern Railroad to Harrods- burg Junction, thence by Southwestern Branch to Har- rodsburg. 508 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Harelip. Hay Fever. Old Sulphur Well. Cub. in. Montpellier. Cub. in. Carbonic-acid gas 2.200 1.401 Marsh gas 0.584 0 053 Sulphuretted hydrogen.... 0.531 0.048 Oxygen 0.291 Nitrogen 0.482 ■ - ■ - Total 3.606 1.984 Meinberg in Europe. Its taste is much pleasanter than any of these. The water is effective in diseases of the skin and mucous membranes, scrofula, liver and kidney affections. This spring is situated on the bank of Bull Creek, one mile from the Ohio River. The country is hilly and af- fords hunting and fishing. The hills contain coal, and there are some oil wells in the neighborhood. In fact, this water was found while drilling for oil at a depth of three hundred feet. The hotel, Rose Hill, accommodates about seventy guests. G. B. F. The slight discrepancy in the above table arises from the omission of traces of calcium fluoride and ammonia in both springs, traces of sodium bromide and iodide, and ferrous and manganese carbonates in the Old Sulphur Well, and traces of organic matter in the Montpellier. The proportion of sodium chloride is rather too large to constitute pleasant beverages, but the reputation of the springs for their curative action attracts large numbers of people annually, chiefly from the west of Scotland and the north of Ireland. A course of treatment usually lasts from one to three weeks. The chief effect of the administration of the waters is purgative; but they are employed both internally and for bathing in cutaneous eruptions, as well as in disorders of the alimentary canal. J. M. F. HARZBURG, or Neustadt-Harzburg. The chief town in the Brunswick circle of Wolfenbiittel, at an elevation of 727 feet, on the right bank of the Radau, a tributary of the Ocker, a terminus of the Brunswick & Harzburg Railroad, eighteen miles from Wolfenbiittel. Since the construction of this railroad Harzburg has become the most popular summer resort of North Germany, a large number of visitors to the Hartz Mountains also visiting the place. Two mineral springs, the Julius and the New, are worthy of notice. The former of these contains 500.73 grains in a pint, of which sodium chloride consti- tutes 469.24 grains. The New Spring contains 535.06 grains, of which 511.10 are sodium chloride. For bath- ing the water is usually diluted to about two or three per cent. It is sometimes used internally, also, diluted with selters water, milk, or whey. A mile and a half south of Harzburg is the Burgberg, on the summit of which, 1,500 feet above sea-level, are a hotel and other buildings for the accommodation of visi- tors. J. M. F. HARTSHORN {Come de cerf, Codex Med.). The horn of the stag, Cervas Elaphus Linn. Order, Ruminantia. This practically obsolete substance is interesting princi- pally as the early source of ammonia, to which it gave its name (" spirit of hartshorn water of ammonia is still frequently called hartshorn). It is occasionally to be seen in the shops in the form of shreds and raspings, probably the refuse of knife-handle makers. Its constit- uents are those of horn and bone in general: gelatin, phosphate of lime, etc. Burnt horn, like burnt bone, used to be employed as an antacid, etc. W. P. Bolles. HAUTERIVE. A village a short distance south of Vichy, France, having mineral springs which belong to the class of bitter waters. The chief ingredients are the bicarbonates, especially sodium bicarbonate. Boucquet's analysis of the principal spring, the Gale- rie, at a temperature of 59° F., is as follows : Parts. Sodium 23.68 Potassium 0.98 Magnesia 1.60 Calcium 1.68 Strontium 0.02 Ferrous protoxide 0.08 Hydrochloric acid 3.34 Sulphuric acid 1.64 Silicic acid 0.71 Arsenious acid 0.01 Phosphoric acid 0.25 Carbonic acid .*.. 56.40 The greater part of the water collected is used for ex- portation. J. M. F. HART'S TONGUE (Scolopendre, Codex Med.). The frond of Scolopendrium rulgare Smith (5. officinale Swartz); Order, Filices. A robust, good-sized fern with a tuft of stiff, dark-green, linear-lanceolate, at the base auriculate, fronds. Sori linear, parallel, in twos, between the nerves, and making a wide angle with the midrib. Indusia attached to the outer sides of the two contiguous lines. Hart's Tongue is a native of most temperate coun- tries of Europe, Asia, and North America, and is an old house-remedy against bronchitis, coughs, catarrh of the bladder, etc., but hardly entitled to serious notice. It is a minor ingredient of several of the preparations of the Codex. The dried fronds have but little smell and an astringent, slightly bitter, and aromatic taste. Dose, indefinite. Allied Plants.-See Male Fern. W. P. Bolles. HART'S WELL. Location, Rose Hill, Pleasants County, W. Va., ten miles from Marietta, O. Post-office, Willow Island, Pleasants County, W. Va. Access.-By Ohio River. Railroad, or by boat to Wil- low Island ; thence by carriage to spring, six miles. HAW, BLACK (Vibumm, U. S. Ph.). The bark of V. prunifolium Linn., Caprifoliacea, a small American tree growing from Connecticut to Illinois and southward, with oval, obtuse or slightly pointed, finely serrated leaves, and sessile cymes of small white flowers. The bark is in thin pieces or quills, glossy externally, of a purplish-brown color, with scattered warts and minute black dots ; when collected from old wood it is grayish- brown ; the thin, corky layer separates easily from the green layer beneath it ; the inner surface is smooth and whitish ; fracture, short; odor, none ; taste, astringent and bitter. The bark is said to contain rib urnin, roderianic, oxalic, citric, and malic acids, besides other ingredients. Viburnum is in a mild way astringent and tonic, but is principally used to prevent abortions, and in uterine and other colic, etc., for which it appears to have some value. Dose, from two to five grams (gr. xxx. ad 3 jss.). A fluid extract (Extractum Viburni Fluidum, U. S. Ph.) is made. Dose, the same. Allied Plants.-Several other species of Viburnum have been used, having similar properties. The orna- mental honeysuckles are in the order. W. P. Bolles. Analysis. Sodium chloride Soda bicarbonate Soda sulphate Potash sulphate Magnesium bromide Magnesium iodide Magnesium chloride Lime bicarbonate Magnesia bicarbonate Alumina phosphate Alumina and iron carbonates Manganese Silica Organic matter Grains (per pint). 30.449 14.215 4.747 2.865 0.035 0.003 0.270 1.595 0.396 0.029 0.088 0.008 0.073 54.773 Therapeutical Properties.-This is a water of un- usual composition, being alkaline and saline, and contain- ing also the cathartic sulphate in marked proportions. It is almost identical with the Borland Well in the same county, and therefore very closely resembles the cele- brated waters of Aix-la-Chapelle, Neundorf, Eilsen, and HAY FEVER is the popular title for an annually re- curring affection which involves the mucous membranes of the ocular and respiratory tracts, and is associated with 509 Hay Fever. Hay Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. certain symptoms which can only be accounted for by a reference to the nervous system. It, or a very closely allied disorder, occurring during the early summer in England, was first described by Bostock in the " Medico- Chirurmcal Transactions " for 1819, under the name of Catarrhus ^Jstivus; and in his work upon the affection now treated of, Dr. Wyman advocates the use of the term Autumnal Catarrh as more correct, and not involving the absurdity of associating a disease with an impossible cause-for the season of hay-making is long past before hay fever makes its appearance. But the title has become so imbedded in the popular mind that there seems to be no escape from what is indisputably a misnomer. Basing the suggestion upon the view that the affection depends upon engorgement of the nasal mucous membrane, with associated reflex nervous symptoms, Mackenzie, of Balti- more, has proposed as a new name Coryza Vasomotoria Periodica. The peculiarity of the affection is its annual recurrence, in the same individuals, with almost ludicrous exactness in point of time, throughout, in many instances, the years of a long life. Thus an examination of the narratives of their cases, written by those who suffer from hayfever, will reveal the fact that the attack in man occurs upon the same day, or even the same hour of the day, in each year, and in none is there a variation of more than a few days. This regularity of return is apparently but little affected by the peculiarity of one year as compared with another. Whether the season is wet or dry, whether as a con- sequence vegetation is rankly growing or falling into decay, appears to make no difference. Another singular fact is that the sufferer from this disease in Philadelphia or Baltimore may rest assured that, at the precise time he begins to feel the approach of his enemy, his fellow-suf- ferer in a place as far removed geographically as Boston is subject to the same attack, though his climatic surround- ings are quite modified. The attacks are, however, not of similar severity each year, but will vary somewhat. Why this should be so it is hard to determine ; but it has been observed that when, as in 1885, there is a prolonged drought in the early sum- mer, succeeded by heavy rains leading to a revival of vegetable growth in the month of August, the season is likely to be a bad one for sufferers from autumnal ca- tarrh. Age appears to have nothing to do with this affection, some persons experiencing their first attack as early as in their third or fourth year, while others escape the forma- tion of so undesirable an acquaintance until quite mature life. It is a curious fact, revealed by an examination of Dr. Wyman's table of eighty-one cases, that males are more likely to be sufferers in early life than females ; which is in accordance with the observation of the writer, although there is no particular significance in it, so far as his knowledge goes. Another peculiarity of this disease, and one which has been noticed by many observers, is its greater prevalence among those who are not compelled to resort to manual labor for a livelihood. Not that it does not occur in this latter class, for some such are recorded by Wyman, and many have fallen under the observation of others; but that it is of comparatively rare occurrence among the laboring classes is a patent fact. The writer's experience leads him, however, to think that this difference is be- coming less marked of late years, and that not only is the aggregate number of cases increasing, but that periodical catarrh is extending among classes which were at one time in a great degree exempt from its visits. Having now referred to some of the peculiarities of this troublesome affection, a description of its symptoms and course, as ordinarily observed, is next in order. About the middle of August the patient experiences itch- ing of the eyesand pharynx, which at times is intense, and is accompanied by most inordinate and frequent sneezing. The irritation of the eyes and throat appears to be with- out cause, but the sneezing seems to be provoked by bright light, cool currents of air, or some exposure to the causes which ordinarily are regarded as provocative of catarrh. At first these attacks are infrequent and of moderate severity, but they soon become more severe and more frequent. On first getting up in the morning, while dressing, and often during breakfast, the attacks of sneezing are prolonged, and altogether unaccompanied with the grateful sense of relief which sometimes is ex- perienced in connection with this manifestation. Every exertion increases these symptoms, and there accompa- nies them a general feeling of discomfort, with slight acceleration of pulse, which have earned for the disease the misnomer of hay fever. The amount and severity of these symptoms will vary somewhat with different years, but they will always exceed in both respects those ob- served in ordinary coryzas. Usually symptoms of bronchial irritation manifest themselves in about a week, and dryness and injection of the fauces are followed by a tickling cough, accompanied with but little expectoration. After a time the cough be- comes more severe, paroxysmal in character, and is often accompanied with much soreness in the chest, which is somewhat relieved when expectoration is established. Like the coryza, the bronchitis varies much in intensity in different individuals, and somewhat in the same per- sons in different years. In some it does not exceed in severity that attending a mild cold, in others it becomes a most serious affection, and is occasionally accompanied by expectoration of mucus streaked with blood. The observation of the writer, however, has not brought him in contact with a case in which true pneumonic sputa were present, although he is familiar with one in which the expectoration has on two occasions very nearly approached that character. The physical signs are those of bron- chitis. In many cases, after a most harassing experience ex- tending over ten days or two weeks, both the coryza and cough lessen in severity. The former entirely dis- appears, and while the latter may persist as a most exas- perating tickling, especially at night, convalescence'passes into complete recovery, the whole course of the disease having lasted from three to four weeks. But in the vast majority of cases the advent of the cough is accompanied by asthmatic symptoms of more or less severity, and in very many these symptoms cause everything else, to appear as insignificant. Indeed, more severe asthma than accompanies some cases of autumnal catarrh is rarely, if ever, seen. The first asthmatic symptoms generally appear about the 25th of August, and are often brought on by a spell of coughing, some unusual exertion, or in many cases by the change of wind accompanying a thunder-storm. From the time of their first appearance these symptoms do not entirely disappear until the conclusion of the an- nual attack, which is ordinarily about the end of Septem- ber, although in some cases prolonged until a later date. All the time there is more or less difficulty of breathing, accompanied with true asthmatic rales. Upon percus- sion the chest is more than usually resonant, showing the existence of at least a temporary emphysema ; but upon applying the ear to its parietes, it is found to be filled with dry cooing and sibilant murmurs, reminding the lis- tener of nothing so much as a bag of whistles. Indeed, these sounds are generally readily perceptible at a con- siderable distance, and become more marked at the ap- proach of a paroxysm. Than a severe paroxysm of dyspnoea, such as is fre- quently seen in these cases, there is scarcely anything harder to bear or more painful to witness. The approach of the attack is signalled by an increase in the loudness of the chest murmurs, and by increased difficulty of breathing. The patient cannot lie down, and, indeed, very soon cannot lean back in his chair. Sitting or stand- ing, the patient will seek a firm surface on which to lean, and planting his elbows firmly upon it for support, will gasp for breath. The sonorous chest sounds lessen, the inspiration becomes comparatively lengthened, and the expiration much hurried. The collar will be unbuttoned, the face assume a yearning and almost despairing ex- pression, the eyes be suffused and tearful, while the ef- forts of the arms, shoulders, and all of the muscles acces- sory to respiration are most severe and accompanied with 510 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hay Fever. Hay Fever. a very copious perspiration. The sense of fatigue is ex- treme, and to the expression of anxiety is added one of intense weariness; but the efforts are unrelaxed, for, though well nigh useless, they are involuntary and can- not be lessened by any effort of the will. No sounds whatever come from the chest, and while the patient feels as if he was breathing in vacuo, the inexperienced spec- tator will think that actual suffocation is impending. If not interfered with, this state of things may last from a few minutes to several hours. Gradually there will be a return of wheezing noises in the chest, the respiration will become somewhat less shallow, and the sense of suf- focation less acute ; and if the improvement continues the expression of relief becomes marked upon the face, and the sufferer drops into sleep without much reference to the position he occupies. But the relief experienced is very generally only par- tial, and the respiration continues laborious and oppressed, while exercise or any physical effort is impossible with- out immediate aggravation of the symptoms. This state of things continues until the end of the season, though lessening gradually with the diminution of the bronchitis and the disappearance of the cough. The writer has known this asthmatic period to last for from three to six weeks, during which time the patient could not go up and down stairs, could not sleep at all without the aid of anodynes, nor indulge in the slightest dietary indiscretion. The eating of large amounts of food late in the day, or of indigestible food at any time, is likely to bring on an acute paroxysm, and the same result is very apt to follow a prolonged spell of coughing. Very often sleep can only be obtained in the upright position, either in a chair or propped up in bed with a large number of pillows. In many cases of periodical catarrh the asthmatic symp- toms never attain the severity of those which have been described, but they are present in a more or less modi- fied form in the majority of instances, especially at night. As has been said, when the asthma is a marked feature in the individual case, it overshadows all other symp- toms, and we shall not obtain the vividly thrilling de- scriptions of the sufferings from catarrh, which encumber books upon this special topic, from those who have severe asthma. They will express themselves as quite ready to bear the annoyances of the most violent coryza and the most irritating cough, if they can only secure immunity from the dyspnoea and orthopnoea which they have learned to dread. After the middle of September there is a gradual decli- nation in the severity of all the symptoms, and by the end of the month they have in great measure disappeared, though in the severer cases there may remain a tickling cough and the liability to attacks of oppression to a much later date. Indeed, it would seem, in the more severe cases, and especially in those who suffer much from asthma, as if there was a tendency to a gradual pro- longation of the after-period, so that throughout the win- ter any severe cold is liable to be complicated with asth- matic symptoms. That this should be the case is quite natural in view of the causal relation existing between asthma and true emphysema. Yet permanent emphy- sema is rarely present, probably owing to the shortness of the attacks, and to the fact that most patients enjoy a sufficiently long period of health between them to pre- vent organic changes taking place in the elastic lung tis- sue. Observation has convinced the writer of this article that the recurrence of these attacks, unmodified by effec- tive treatment, tends to fasten the habit more firmly upon the system, as well as to increase the length of the after- period. His experience has taught him that if the season is anticipated by a suitable change of residence, and the severity of the attacks modified by appropriate treatment, the force of the annual habit is lessened, and while it may not be entirely obliterated, the acuteness of the peri- odical attacks will be diminished. It is this fact which leads him to urge careful attention to those cases which occur in children, as in them there is more hope of being able to attain good and permanent results. As a general thing, the first attacks are less severe than the succeeding ones, and there would seem to be more encouragement to expect good results by prompt and early treatment. When we come to consider the nature and cause of this curious affection we enter upon a wide field, and one upon which most conflicting theories contend. That this should be the case is natural from the absence hitherto of any researches throwing much light upon any anatomical peculiarities pertaining to the affection. That there are such peculiarities, however, at any rate associated with it, cannot be doubted in the face of the observations re- cently made by such authors as Harrison Allen, J. N. Mackenzie, Sajous, and others; but it is as yet too early to conclude with certainty that these anatomical peculi- arities are undoubtedly the cause of the affection under consideration. According to these observers the subjects of "hay fever" are all alike in presenting certain peculi- arities in the anatomy of their nasal cavities. According to Harrison Allen, the nostrils are obstructed by deflec- tion of the septum, hypertrophy of the soft parts and bones, or turgescence of the mucous membrane, and al- ways an undue prominence of the inferior turbinated bone. J. N. Mackenzie, Roe, Daly, Hack, and Sajous hold that there exist in these cases both an unusual de- velopment and an unusual excitability of the mucous membrane covering a well-defined sensitive area, which is known to be conterminous with the inferior turbinated bone. According to these observers the symptoms of periodical catarrh are reflexes induced by irritation of this area, in cases which possess at the same time abnormal vasomotor excitability, and hence J. N. Mackenzie pro- poses the name of coryza vasomotoria periodica for the disease. The theory of these gentlemen, though revolutionary in character, has much to recommend it, and is found to be in strict accord with many of the observed facts in these cases. Yet in some respects it is not altogether satisfactory, especially when the question of periodicity is considered, or when regard is had to effects often no- ticed when a change of climate, or rather of place, is re- sorted to. Thus it is difficult to see how turgescence of the erectile tissue over the turbinated bone should occur, or, at any rate, produce serious effects only at one sea- son of the year. Then it is certainly going too far to ac- count for the benefit secured at certain sea-shore places simply by the tonic effects of the sea-air upon the ner- vous system, and to point to the well-established fact that a land breeze is injurious, and claim that it is so only so far as it is relaxing and enervating. At every place on the sea-shore there are alternating sea and land breezes ; yet relief from autumnal catarrh is experienced at but few of them, and those that experience has proved to be suit- able places of resort are such as by their topography re- ceive no breeze from the land until it has passed over a considerable expanse of water. But these observers, while maintaining the anatomical and nervous basis of the disease, do not deny that pollen may be one source of irritation among many others, and even should the theory they propose not be reconcila- ble with all the facts in any given case, it is reasonable to anticipate that further observation and closer study may tend to complete elucidation of it. Hitherto there has been nothing more definite than the supposition that the affection was produced by one or more kinds of pol- len acting upon a personal idiosyncrasy-the latter term, of course, being only a convenient expression to cloak ignorance. This theory has been upheld by the majority of writers in the past, and is still contended for by Morell Mackenzie, Blackley, and some others. According to these writers, at a given season there is a large amount of pollen-grains afloat in the atmosphere, which serve as the exciting cause, in cases possessing that personal peculi- arity or idiosyncrasy wherein lies the true essential char- acteristic of the disease. When tested by experience the theory is found to fit in almost every particular. That there is some peculiar atmospheric condition only present at a given season would seem to be proven by the fact that in the vast majority of cases there is an entire ab- sence of symptoms at all other times. That this condi- tion is imparted from the vegetable kingdom would seem 511 Hay Fever. Hay Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. proven, because almost all cases are benefited by a resi- dence, during the time, either at certain places among the mountains, at certain sea-shore resorts separated from the main-land where there is little vegetation, or most cer- tainly during a sea-voyage. The malign influence of vegetable exhalations in these cases receives support also from the well-known fact that the kindred affection known as rose-cold seems to be largely dependent upon such irritants. The writer is acquainted with one gentle- man who suffers acutely in September, but is perfectly well in June. His mother-in-law, for very many years and until her death, suffered in precisely the same way, and was also well all the early summer. They were both re- lieved by removing to Beach Haven, on an island off the New Jersey coast only six miles distant from the home of the mother-in-law. In this coincidence there is, of course, nothing peculiar ; but two of the brothers of the gentleman mentioned, with his wfife and sister-in-law, have been severe sufferers from acute coryza in June, and are all quite well in September. We have here a group of six cases, five of whom would be properly described as very far removed from the category of nervous persons, who have for many years suffered periodically, in all of whom relief is, at least, associated with the comparative absence of vegetable influences. Of the June cases, two were always better in town, and the attack was not so severe as to require other measures of relief ; one is free from attack at Beach Haven ; while the fourth, whose at- tacks are the slightest, gets comfort by keeping most of the time in the house. In none of the June cases is asthma present; but all have noticed great aggravation of their symptoms when exposed to various kinds of pol- len, notably that of the horse-chestnut, the ailanthus, and the scented honeysuckle. In one of the June cases, and in one of fhe September cases, prominence of the inferior turbinated bone has been noted. The object in citing these cases is not to bolster up the old and exclusive pollen theory, but to submit them merely as cases which show the difficulty which presents itself to anyone who attempts a close and exclusive defi- nition which will include all cases. Advocates of the purely nervous and anatomical theo- ries maintain that their theory is supported by the results of treatment, and this will be spoken of more at length in its proper place ; but the claim is as yet not fully substan- tiated, and quite a number who have undergone local and tonic treatment are known to still suffer from their old enemy. Whether this will continue to be true when they have undergone a sufficient number of applications to the nasal mucous membrane remains to be seen, but it is not as yet proven. It is still sub judice, and is subject in some measure to the well-known disposition-or idiosyn- crasy shall we call. it-possessed by many hay-fever pa- tients, to be cured in succession by many forms of treat- ment. In his recent work on hay fever, Sajous recognizes the difficulty of precise and exclusive definition, and for- mulates a theory which is comprehensive, and which may at least serve as a working hypothesis until more extended and complete observation furnishes us with one that is entirely satisfactory. According to this author, hay fever requires, first, an external irritant; second, a predisposi- tion to become influenced by this irritant; and, third, a vulnerable or sensitive area through which the irritant may exert its influence. It may be safely concluded that autumnal catarrh is largely dependent upon some disorder of the vaso-motor nerves, that the sympathetic system is partially responsible for the trouble, and that many of the symptoms are true reflexes ; but what is the precise character of the trouble is not known ; undue excitability there may be, and prob- ably is, but that tells us little more than the old term idiosyncrasy. It has, however, the great advantage of directing our treatment into a definite channel. While admitting the implication of the nervous system, it can- not, however, be concluded that pollen has no share in producing the disease. That it has a large and important part as an exciting cause, it seems impossible to doubt. Ou the other hand, pollen is not the only excitant, but dust, heat, electrical conditions of the atmosphere, and many other things share with pollen the ability to provoke an attack in properly disposed persons. Treatment has hitherto been of two kinds, namely, pal- liative at home, or radical by removal to a locality which experience has proved to be exempt from the exciting causes of the disorder. While the former has been un- satisfactory-so much so, indeed, as to lead many sufferers from hay fever to disregard it altogether-there is no doubt that much can be done to lessen the severity of the attacks, and to mitigate the suffering they cause. Leav- ing out of view, for the present, the local treatment, so much lauded of late as the only radical one, the follow- ing line of procedure may be safely followed as rational, harmless, and as proved by experience to be beneficial. The patient should lead a very quiet life from the be- ginning to the end of the period, avoiding exposure to draughts, the direct rays of the sun, and any exertion which may tend to quicken the circulation. He should pay particular attention to his diet, especially during the later hours of the day. By this it is not meant that he should go upon a low diet, but that he should avoid any- thing that is indigestible, or which during digestion gives off a large amount of gas, such as sweet potatoes or lima beans. In many cases watermelons act injuriously, and the individual powers of digestion should always be care- fully considered. Keeping this last point in view, there is no reason why rich soups, meats, the less starchy vegetables, and many fruits, should not be indulged in. He will do well to have any peaches he may eat pared before they are brought into the room, and he will be wise if he eats nothing after the early hours of the after- noon. For the conjunctivitis, or rather the ocular injection, which exists in these cases, a weak solution of brandy and water, or some other mildly stimulating collyrium, will prove most comforting. When obliged to go out in the day- time, dark-colored spectacles will afford considerable re- lief. Similar locally stimulating treatment will be found beneficial to the coryza. Weak solutions of quinia, of sea-salt, or any other suitable substance, will afford tem- porary relief, and if attention is paid to the specific grav- ity of the solutions by the addition of a saline, so that they approach that of the blood, they can be fre- quently repeated without injury, and with positive ben- efit. In the use of hydrochlorate of cocaine, there is every reason to expect decided benefit. Dr. Da Costa has found it useful in a number of cases, when applied to the nasal mucous membrane, and there would seem to be good grounds to anticipate advantage from its further use in solutions of varying strength. Stimulating gargles, such as vinegar and salt, are useful by temporarily allay- ing the intense itching in the roof of the mouth, and les- sening the hypersemia of the mucous membrane of the fauces and pharynx. When the bronchitic symptoms appear, the use of mild expectorants with opium will be found decidedly useful in allaying the cough, even though they do not abolish it altogether. Neither physician nor patient should allow the fact that the disease is annually recurrent, and that the predisposition cannot be destroyed, to prevent the use of ordinary remedial measures to palliate the severity of the symptoms. Very many cases will be benefited by some such prescription as the following : B. Morphias sulphatis, gr. j.; extract, belladonna?, grs. ij.; extract, prun. virg. fluid., syrupi lactucarii, Sa f § j. Dose, a tea- spoonful every four hours. Beyond the fact that they divert the attention of the patient, counter-irritants ap- plied to the chest do not appear to do much good, while they possess the disadvantage of sometimes provoking troublesome skin affections. When asthmatic symptoms present themselves, opium, in one form or another, will be found to be by far the most efficient remedy. Two or three doses of one-fourth of a grain each, taken two hours apart in the evening, will be found to diminish the spasmodic tendency most ma- terially, and by cautiously increasing the dose from time to time, or by changing the form of the drug, it will be found possible to maintain the good effects throughout the 512 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hay Fever. Hay Fever. time of the attack without resorting to a very large dose. In recommending this method of treatment the physician should carefully weigh the risk that the patient runs of acquiring an evil habit, and should always insist that it should only be pursued, under competent medical over- sight, when the discomfort is severe. He should, above all, urge its abandonment at the earliest possible day. He should always bear in mind the fact that, while the im- mediate comfort of the patient may be promoted, his ulti- mate well-being may be seriously imperilled by a drug which is so potent for both good and evil. When the physician is called to witness one of those extreme attacks previously described in this article, when the orthopnoea is complete, and the sufferings of the pa- tient far greater than are usual at any death-bed, he will find that in his hypodermic syringe he possesses an imple- ment of almost magical power. The injection beneath the skin of one-fourth or one-third of a grain of sulphate of morphia will, in the vast majority of cases, afford com- plete relief in a very few minutes. The practice of the writer has been to use seven minims of Magendie's solu- tion, and he has never witnessed more marvellous effects from any medication. Generally within fifteen minutes the spasm has entirely disappeared, and the patient has fallen into a quiet sleep. Rarely, and only in those cases where the remedy has been often administered, he has had to use a supplemental injection of four or five minims. Smoking various kinds of cigarettes, burning saltpetre papers or some of the various quack compounds so ex- tensively sold, often afford some relief, generally just in proportion as an anodyne has been incorporated in the mixture. Chloral will afford relief in some cases, but, apart from the danger which attends its use, it is much less efficacious than the course of treatment above indi- cated. When resorted to it may be advantageously com- bined with full doses of one of the bromides. These last- mentioned remedies may often be used with benefit. Twenty grains of the bromide of potash, repeated every hour until a drachm has been taken, will frequently secure a quiet night. The bromides and chloral may be usefully added to, or alternated with, opiates. Musk, camphor, assafoetida, stramonium, and very many other remedies addressed to the nervous system, have been recommended, and may be tried sometimes with advantage, both from their own intrinsic power, and from the aid they lend to the effort to keep within bounds the dose of opium neces- sary for the control of spasm. The treatment above indicated will enable a sufferer from hay fever to exist with a minimum of discomfort at home, but in those cases which suffer much from asthma it will be a period of confirmed invalidism at best, and they will long for more radical and more effectual means to entirely abolish the recurrence of the annual attacks. There are very many who merely suffer the inconvenience of a severe coryza and an annoying catarrh, but who are able to go about and attend to business, with discomfort, indeed, but without interruption. Such cases may afford to consider whether they will continue satisfied with pal- liative treatment, or seek that which, while more severe, is certainly more effectual. But the patient who has had one attack of severe asthma will share the anxiety of his friends that he may escape another such, and will be willing to make great efforts, to endure many discom- forts, aye, go even to the ends of the earth, if he may only thereby avoid another attack. Fortunately, a change of location can be recommended with confidence. Experience has proved that immunity is enjoyed at Bethlehem, and many other localities in the White Mountains, as well as other elevated locations ; at Beach Haven, N. J., Fire Island, N. Y., and a few other places on the sea-shore ; or, better than all, at sea, out of sight of land. It would be out of place, in an article like the present, to go into a discussion of the reasons for the immunity enjoyed under the circumstances, yet it may be well to refer to certain facts as tending to an elucida- tion of the matter, or at least as helping us to a knowledge of the conditions essential to immunity. Why certain mountainous regions should be exempt and others not is not known. It cannot be elevation, for all elevated re- gions do not afford relief, while those which do are often less high than those where no relief is obtained. It can- not be altogether the absence of pollen, for none of the localities proved to be beneficial are entirely destitute of vegetation. Yet the fact remains, and it is idle to deny it, that autumnal catarrh is escaped at Whitefield. Franconia, Fabyan's, Crawford's, Mount Washington, Gorham, and many other places in the White Mountain region, at many places in the Adirondacks and in the Catskills, at the Straits of Mackinaw, and some other points in the North- west. When we come to the sea-shore, we find that Fire Island and Beach Haven are both situated upon islands of limited extent, somewhat removed from the main-land, and, so far as our present knowledge goes, it is only at places similarly situated on the sea-shore that exemption from hay fever is enjoyed. These islands are very low, Beach Haven not being more than eight or ten feet above high-water. Nor is there an entire absence of vegetation, there being an abundance of marine plants, and the up- land flowers, though few in number, are yet amply suffi- cient to supply pollen to a disastrous degree, did it pos- sess the virulent properties supposed to belong to it by Morell Mackenzie and Blackley. Yet, as was pointed out by the author of this article some years since, very many persons entirely escape their annual attacks of hay fever at Beach Haven, and all enjoy a greater or less measure of relief. While the wind is from the sea com- plete immunity is enjoyed ; when it comes from the land some inconvenience is experienced, but the attacks are always of modified severity. Although, therefore, it is difficult or indeed impossible to give a satisfactory explanation of the reasons why certain places are safer resorts for sufferers from autumnal catarrh than others, it is safe to advise such cases to make trial of one of them, making the selection according to the dictates of individual convenience and inclination. But it is im- portant, when the patient goes to one of these resorts, that he go before the time of the expected attack, and observe ordinary hygienic precautions while there. Personal ob- servation leads the writer to believe that it is of impor- tance to anticipate the attack by several days, and that, when it has once begun, it is much more difficult to get rid of it. Yet many persons will arrive at their safe harbor suffering acutely, and find complete relief in a few hours. Nourishing food, light woollen clothing, thin flannel next the skin, the avoidance of undue exertion, and rational medical treatment for any symptoms which arise, will give comfort, even though the exile-for an exile it is when enforced from year to year-may be inconvenient and hard to bear. The writer would especially urge the im- portance of sending children to some safe place, as he is increasingly convinced that, if there is any hope of break- ing up what may be in part a systemic habit, it may be most reasonably indulged in the case of very young per- sons. To accomplish this is worth every effort, for while autumnal catarrh is not a disease endangering life, and the suffering attendant upon it may be alleviated or borne, its annual recurrence does most seriously interfere with all the avocations of the individual, whether he remains at home or seeks refuge in an exempt locality. Experience would seem to show further, that when complete exemp- tion is enjoyed for a series of years, recurring attacks ex- hibit less severity. The new pathological views to which reference has been made, and which identify the jiisease in question with certain abnormalities and pathological changes with- in the nasal cavities, have led to local treatment of greater or less severity, instituted with a view of getting rid of the cause entirely. Any abnormal prominences or growths connected with either the mucous membrane or the bones are attacked by the snare or galvanic cautery and destroyed, or, if the trouble is found to consist in turgescence of the erectile mucous membrane, various stimulating applications are resorted to, and with most satisfactory results to those who have used them. The method is recommended by such capable observers, and specialists so skilful in their departments, that it is cer- tainly worthy of more extended trial. As reported, the results have been very good, but it is yet too early to 513 Hay Fever. Headache. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. utter any ex-cathedra opinions upon the subject. Sev- eral who have undergone the treatment referred to have fallen under the writer's notice. Some have thought they were benefited, others that they were not improved, and one, at least, believed that he was worse than before. Most of the cases were met at a hay-fever resort. It is but right to add that some of the cases had not under- gone the number of local applications which their attend- ants thought were necessary to work a complete cure. While the application of mechanical and operative meas- ures may be safely tried within certain limits, there would seem to be danger of carrying the practice too far. It should not be forgotten that extensive tracts of cicatricial tissue may become the seat of more serious disease than hay fever . For the latter we have a tolerably certain and satisfactory palliative, if not a permanently radical cure, in temporary change of residence, while at present opera- tive interference is undertaken only with the chance of permanent relief. Those who desire to familiarize themselves with the natural history of hay fever will do well to consult the admirable work, "Autumnal Catarrh," by Morrill Wy- man, M.D. (New York, 1872), in which they will find the best account of the disease and the most careful study of places where exemption from its attacks exists. Those who desire to know al! about the pollen theory, and the extent to which it can be carried, will do well to consult " Ex- perimental Researches on the Causes and Nature of Ca- tarrhus JEstivus," by Charles II. Blackley, M.R.C.S. Eng. (London, 1873), and " Hay Fever ; its Etiology and Treatment, with an Appendix on Rose Cold," by Mo- rell Mackenzie, M.D. (London, 1885). This last book is most vigorously reviewed in the American Journal of the Medical Sciences for October, 1885, by Dr. John N. Mackenzie, of Baltimore, who has also contributed several papers bearing upon hay fever to various jour- nals, in which he ably upholds the neurotic and ana- tomical theory of the disease. An able and suggestive paper will be found in the number of the American Journal for January, 1886, in which Sir Andrew Clark maintains very similar views, but would account for the asthmatic spasm by temporary and sudden congestion of the mucous membranes rather than by muscular constric- tion of the bronchial tubes. In " Hay Fever and its Suc- cessful Treatment by Superficial Organic Alteration of the Nasal Mucous Membrane," by Charles E. Sajous, M.D. (Philadelphia, 1885), there will also be found an expo- sition of the modern views, and details of the treatment recently so highly lauded for this most troublesome affec- tion. Other papers upon the subject will be found scat- tered through the journals by Daly, Roe, Allen, Bosworth, Da Costa, Beverly Robinson, S. S. Cohen, and Hack. Samuel Ashhurst. In some instances of severe supra-orbital pain there may be a free flow of tears on the same side. Patients characterize the sufferings of headache by a variety of expressions, as dull, sharp, snapping, boring, splitting, squeezing, or sore pain ; or as hot or heavy pain. The pain may be accompanied by tinnitus aurium of a continuous or pulsatory character, in one or both ears. The scalp is sometimes tender to the touch ; movements of the hair, as in the act of combing or brushing it, may be painful, and any jarring of the head may aggravate the suffering. Photophobia may be present, even in an extreme degree ; and sometimes during an attack of head- ache, or just preceding it, the sight may be lost, or some other aberration of vision may occur for a time over a part or the whole of the field of vision of one or both eyes. The patient is often as sensitive to sounds as he is to the light, and loud noises, or disagreeable sounds that are not loud, increase the pain. Sounds that at other times are not unpleasant become exasperating in the presence of headache. The general surface of the body, and the extremities in particular, are usually cool or cold in headaches not in- duced by fever or some general disease, and the surface of the head may be warm or cool. The pulse may be slowed or accelerated. Anorexia is usually present, al- though the opposite condition may obtain, and actual vo- racity exist. Eating may be followed by relief of the headache to some extent, or, what is much more likely, the pain may grow worse and the food be vomited, almost or quite undigested, perhaps hours after being swallowed. In some attacks of headache the urine is in- creased, and of low specific gravity and watery appear- ance ; in others it is scanty, high-colored, and of high specific gravity. In some attacks of headache mental action of any kind, particularly close attention or strong emotion, aggravates the suffering, and the patient seeks perfect quiet and free- dom from thought and worry. Vertigo may be present, even to the extent of affecting the gait in walking, and changing from the recumbent to the vertical posture, or the reverse, may aggravate the pain, as the former may increase the vertigo. The forms of headache are numerous and varied. A common form is that known variously as sick-headache, hemicrania, nervous headache, migraine or megrim. It is a regularly recurring, periodical headache, and some con- fusion might be avoided by using this term to designate it. Migraine is by some writers restricted to cases of so- called hemicrania, a periodical headache with the pain confined to one side, and accompanied by less nausea and vomiting than sick-headache. Periodical headache is a nearly life-long experience of certain persons. Attacks recur at intervals varying from three days to several months, frequently with a good deal of regularity, which may be unbroken from childhood to age, although the intervals often grow longer after forty- five, and the attacks less severe. There is an hereditary tendency to this form of head- ache, the children of victims being most likely to have it. Perhaps it is more prone to attack females than males, but the difference in susceptibility of the two sexes is not great, except, perhaps, in the variety known as hemicra- nia. While it is a constitutional neurosis, it is, contrary to the statements of writers, rarely found to have any nexus with such neurotic affections as epilepsy, spas- modic asthma, and hysteria, and is very seldom converti- ble with either of them. The children of the subjects of periodical headaches in this country are not more likely than others to have epilepsy or insanity. The attacks of this disorder are usually brief, lasting from a few hours to two days, the average being proba- bly eight hours or less. With some persons the attacks begin suddenly, with others gradually, the patient being able to predict the occurrence beforehand by certain sen- sations peculiar to his individual case. In symptomatol- ogy probably no two cases are even nearly alike. The premonitory sensations are in the stomach, head, and ex- tremities, and may last from an hour to a day. The pa- HEADACHE. Headache attends the diseases and dis- orders of the body with remarkable frequency ; it consti- tutes a large share of the sum of human suffering ; and as to certain diseases, it is not only the chief symptom, but it constitutes almost all that is known about them. Headache, as a symptom, has all degrees of severity, from a dull, disagreeable sensation to the severest possi- ble agony. It may be continuous-lasting a number of hours, days, or even months, uninterruptedly-or be so brief as to fix the attention of the patient but a moment. Sometimes it is uniform in severity during its continu- ance ; sometimes interrupted, coming in paroxysms like the pain of colic ; or there may be continuous pain with exacerbations of severer suffering; or the pain may be throbbing in character, in unison with the heart's action. The pain may spread over the whole head, and so con- tinue, or be circumscribed, involving only a small area ; or, again, during a single attack, it may migrate from point to point, and at times involve the whole head. The circumscribed regions of its most frequent occurrence are the whole forehead, a single supra-orbital region, the tem- ples, the vertex, and the occiput. An entire lateral half of the head may alone be affected (hemicrania). The severest pain is that which is sharply localized (clavus). 514 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hay Fever. HeadacJie. tient may have a feeling as though a cincture was drawn tightly about the head, or some other sensation not a pain, with a general disinclination to mental activity ; sometimes loss of memory, or nervousness, or irritabil- ity of temper, may ensue ; the extremities are apt to be cold and clammy, and the stomach to have a sensation of uneasiness, irritation, or weight that is unmistakable to the patient himself in its portent of an attack. A great increase of urine, limpid in character and of low specific gravity, is a premonitory symptom with some patients. The vision may be disturbed : motes, spots, and fantastic shapes of light and dark of various colors, may dance before one or both eyes with a shimmering movement; sharp flashes of light may shoot across the field of vision, and the patient momentarily fancy himself to be blind. The attack begins differently in different patients, nearly always the same way in a given person. The pain may be first felt on awakening in the morning, or it may come on late in the morning, or soon after the midday meal. During the attack anorexia is the rule, but just preceding it the appetite may be excessive and the eating reckless. After suffering severe pain for a number of hours, vom- iting may occur and speedy relief ensue ; or, in spite of this the pain may continue until sleep is secured, a thing often difficult of accomplishment, but from which the patient usually awakens free from suffering, save per- il aps some sense of soreness of the head that may last a few hours. The matter vomited at these times appears to be mostly undigested food and mucus having a vilely .sour smell and taste, often causing a burning sensation in the throat and roughening the teeth it touches. There is no regularity about the vomiting; some patients vomit with nearly every attack, others rarely do ; some vomit many times during an attack, bile being often brought up and the nausea being extreme. The pain of the paroxysm may be entirely unilateral, remaining on one side during the attack, or shifting once or twice from side to side ; frequently it is general over the head, but it may be confined to the base or the fore- head and temples, or it may migrate from one part to another. There are usually no acutely sensitive spots or points ; the head is rarely tender to the touch ; sometimes it is cool, sometimes hot. Some patients find comfort in compressing the head firmly with a bandage, others like cold applications or hot ones, and most comfort is usually found with the head elevated. Bright light and noise aggravate the suffering ; the pa- tient seeks quiescence and darkness ; jarring movements of the head increase the pain, as from riding in a jolting vehicle, or the movement caused by a heavy footfall on the floor may aggravate it. Certain odors, ordinarily not disagreeable, may increase the pain and cause nausea; among such are those of cooking food, tobacco smoke, and certain flowers, as tuberoses and highly scented lilies. The slightest mental strain or worry usually increases the suffering; the most comfortable condition is one of perfect mental inactivity. The patient frequently charges the attack to indiscre- tion in diet, or to eating hurriedly, or out of the usual meal-time, or under strong emotion, or to intense occupa- tion with affairs immediately after eating, or to sight-see- ing. But, notwithstanding this easy explanation of the seizures, whenever he attempts with the greatest care to regulate his life and ward them off, he never quite suc- ceeds ; they return at intervals, perhaps a little longer than before, but they return like epileptic attacks, regard- less of any and all hygienic influences. Sometimes, as with advancing years, the attacks grow less intense; there may at first be merely a cessation of the pain, the prodromes occurring as usual and at the customary inter- vals ; then these grow less, and in rare cases the par- oxysms may be represented by some other disorder, as a fit of indigestion, a diarrhoea, or a myalgia. In the cases to which the term hemicrania has been particularly applied vomiting is rare, and the pain is al- ways mostly unilateral, and may be entirely so. In rare cases, mostly in the prodromal periods, the painful side of the face is paler than the other, its temperature is slightly lower, and the eye may be slightly sunken and the pupil dilated. In other cases exactly the opposite conditions obtain, and obtain mostly at the time of great- est suffering, the vessels being congested, even those of the conjunctiva and the fundus of the eye. Unilateral and excessive perspiration may occur ; there may be con- fusion of ideas and loss of memory temporarily ; and er- ratic nervous symptoms may appear in distant parts of the body, such as numbness and formication. This variety is equally hereditary with the others ; it occurs oftener in females than in males-according to some writers, in the proportion of five to one ; it may be asso- ciated to some degree with epilepsy, insanity, and hys- teria, and is sometimes convertible with them ; it cannot as often be attributed to some particular exciting cause as a sick-headache can. It is the experience of many women to have paroxysms of headache in connection with menstrual periods, and rarely at other times. The attack seldom lasts more than twenty-four hours ; it may begin before the flow is estab- lished, or during any part of the period of it, or not come on till after it is over. Its most common time of occur- rence is shortly before or during the first day of the flow. It may not attend every period, the patient being most likely to be spared if she has passed a month of mental and bodily tranquillity, is in good physical strength, and has otherwise perfect functions. In character these seiz- ures correspond to a large extent with the periodical head- aches already referred to ; they vary widely in the differ- ent patients, in no two being exactly alike. In some cases there is frequent vomiting of bile and mucus, with nausea to such a degree as to compel the patient to keep the recumbent posture; in some there are the blindings and other aberrations of vision already referred to ; sometimes the pain is unilateral, sometimes it covers the whole head, or gives the patient the impression in local- ized regions-the temples chiefly-of hammer-blows or bullets crushing through the head, these piercing sensa- tions being momentary but often repeated. There may be a good deal of local tenderness about the head, some- times distinctly in the track of the larger nerve-twigs, stamping the case as a neuralgia ; but generally the suffer- ing is located by the patient inside the cranium. That there must be some personal predisposition to the periodical headaches on the part of women who have this variety is apparent from the fact that some of them have such experiences before the menstrual function is estab- lished, and occasionally after the menopause. Moreover, a serious nervous shock may at any time bring on an attack between menstrual periods, and if the patient becomes greatly debilitated from any cause, such attacks may be frequent. The pain in the head does not have any neces- sary relation with that in the pelvic organs ; it occurs in cases with no pelvic pains, and in those where such pains are severe in the extreme; pain in one region gives no immunity to the other. Another form of headache is that which follows acute indigestion and biliousness. A suddenly developed head- ache of a good deal of severity, often of a darting, crack- ing character, may follow overeating, or the devouring of indigestible foods, or stimulating foods and drinks. This is the headache of wine-suppers, banquets, and de- bauches. As nausea and vomiting frequently are a part of the attack it has been called sick-headache, which, as a descriptive term, is proper enough ; but this disorder differs widely from the periodical sick-headache already described. The headache of acute indigestion is of short duration, only lasting usually until the stomach is freed from its incubus, and has time for some degree of recuperation. Not only vomiting but purging as well (cholera morbus) may occur, it being a diarrhoea of acute indigestion which certainly exists in these cases. The eyes are often suffused and bloodshot, and the urine is dark-colored and highly charged with urates ; the voice may be hoarse, and temporary jaundice set in ; but these symptoms are generally transient, unless the abuse of the stomach is continued. Some persons have this form of headache from very slight dietetic abuses ; others seem to be proof 515 Headache. Headache. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. against it, and can eat and drink all sorts of indigestible things in the most reckless way, for a long time, with- out seeming to be inconvenienced. People are suscepti- ble whose powers of digestion and assimilation are but slightly above the every-day needs, and who have a sensi- tive nervous organization and great tendency to sympa- thetic nervous explosions, and in whom, therefore, the circulation in the stomach, and the action of the glands, are easily disturbed by nervous influences. Headache may be an almost daily, if not constant, con- dition in persons with the habit of so-called biliousness. The term is a misnomer as it is often used, since in many cases there is small evidence, or none, of any derange- ment of the liver or stomach. The morbid condition is more likely to be in the stomach than the liver, and dyspeptic headache would be a better name. In these cases there may be habitually a coated tongue, a bad breath, disagreeable sensations in the stomach, acid eructations after eating, and constipation ; the most con- stant of these symptoms being the acid eructations and gastric sensations. The patient awakens in the morning with a slight headache, which wears away during the morning; or the pain comes on gradually, later in the day, and grows worse till bedtime. Such is the fre- quent or daily experience of some people for many years together. The symptoms fluctuate ; variable periods of absence of pain occur, to be followed by others of severer suffering or prolonged seasons of steady mild headache, the severer seizures marking the times of greatest aber- rations of the digestive functions. Some of the more painful experiences resemble the paroxysms of periodical headache, or are identical with them, and disable the pa- tient temporarily ; but at all other times the degree of pain is hardly inconsistent with attention to the duties of life, and the patient bears it with a habit of stoicism. This form is usually free from the disturbances of the circulation, sight, and hearing so common in the period- ical headaches. In the severer seizures vomiting may occur, and unless improvement is prompt, duodenal con- gestion may supervene and jaundice be produced. A large number of nervous people have frequent, al- most habitual, headache from mental or bodily overwork, from the nervous strain of care and responsibility, from worry of mind, or from disappointment, grief, or other depressing emotions. This goes by the name of nervous headache. It may be paroxysmal or not. During a par- oxysm, which may last as long as an attack of sick- headache, vomiting may occur, although usually it does not, and the vomited material may be exceedingly acid. Photophobia, and all the disturbances of vision already referred to, may be present, as well as the sensitiveness to sounds as in the periodical headaches, and in some cases there are great general irritability and peevishness. This variety resembles sick-headache in several particulars, but differs from it in being more preventable by good regimen and the avoidance of mental perturbation. But nervous headache in many persons is never paroxysmal, always a daily, steady, not grievous pain, and the de- scription of the form last referred to might fit this, except for the fact that here the headache has no apparent rela- tion with digestive derangement, but a close one with distinctly nervous phenomena and susceptibilities. A large proportion of patients with nervous headache are women and children. The women are mostly those of weakly constitution, poor digestion and nutrition, with often more or less menstrual difficulty, of distinctly ner- vous, perhaps hysterical, temperament, which may be hereditary. But some of them are vigorous and have all the appearances of good health, and of these many take too little exercise, and are nourished and stimulated to plethora. The headaches of childhood, of which the variety just referred to forms a part, are more common and trouble- some than is usually supposed ; children doubtless have headaches before they are old enough to describe or characterize them, and later they suffer from nervous and sick-headaches and from other forms that are either laughed at or misunderstood by their elders. Some chil- dren have frequent nervous headache without overstudy, overwork, eye-strain, bad air, or particular indigestion. These are often the progeny of nervous or weakly peo- ple, and many of them have poor, weakly bodies, over- developed brains, and all the highly wrought sensibilities of adult life. They are top-heavy ; there is too much of the great nerve-centres, too little muscle, weak circula- tory apparatus, and poorly developed glandular struct- ures, especially of the digestive and excretory organs. In tubercular meningitis in young children, occasional violent darting pain in the head is a common symptom. It is sometimes an early manifestation ; for several days before other symptoms supervene there may be, in the intervals of the pain, no discomfort of any sort; the child plays about as usual till the pain recurs, when he stops, shrieks and cries for a minute, is quieted, and then resumes his play. A variation from the forms of nervous headache already referred to is that which is observed in school children and students. Many of these are emotionally nervous, dys- peptic, and debilitated, and constantly anxious about their studies. A proportion of them study and live in the stuffy atmosphere of illy ventilated rooms, which adds to the difficulty. Some have disorders of the eyes that provoke pain on close study. The headache usually oc- curs each day of study, and is absent or much reduced on the days of recreation. The pain rarely begins with the beginning of the day, but comes on gradually after some hours of work, to disappear after rest and sleep. Headache comes sometimes to men and women much given to worrying over the affairs of family and business. A state of susceptibility is sometimes reached in which the slightest concentration of attention, the fixing of the mind on business for a few minutes, is followed by pain. If the headache is severe there may be a flushed face and red eyes, a feeling of fulness in the head, slight vertigo, and possibly a staggering gait, tinnitus aurium, diplopia, and Hashes before the eyes-any or all of them symptoms that are more or less relieved by rest. These experiences, which point unmistakably to cerebral congestion, may con- tinue with fluctuations for weeks or months, till the pa- tient is forced to seek prolonged rest, or, failing in that, is overtaken by more serious disease. In a small propor- tion of cases meningitis is eventually developed, ending sometimes in mania or death. There is a headache of bad ventilation that might be called the carbonic-acid gas headache, if it was not for the probability that the lack of oxygen and the presence of other contaminations than carbon dioxide are partly responsible for it. The common experience of sensitive persons, after remaining an hour in a crowded audience- room with unchanged air, illustrates this form, as does also the headache with which such people rise in the morning after sleeping in closed rooms-sufferings that always disappear soon after reaching a wholesome atmos- phere. A great many people innocently attribute this latter headache to failure to digest a supper, or to bilious- ness, or some other equally foreign cause. Malarial cephalalgia is a form of paroxysmal headache that is nearly always unilateral and supra-orbital. The paroxysms have a periodicity as regular as ague ; they usually occur daily, begin abruptly, mostly about mid- day, last a few hours in great intensity, and pass off slowly, leaving a slight soreness of the region involved, which does not entirely disappear before the time for a subsequent seizure. At times considerable swelling, to some extent oedematous, surrounds the eye and covers the supra-orbital region, and the eye may be bloodshot; in exceptional cases the oedema closes the eye entirely. Fever rarely attends this form of malarial disease ; apart from the local symptoms the patient may feel well, and the disorders of the blood, liver, and spleen of malarial fever are wanting. If undisturbed by treatment the dis- ease may continue in the manner described for many days. Rheumatism may attack the musclesand fibrous tissues covering the skull, and cause pain and tenderness. This, however, is not a common occurrence even in rheumatic subjects. When it does occur it manifests the same sen- sitiveness to the movements of the barometer as other forms of rheumatism. 516 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Headache. Headache. Headache is a frequent symptom of such uterine dis- eases as ulceration, cervical and corporeal inflammations, and ovarian irritation and inflammation. It may be con- joined with other nervous symptoms or be the only one present. The pain is generally not severe, but may be almost constant, and is often confined to a circumscribed region of the vertex, where at the same time a sensation of heat and downward pressure may be felt. Some pa- tients complain bitterly of a sensation of beating in the top of the head, as well as in the chest in the neighbor- hood of the heart, or in the abdomen, and a few have slight vertigo. The suffering is liable to be a daily ex- perience ; it is seldom paroxysmal, and rarely continues through the whole of a day, but is chiefly confined to the afternoon, when the abdominal distention from gas is greatest. These patients are not specially obnoxious to paroxysms of headache at menstrual periods ; many of them menstruate with little or no difficulty. Nor are all the patients by any means debilitated or anaemic ; some are robust and ruddy, whose appearance disavows their complaints. Headache is often associated with constipation, especially when this is an uncommon condition. The pain is not paroxysmal, is rarely severe, is usually dull in character, and there is more or less inaptitude to good mental work, all of which symptoms clear up like magic on the dis- appearance of the constipation. Intercostal neuralgia frequently goes along with the headache, especially in women, and most in those who indulge largely in tea. There is a headache of hysteria, not so common as other symptoms of this many-sided disorder, but some- times extreme in severity, if the statements and outcries of the patient are considered. The pain fluctuates much, is rarely prolonged ; one moment there is the most vio- lent cephalalgia, next the complaints may be wholly directed to a distant part of the body, then the patient may declare that she cannot see a thing, and in a few minutes make movements quite inconsistent with blind- ness. Sometimes, after complaining of severe headache for a while, the patient passes into a convulsion or coma, from which she may be aroused, or may awaken spon- taneously, after a variable time, to renew her complaints of the headache. In various diseases of the brain and spinal cord there is more or less headache. Sclerosis of the cord, especially posterior and disseminated, is occasionally accompanied by pain in the head, rarely severe or of a sustained char- acter, usually momentary and piercing. Pain in the head is an unvarying accompaniment of certain diseases, chiefly inflammatory, of the brain and meninges, while its absence is conspicuous in others. In nearly all cases of meningeal inflammation of an acute character there is more or less pain ; sometimes it is quite severe and accompanied by a sense of snapping and ringing in the ears, and by optical illusions of flashing or sparkling light. In the severer cases the pain may be varied by occasional brief outbursts of mania or frenzy. Headache occurs in many cases of cerebral haemor- rhage with hemiplegia, and is a part of the clinical history of general paralysis ending in dementia. It is a more or less uniform symptom of tumors of the brain and meninges, and of cerebral abscess produced by any of the manifold causes of that lesion. Pain occurs in a ma- jority of the cases of abscess, and in most of the cases of tumor which develop rapidly ; tumors of slow growth may not produce symptoms. The pain may be at first distinctly paroxysmal, resembling the periodical head- ache, and becoming continuous afterward ; or it may be steady, constant, and unyielding from the first, and of all shades of severity from slight discomfort to the worst clavus. The pain does not necessarily correspond to the location of the local lesion ; it may be in the same re- gion or the very opposite, as when a tumor or abscess of the cerebellum induces pain in the forehead. Where the cause of the symptoms is such a pathological con- dition as caries of the petrous portion of the temporal bone from suppuration of the ear, or analogous lesion of some other part of the skull, the pain is generally most felt in the region involved. The pain is usually followed, sooner or later, by more formidable symptoms. Vertigo, roaring in the ears, mental hebetude or coma, vomiting, convulsions, and fever may come on, to be followed per- haps by various paralyses, sometimes complete hemiple- gia, and death. Headache is an almost constant symptom of many/eyers and other constitutional diseases. In typhoid fever, in the paroxysms of malarial fever, in most of the eruptive fevers, and in many irritative and inflammatory fevers, as well as in dengue and relapsing fever, headache is usually present to some degree, especially when the temperature is high. While the pain corresponds in some measure to the degree of fever, it may be present in the apyrexy. In various diseases causing a disturbance of the physio logical processes without fever, headache may occur. Thus in some cases of jaundice, dyspepsia, and mal-as- similation, with an abundance of urates and uric acid in the urine, there may be headache as well as pain in the back. Headache is prone to occur in anosmia, great debility, and bloodlessness. Girls with delayed menstruation and with chlorosis are liable to have it. When the debility is due to mal-nutrition the headache is more likely to be present, and in extreme anaamia due to this cause the pain is some- times almost incessant. It may be absent when the patient is mentally and bodily at rest, to break forth with perhaps a sense of great fatigue on slight exertion or mental ac- tivity. Sometimes the pain has a throbbing character, synchronous with the heart-beats. Headache is one of the later manifestations of syphilis. The pain is sometimes severe in the extreme and may be paroxysmal, although it is more apt to be continuous ; it occurs most at night. The patient locates the suffering in the superficial tissues of the head, the inner or outer surface of the skull. It may be unaccompanied by any demonstrable nodes or enlargements about the head, although these developments often exist in such cases. The head-pain may be the only symptom of the disease present. But other symptoms are liable in bad cases to supervene, such as dulness of intellect, loss of memory and of muscular power, and there may be deep stupor and photophobia. Astigmatism and hypersesthesia of the internal struct- ures of the eyes are occasionally attended with pain in the head whenever the eyes are much used for fine objects, or in a bright light (eye strain). The frontal region suffers most; generally there is no pain when the eyes are at rest, and there are frequently no other symp- toms. A considerable aggregate number of students are prevented by these conditions from scholastic pursuits. Headache in the occipital region may be simply a neuralgia of the occipital and cervical nerves, as in the anterior portions of the head it may be a neuralgia of the fifth pair. In either case the pain is localized, does not shift about, and is certainly superficial; usually points of tenderness in the track of these nerves are easily demon- strable. Following a sunstroke, sometimes for several years, one may be repeatedly harassed by headache from slight ir- regularities in life and health, and especially from expos- ure to the rays of the sun in summer. This sensitiveness wears away gradually, so that after a number of years it may be hardly noticed, but sometimes the victim never entirely recovers from the nervous shock of the insola- tion. Headache is a symptom of certain forms of Bright's disease ; of acute desquamative nephritis sometimes, but oftener of the slowly progressing interstitial nephritis. The headache may be only occasional and otherwise apparently causeless, a seizure lasting a day, perhaps, with a good deal of severity, or it may occur a part of nearly every day for many months, being most severe when the patient is overworked mentally or bodily. With it there are often a poor or an indifferent appetite ; constipation as a constant condition, or alternating with diarrhoea ; a coated tongue, and, during the height of suf- fering, prominent veins and arteries of the head. Traumatism of the skull, even slight fractures and trivial depressions from blows and bullet wounds, are 517 Headache. Headache. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. liable to be followed by a chain of melancholy symptoms, one of which is headache. This is often the first symp- tom, and may not appear for a number of months after the injured tissues are supposed to be well. Soon a sense of pressure follows, with numbness, and possibly formi- cation and aberration of circulation in the extremities of the side of the body opposite to the injury. The head- ache is rarely a severe, cleaving pain, but is more apt to be a steady sense of painful pressure ; it is not continu- ous, and is frequently exaggerated by fatigue, mental excitement, or hot sunshine. In some cases the patient becomes, by slow degrees, irascible, suspicious, and ec- centric ; epilepsy may occur, and seizures of mania with homicidal or suicidal tendencies. Finally, there are headaches that find no place in the preceding enumeration, and that defy all attempts to find their cause or explanation. These mostly occur, not in occasional severe paroxysms of short duration, or brief paroxysms at all, but in protracted, moderate suffering diffused over the head and lasting sometimes for a num- ber of days, and without particular variation in the dif- ferent hours of the day or in different kinds of weather. Some of these cases are unaffected by psychical or bodily activity, and are wholly independent of any discoverable disease. Etiology.-In any statement of the etiology of head- ache an organic predisposition or idiosyncrasy, heredi- tary or acquired, must stand first. This is the same whichever way it is acquired, and consists in an increased capability of suffering this form of pain from any cause, so that headache arises from influences totally incapable of inducing it in normal persons. There are persons who have this idiosyncrasy in so high a degree that they ex- perience headache, occasional or constant, from the nor- mal conditions of their environment, from the ordinary and unavoidable vicissitudes of life. They constitute a proportion of the cases of periodical and nervous head- aches, headaches from moderate study, trivial anxiety, and slight hygienic disarrangements. The predisposition, when inherited, may have been determined by the like idiosyncrasy of the parents, or by their constitutional debility ; by their lowered vitality and mal-condition, in- duced by general sickness, vice, excesses, some morbid state of the nervous system, as epilepsy or insanity ; or, on the female side, by too rapid child-bearing. The predisposition may be acquired by a multitude of influences, and, continuing long, tends to become perma- nent and transmissible. Simply a repetition of headaches may cause a predisposition ; one attack tends to another ; the nerve-centres disturbed in a particular direction are more easily so disturbed again than in another way. Pre- vious sickness of any kind, but especially of the brain and nervous system, acts in the same way ; so does ex- cessive use of the poisons to the brain, such as opium, alcohol, haschisch, and chloral. Headaches are produced often by overwork, too little variety in occupation, severe tasking of a particular part, too constant tension of the nervous system or the mind, and particularly the emotional side of it. Various dis- turbances of the circulatory apparatus and blood-supply of the brain and head lead to headache. Acute congestion of the brain and head may cause it; so may inflammation of the tissues, meningitis, tumors, abscess of the brain and its membranes, cerebritis, inflammation of the external tis- sues of the head, erysipelas, carbuncles and furuncles on the head, face, and neck, inflammation of the internal ear, and suppuration and caries of the bone. Anaemia also may cause it; anaemia from haemorrhage, starvation, alcoholism, organic heart-disease, various affections that directly induce the condition mal-assimilation, or any of the multitude of other influences capable of inducing it. In some cases of headache accompanied by a surging sound with each heart-beat-as well as cases in which the sound is experienced without the pain-there is reason for the suspicion that some of the cerebral arteries are per- manently enlarged, or that the nerves of adjacent tissues are particularly sensitive, since the trouble sometimes per- sists for years in spite of all treatment. Headaches are produced by poisons or harmful things in the blood, introduced or retained, or by blood unfit from the deficiency or excess of necessary constituents. Of the harmful things introduced there are : Various substances foreign to the body, which are found to produce head- ache in some doses in certain persons, as quinine, the sal- icylates, alcohol, tobacco, tea, and coffee ; various efflu- via ; gaseous or microscopic poisons like malaria, car- bonic-oxide and other poisonous gases, including some constituents of sewer air. In plethora there is an ex- cess of the normal nutritive constituents, which favors the occurrence of headache. Of harmful things retained there are: Effete matter from lack of excretion by the kidneys (uraemia), lungs (carbonic-acid gas), intestines, and probably the liver and skin. In plethora and gor- mandizing there may be such an excess of waste matters to be excreted that the normal function of the emunc- tories is insufficient to discharge it completely and regu- larly. The retention of dead material, in the physiologi- cal disturbances of general diseases, especially fevers, and of chronic alcoholism, doubtless is a factor in the causation of the headaches of such affections. Deficiency of oxygen in the blood, as well as an excess of carbonic- acid gas, is undoubtedly a cause of the headaches from poor ventilation. The proper balance of the substances of nutrition and decay in the blood, any serious disturbance of which may cause a headache, can hardly be perfect with disease or poor nutrition of any part of the body ; so local disease distant from the head, and lack of general exercise of the body, may produce this disorder. Many influences bear in an adverse way directly upon the head and brain. Cold to the head, or heat, as in fever; surgical injuries to the head, local disease of the head outside the skull, of the skull itself, of the mem- branes lining the skull, and of the brain itself; erysip- elas, eruptions, phlegmons, nodes, caries, meningitis, cerebritis, abscess, tumors, syphilis, are a few of such agencies. The sympathetic or reflex influences cause a large num- ber of headaches. These influences are almost number- less ; among them are biliousness, gastronomic excesses and vices, constipation, particular articles of food, uter- ine and ovarian irritation, and various localized inflam- mations and pains in parts distant from the brain. Emotional disturbance, when experienced during or directly after a meal, may stop digestion, lead to fermen- tation of the food, and so cause headache by reflex ac- tion. Emotional shock or perturbation may cause head- ache directly by its action on the brain-centres, or the sympathetic system, or both. Preputial, vaginal, and vulvar irritations are by no means infrequent in children, and when they continue long, as they often do, invariably cause more or less gen- eral nervous and emotional erethism and proneness to headache. Pathology.-The seat of pain differs in the different forms of headache. Its location in particular nerve areas as a neuralgia is, in certain forms, very evident, as, for example, in the supra orbital headaches of malaria, and in those due to local injury or disease on the outside of the skull. The explanation and localization of the peri- odical headaches is difficult or impossible. After all the study, observation, and experimentation that have been given to the subject, the exact location of the pain is a matter of conjecture, and the explanation of its occur- rence is hardly more satisfactory. One view locates the pain in a single division of the fifth pair of nerves ; an- other in the intra-cranial branches of all three divisions- the minute branches distributed to the dura mater ; an- other in the sympathetic nerves exclusively; another in the cerebral centres and cortical substance, "neu- ralgia cerebralis ; " another in the muscular fibres of the walls of minute blood-vessels (of course meaning the nerves of these blood-vessel walls), that are in some cases in a condition of spasm during the suffering, espe- cially in hemicrania. Nor is the explanation of the suffer- ing any more satisfactory. One opinion holds that in hemicrania, for example, the pain must be produced by spasm of the blood-vessels on the side affected ; another. 518 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Headache. Headache. that dilatation of the vessels, paralysis of their walls, causes it; another, that either of the views stated may be correct in certain cases ; still another, that the pain is a ' ' nerve-storm traversing " the brain-centres-an explana- tion that would be excellent if it did not itself quite as much need to be explained. Certain phenomena of the attack, taken in connection with physiological considerations, tend to confirm each of these theories. The affected side of the face and head in hemicrania is sometimes paler than the opposite side, the eye is slightly sunken, the temperature of the part is lower, and the arteries are small and cord-like. These facts all point to a contraction or spasm of the vessels of the suffering side. But the affected part is, on the other hand, sometimes more red than normal, swollen, and con- gested ; the conjunctiva is injected, the vessels of the fundus of the eye are dilated, and the temperature is higher than that of the other side of the head. This com- mends the theory that paralysis of the vaso-motor nerves causes the pain. In other cases there is no apparent change in the circulation in the painful side. In some attacks, during the intensity of the pain, the pupil on the affected side is dilated, a fact that speaks for the involve- ment of the sympathetic, since the nerves controlling the dilator muscular fibres are said to belong to this system. In other cases the pupil is contracted, a fact which points to the partial or complete paralysis of the nerve-fibres re- ferred to. The extreme, and sometimes unilateral, sweat- ing is distinctly a phenomenon of the sympathetic, as is also the marked coldness of the extremities which char- acterizes so large a proportion of cases of headache. Taking into account all the facts in this curious class of headaches, the notion seems irresistible that the char- acteristic pain is located entirely within the cranium. Whether it is in the nerve-centres of the brain or in the nerve-fibres distributed to the intra-cranial structures surrounding the brain is a matter for speculation in re- finements which it is perhaps hardly profitable to pursue here, although it is a suggestive fact that the pain is often located by the patient in the surface region of the brain. The thought that brain-centres may ache embodies no pathological inconsistency, since all pain, as a form of con- sciousness, must be perceived by nerve-centres and by cerebral nerve-centres. We attribute different varieties of pain to different parts of the body, often distant from the nerve-centres, as the points where pathological condi- tions exist-the cause of the pain, as we put it-and we say the pain is at that point or this ; but the consciousness is, all the same, centric, and the only difference notable in the periodical headaches is that the pain is referred to regions in the neighborhood of the centres themselves. .For all there is known about the matter, there may be in these affections no difference in the condition of the cen- tres from what exists when a pain is located in the sciatic nerve. In explaining the recurrence of periodical headaches, the theory seems rational that supposes a nerve explosion or storm to occur at stated intervals, regardless of excit- ing causes, as the centres reach a climax of accumulation or exhaustion of energy or of some force or principle. Such an unavoidable recurrence is exactly what happens; a seizure will come when the time is ripe for it, whatever is done to prevent it. But even the subjects of sick- headache and hemicrania find seizures often provoked by errors in regimen, by deprivations and excesses of vari- ous kinds, most or many of which are preventable. The explanation of reflex headaches is nothing more nor less than the explanation of reflex pains of other parts of the body, and may be omitted here. The headaches produced by known diseases of the tis- sues of the head are in the main easily enough explained. Tumors, whether syphilitic, cancerous, bony, or other- wise, developing in or about the membranes of the brain, produce pressure upon, and stretching of, these tissues, and pain in their nerves, rather than in the deep centres of the brain. When this condition occurs the pain is li- able to be continuous, although, if the lesion is syphilitic, the suffering is nearly always worse at night. Thicken- ing of the dura mater, as well as of the periosteum, may occur from syphilis, and whenever a considerable surface of the former is involved in this change the brain-tissues are sure to be affected to the extent of producing other symptoms besides pain, and among these are mental apathy and muscular weakness. In the headaches induced by business and personal cares and troubles, in which mental excitement and a flushed face occur, there is doubtless always cerebral hyperaemia-true active congestion ; yet there may be no evidence of the fact post mortem in cases that result in death, even when severe delirium existed, beyond very slight enlargement of the vessels and puncta vasculosa, and even this may be absent. Diagnosis.-The only practical question in the diag- nosis of headaches is that of their causes. This question is often presented to the practitioner, and is often per- plexing. A study of the history of the patient, his environ- ment, occupations, habits, and regimen, will generally enable the practitioner to hit the explanation of the head- ache. The mistake frequently made is to neglect some of these considerations in some of their details. It should be understood that no minutiae are insignificant or to be ignored. The patient must be interrogated in detail, spe- cifically, as to all these topics, in such a way as to tax his judgment as little as possible, and as not to suggest his answers. For example, it will not do to ask the patient to describe his habits of eating and drinking, and whether he has discovered any bad results from them. He must be asked to name the articles he eats and drinks for breakfast, dinner, and supper, respectively ; as to the cooking of any of them, and the temperature at which they are taken, the amount of each kind which he devours, and the time he takes at his meal in each case ; as to his sensations before and after eating, and the frequency, character, and amount of his al vine evacuations. We must know whether he eats between meals, and if so what and how much ; and what and how much stimulating drink he takes, and at what times, and with what sensations and experiences. If the character of the case has any obscurity, the in- vestigation in all its particulars must be as minute and painstaking as here indicated. There should be learned the family history of the patient ; his own complete health history; the details and hours of his work and study; the character and extent of his recreations and sleep ; his sexual habits, if any ; the hygiene of his sur- roundings ; his family relations ; his moral and emo- tional atmosphere ; his appetite, and food and stimulants of every sort ingested; and the medicines and poisons which he may take, wittingly or not. The condition of each of the important organs of the body should then be inquired into, as to the character of function performed, and for pathological changes; particularly should the brain, spinal cord, eyes, ears, teeth, stomach, bowels, kidneys, and sexual apparatus be studied carefully. The relation of the headache to the weather must be learned, as well as to any general disease or disturbance of the system. The urine ought to be examined for evidence of Bright's disease in all cases of chronic headache not otherwise easily explained. There may be no oedema or albumin in the urine, the sole proof of the disease being the discovery by the microscope, in the sediment of the urine, of cylinders and epithelium from the tubules, and epithelium from the pelves of the kidneys; and these elements may be so few as to elude any search that is not careful and made after the specimen, antisepticized, has stood still for twenty-four hours. Every case must be studied by itself, and not infrequently, after the most careful scrutiny, the discovery of the cause of the head- ache must be left to the result of treatment or regimen. A few large doses of quinine may stop the headache ; or omitting tea or coffee for a month may be followed by partial or complete cessation of it; or going to bed earlier for a month, or the cessation of evening reading or so- ciety, may succeed ; or antisyphilitic remedies, or a tonic for gastric digestion, or more out-door exercise. The diagnosis in headaches of childhood requires a somewhat different study. If a headache persists in peri- 519 Headache. Headache. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. odical attacks it may be the hereditary trouble already described. The influences that increase, and the changes in living that will reduce, the force and frequency of the attacks should be learned if possible. Every chronic case must be scrutinized for the influence of the emo- tional excitement of too much society, which is the bane of some child-lives, for over-study, eye strain, over-strife at school, bad air, pudendal irritation, and, the most common difficulty of all, bad digestion, so often over- looked, and over-stimulation with condiments, tea, and coffee. Experimenting with and varying the dietary in manifold ways will often enable one to discover the diffi- culty-a discovery sometimes not otherwise possible. In all persistent headaches the patient should be inter- rogated as to whether he has had pain in either ear, or ear-discharges, or deafness. Severe pain in the head of a child or adult, with nausea, vomiting, and constipa- tion, if long-continued, suggests meningeal irritation or inflammation. And all severe headaches that are contin- uous, and rebellious to all treatment, are almost without exception due to organic disease within the cranium. Fever, arising after some days of rather continuous se- vere headache, unless this can be otherwise easily ex- plained, strongly suggests intra-cranial disease ; although typhoid fever is the diagnosis most likely to lie reached on a cursory examination of such a case. The occur- rence of some clumsiness of speech, or vomiting unre- lieved by the evacuation of the stomach, or both, would make the diagnosis positive. Treatment.-The first step in treatment is, if possible, to remove the cause if it is known. Nothing could be more irrational than a routine administration of medicine, or, in general, the giving of any medicine at all, to quiet the suffering, without attempting to correct the cause when this can be done. And yet such is a very common way of doing; medicines supposed capable of stopping headache are swallowed in enormous quantities by pa- tients who do nothing further or better. There is cer- tainly no objection, during an attack of headache, to seek- ing relief from the suffering by anodyne medicines, but the contrary. The thing objected to is the common practice of allowing many attacks to occur in succession without efforts to prevent them. Many of the forms of headache already described are susceptible of prompt relief or entire cure by timely and sensible regulation of the life of the patient, his habits, surroundings, the influ- ences of occupation, and the like ; by the correction of diseases and disorders on which the headache depends, and by the removal of very patent causative influences. In these various ways may be influenced the headaches of indigestion, biliousness, and constipation; of cerebral overwork and emotional excitement; of insolation and eye strain ; of many cases of debility, of bad ventilation, malaria, and over-stimulation of various sorts ; of uterine and ovarian disease, and of syphilis. The proper treatment of the periodical headaches is di- vided into three sections : the treatment of the interval between the attacks, of the premonitory symptoms, and of the attack itself. In all habitual headaches-the ner- vous, bilious, and dyspeptic, as well as sick-headache, hemicrania, and migraine-the principles of management and treatment are substantially the same ; the differences are matters of detail. 1. The Treatment of the Interval.-During the interval, the double purpose should be had to reduce gradually the permanent predisposition if possible, and to lengthen the intervals between the attacks ; it is useless, generally, to attempt to stop them altogether. To reduce the idiosyn- crasy the system should, if possible, be brought up to a normal condition of vigor in all its organs and functions, and so maintained, and all those influences which tend to invite a seizure should be removed or lessened if they can be. Any prolongation of the intervals of the attacks reduces the organic predisposition to them, since the idiosyncrasy is intensified and maintained by the repeti- tion. A large number of such patients are constantly below the physiological standard, and require tonic regimen and treatment. If this can be had for a long time, the form of medication being changed occasion- ally, and if the excretions can be kept active, the at- tacks may often be somewhat reduced in number, unless at the same time the rules of good hygiene are defied. This unhappily is the case with many such persons, and nothing but a complete change in the sanitary character of their environment, and a resolute cutting oft of all bad habits of regimen-including the use of all pastry and foods difficult of digestion, and stimulating condiments, beverages, and such things-will be followed by any sub- stantial gain. Coffee and tea induce or prolong many cases of sick-headache, coffee being probably fourfold worse than tea. Many other nervous symptoms are produced by these beverages, but the headaches are the most serious. A victim of any sort of headache who uses coffee, should omit it for a month and note the effect. The result will be, in a large minority of cases, more or less lengthening of the interval between the attacks, and an amelioration of these both in severity and duration. This result will follow the omission of tea and tobacco less often, but often enough to warrant the trial. Cessation of the habitual moderate use of coffee is sometimes followed by surprising improvement, even in cases in which the headache began, and became habitual, long years before the coffee habit was acquired. If no improvement follows the continuous abstinence from the beverage for thirty or forty days, probably none will fol- low a longer trial. The deprivation of coffee or tea for a day, or even a single meal, may in sensitive persons cause an intense paroxysm of headache. This experience may be taken as an indication that the nervous system has reached a baneful dependence upon the stimulant, and that it ought to be abandoned altogether. As an attack of headache is often precipitated by emo- tional and nervous excitement, the intervals may be pro- longed by avoiding such perturbations. The patient should live a life of perfect tranquillity and freedom from nervous turmoil, if possible ; recreations should be had, vacations and rest, but they should always be without excitement, and the greatest possible amount of sleep should be obtained. Doubtless the intense ri- valry, push, and pressure of the time, both in business and for preferment-influences that spend themselves mainly on the nervous system-are responsible for some of the increase of headaches of the last few decades, es- pecially in this country. For those who have acquired the headache habit these agencies should be reduced, and kept by a sustained effort at a minimum. While the forms of headache under consideration can probably rarely or never be entirely cured, they certainly can, by proper care and regulation of the habits of life, be greatly amelio- rated. The hygienic treatment is much more difficult to carry out than the medical; patients, in the intervals, are usually so well, that it requires a good deal of self-con- trol to avoid eating, drinking, and doing the things that even the patient knows invite the headache. Tonic treatment, with some product of calisaya bark and strychnine, is the best. The doses should be moder- ate, one grain of quinine, and one-sixtieth (/0-) grain of strychnine being sufficient, and it should be long contin- ued if it agrees with the case. Where this combination disagrees, some other bitter tonic may succeed well. Iron agrees with some patients, and disagrees with others; with some its first effect is good, and its secondary effect an annoying sensation in the stomach and constipation of the bowels. With the tonic medicines, laxatives, which in moderation often act as tonics to the intestines, may frequently be given with much advantage, since many of the subjects of these forms of headache are habitually constipated. The laxatives should be such as will act without pain ; they should be taken daily, and in doses too small to cause purging, one free, natural evacuation daily being enough. Medicines which fulfil these indica- tions may be used without harm as long as they continue to be efficacious ; the popular notion of the banefulness of the habitual use of laxatives in this way, and for this purpose, is entirely groundless. Of the saline laxatives the sodium salts are to be preferred, the sulphate being probably the best. Several of the mineral waters which 520 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Headache. Headache. contain a large proportion of these salts have a happy effect in many cases when used regularly. Of the vegetable laxatives, aloes, rhubarb, colocynth, senna, podophyllin, cascara are efficacious in various combinations and doses, which have to be determined by trial in each case. The addition to such a combination of nux vomica or strychnine is usually advantageous, as also is belladonna in many cases. 2. Treatment of the Premonitory Symptoms.-When the premonitions of a paroxysm of headache begin to be felt, efforts to abort it are sometimes successful, sometimes, futile. A patient may from some change, accidental or designed, in the conditions of life find an occasional parox- ysm pass by with only these feelings ; and as the habit of recurring headaches wanes with the later physiological evolutions of life, this is often the change first noticed; the seizures come to be represented by the premonitory symp- toms only. The attack is sometimes preventable by man- agement, at others by medication; all cases cannot be dealt with alike, they must be treated differently. Some pa- tients find they can abort an attack by shutting themselves in a quiet, dark room, and resting-sleeping, if possible -till the time for the seizure has passed by. The pro- cess is aided in some by totally abstaining from food and drink from the moment the premonitory sensations be- gin till they cease entirely ; others find that such a course aggravates these symptoms and hastens the full force of the paroxysms, and that eating heartily of highly spiced foods may ward off the attack. Some patients find comfort in gentle and long-continued exercise of the lower extremities, as in a long, slow walk ; violent walk- ing or other exciting exercise nearly always aggravates the suffering and hastens the paroxysm. Patients in this stage almost invariably have cold ex- tremities, especially cold feet and legs, and are greatly relieved by artificial heat to these parts. For some pa- tients the most potent and comforting remedy of all is a bucket of very warm water, into which the lower extremi- ties are plunged to the knees and kept for an hour. A prompt purgation may abort an attack-it may have no effect whatever ; and if the premonitory feelings come on immediately after a full meal, free emesis, produced with little nausea or straining, may have the same effect. A saline purgative often has a happy effect, but it may be rejected by the stomach ; a mercurial purge is rarely vomited. A full dose of guarana, or of some bromide, of valerian, asafoetida, or caffein, may help to ward off an attack ; or a cup of strong coffee or tea, or a dose of whiskey or other alcoholic stimulant, may do the same thing for per- sons not addicted to their use ; or a full dose of chloro- form, the spirit of chloroform, or the compound spirit of ether, or the aromatic spirit of ammonia, may accomplish the purpose. For many of these medicines the patient has, in the presence of the premonitory symptoms, a strong repugnance, and they are apt to cause nausea and vomiting. Acids and alkalies have these effects less often, and, curiously, each of this class of agents is capable in certain cases of driving away the symptoms and post- poning the attack. The alkalies seem to help more cases than the acids, and an excellent way to take them is in carbonated water. Here, again, the sodium salts are the best. It is a great advantage, in these cases, to have medicines administered in effervescing draughts ; such are often retained when otherwise they would be vomited, and the little carbonic-acid gas is very grateful to many qualmish stomachs. The arts of pharmacy have of late made it possible to administer many of these medicines in this manner, to the comfort of most patients. A few, especially children, object to them, on account of their bulk and the formidableness of the effervescence. 3. The Treatment of the Attack.-Frequently the sever- ity of an attack of headache can be somewhat reduced by judicious treatment; sometimes nothing the patient can or will do has any particular influence-the seizure runs its course like a fit of epilepsy, and ends in the usual time. Many measures already referred to as valuable for the premonitory symptoms are efficacious here, such as abstinence from food (except in the rarest cases, where the opposite avails), evacuation of the stomach of undigested food and mucus, alkalies for the gastric acidity so com- mon, a quick cathartic, perfect rest of mind and body, freedom from worry, freedom from light, and heating the feet and legs thoroughly with hot water. The last-named measure is sometimes enough to assist greatly in procuring sleep and thus oblivion from pain. Sometimes cold ap- plications to the head and evaporating lotions lessen the pain, and a few patients are somewhat relieved by very hot applications. A bandage drawn tightly about the head just above the eyebrows is a remedy used for centuries, and often with good effect. For the direct relief of the pain the medicines are few and their value small; the ano- dynes, commended for the premonitory symptoms, are of some value in the seizure ; but a serious drawback to their successful use is, in addition to the great liability of their being vomited, an acute catarrh of the stomach, which is very liable to coexist with the headache, and which sometimes almost entirely prevents absorption at the moment when it is most necessary. A large dose of some bromide, guarana, caffein, or some of the prepara- tions of chloroform and ether, or the aromatic spirit of ammonia, or a cup of strong tea or coffee, may reduce the severity of the suffering, but will fail to stop it en- tirely. These agents are much more efficacious in cases of nervous and dyspeptic headaches, and in the pre- monitory stage of the paroxysmal variety, than in the fully developed paroxysm of the latter. Since the pa- tient often awakens from slumber free from pain, chlo- ral to procure sleep is an eligible medicine. When the stomach is at all disturbed or uncertain the best means of introducing the drug is by enema. For the sick-head- ache of children this is often a most successful treat- ment. The child will fall asleep from his dose of chloral and awaken well. Attempts to stop the nausea of an attack are generally futile until the stomach is evacuated, and the more thoroughly it can be evacuated the better. If then the nausea persists, it may often be quieted by a large dose of bismuth or the aromatic spirit of ammonia, or by a draught of very hot water. In paroxysmal headaches opium and its preparations should be advised with great caution. They disagree with many patients, and where they fit the case and give great comfort, as they sometimes do, the opium habit may be acquired. For the headache of fever some relief may often be se- cured by reducing the temperature of the body, or of the head, or both, by the use of cold applications and evapora- tions from the surface. When this cannot be accomplished, some anodyne medicine may properly enter into the gen- eral treatment. The best is some mild preparation of opium, like the camphorated or deodorized tincture, and large doses are rarely required unless the fever is due to inflammation of the tissues of the head outside or inside the skull. These conditions, contrary to a widespread notion, do not contra-indicate the use of opium when called for to stop headache. It is often desirable to com- bine with the opium belladonna or atropine, or, what is perhaps as desirable, hyoscyamus or hyoscyamine. In some cases of insomnia with headache, with or without delirium, the alkaloidal preparations of hyoscyamus are eligible remedies. For the headache of fever and some other general con- ditions, the bromides are sometimes sufficient to give com- fort, but usually they are required in large doses. Where insomnia is a disagreeable symptom in conjunction with the headache, both may sometimes be helped by chloral in doses sufficient to procure sleep. In such general con- ditions as anaemia from known or unknown causes, the pain is frequently aggravated by cold applications to the head and relieved by hot ones, or by a tight bandage to the head. This is the case also with quite a proportion of cases of nervous headache, as well as migraine in per- sons of nervous temperament, who are more or less de- bilitated, and of many cases of hysteria, or a condition analogous to it, in which severe pain vibrates rapidly be- tween the head and other parts of the body, and in which the head-pain, while somewhat constant, yet comes in 521 Headache. Head, Wounds of. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. waves of severer suffering every few minutes. Not only in these cases does pressure on the head sometimes give comfort, but pressure elsewhere ; pinching or squeezing firmly the hands, wrists, legs, or toes may give instant re- lief to the headache. The relief is generally only mo- mentary, lasting at best while the artificial irritation is maintained ; but occasionally it is permanent, and drives away the attack altogether. In all this class of cases -the headaches of anaemia, debility, nervousness, and hysteria-anodynes are often required. As their use may be prolonged, such medicaments ought to be selected as will least disturb the functions of the system. Among the safest are the bromides, guarana, caffein, valerian, and hyoscyamus ; great caution should be observed in the use of opiates. The proper treatment of nervous headache, not peri- odical, in both adults and children, corresponds some- what closely with that for the intervals between the attacks of periodical headache. When the nervous headache is habitual, there is even more necessity of securing tran- quillity of the nervous system, of keeping emotional per- turbations at a minimum, except the pleasurable ones, and even these should never be exciting. The duties of life should be as free as possible from worry of mind and bodily exhaustion, and the largest possible measure of sleep should be obtained. Here, too, careful trial should be made of omitting all stimulating foods and beverages, and of changes in the regimen and habits, and the patient should live in the way by which he can escape the most headaches. If the system is below a fair standard of health, tonic treatment must be instituted. It should be continued for a long time, and may include a wide range of agents -quinine, iron, strychnine, the malt preparations, the hy- pophosphites, cod-liver oil emulsion, peptonized or not, and others. A tonic in moderate doses, continued long, with occasional variations in the preparations, is much better for such cases than a more powerful one which can only be used a short time. The headache of hysteria is often due more to debility than to any other one cause, and a long tonic course of treatment, with the addition of a change of scene for a number of weeks at a time, if possible, should be instituted. If there is plethora, over- feeding, and lack of exercise, a low, unstimulating diet with abundant out-door exercise are better than medicine. The dyspeptic headaches are to be relieved by correcting the dyspepsia. While this may generally be done by a study of the behavior of the digestive organs with a vary- ing dietary and regimen, still in most bad cases the sim- plicity of diet is not sufficiently sought. The best way to begin is at the bottom, if the patient will consent to it; put him on a simple invalid diet of stale bread with milk and cream, taken in small quantities very slowly, and oftener than the regular meal-times, nothing in addition to this being swallowed unless it be water. Some other invalid diet may be chosen should this disa- gree, as meat preparations, eggs rare or raw, or gruels peptonized with the pancreatine preparations if neces- sary. A slight digestive tonic may be added if it seems called for-the quinine or the simple bitter, with strych- nine in small doses-and any constipation must be cor- rected. If there is catarrh of the stomach, benefit may be derived from a dose of some simple alkali dissolved in a draught of hot water and taken just before eating. This measure gives comfort in cases not supposed to be gastric catarrh, but simple atony of the peptic glands. This course will in most cases soon correct the dyspepsia, and the headache will vanish, but the patient may long for a different diet. Then such additions and variations may, step by step, be made to the dietary as will in no way disturb the digestion or bring back the pains, and yet a diet in the highest degree nutritious and pleasant be soon reached. There is no objection to the indefinite continu- ance of needful laxatives in these cases, nor of repeated recurrence to the gastric tonics and aids to digestion-the fault is in the neglect of these measures. Neuralgia of the head requires treatment similar to neuralgia elsewhere, except that due to malaria, which usually stops as soon as the system is brought under the full physiological effects of quinine. Recurrences are not as liable to follow as is the case with other forms of malarial disease. The headaches of childhood require special study and consideration. Children can but poorly describe their sensations, and cannot reason about them. Hence the causes of the headache must be discovered and corrected with small assistance from the patient. Several mistakes are common both by parents and doctor. Because they do not dwell upon all its sensations and variations, children are supposed to have indigestion very rarely, when, as a matter of fact, they often have it in one or other of the divisions of the alimentary canal, and the cor- rection of it will frequently be followed by the disappear- ance of headaches as well as a dozen other annoyances of various magnitudes, such as skin eruptions, pruritus, symptoms of "worms," so-called growing-pains, and many other disagreeable sensations. Then, irritation of the sexual apparatus as a cause of headache, as well as great nervousness, irritability of temper, and even slight paresis of the legs, is frequently entirely overlooked by the practitioner and neglected by the parents, who often know of its existence, but do not think it necessary to tell the doctor about it. The irritation can easily be cor- rected in most cases in the female by cleansing vaginal injections and soothing applications to the irritated re- gions of the vulva, and in the male by liberation of the phymosis by cutting or stretching the prepuce, and by perfect cleanliness afterward. Another mistake made with many of the weakly children is in the notion that they must be kept in school and must keep up with their classes, and that somehow out-door air is harmful to them. The fact is, these headache patients should spend as much of their time as possible out of doors ; when indoors they should always be in well-ventilated and well-lighted rooms, and their race for an education is of trilling mo- ment, compared with their vigor of body. The whole basis of management of a large class of such children needs to be changed radically. The headache of the menstrual period, when the parox- ysms occur at these times only, may best be treated with anodynes in positive doses. A mixture of morphine and atropine, or some other opiate in a full dose, will fre- quently ward off or stop an attack. This end may also be accomplished by compound spirit of ether, or valeri- anate of ammonia, if the doses are taken in rapid succes- sion. The most common domestic remedy in many quar- ters is gin, or some other alcoholic stimulant, which is often taken in intoxicating quantities. It lessens the sense of suffering, doubtless, as it benumbs the senses gen- erally, but it is much less rational and efficacious than the preparations of opium and ether. The headache of cerebral congestion or hyperoemia, with which there are in some degree a flushed face, red eyes, sensations of fulness in the head with tinnitus aurium, and possibly vertigo, calls for treatment that will, if pos- sible, reduce the amount of blood in the vessels of the brain. The best medicines to accomplish this purpose are perhaps the bromides and ergot. These may be given freely, and to be of value must be given in relatively large doses, and may be continued for a number of weeks without harm. The habit of continuing these drugs in large doses for several months, without cessation, is a bad one, for then they probably for the most part cease to ex- ercise a good effect, and may do harm. During the severity of the suffering the head should be elevated, and be kept cool by the local application of cold or by evaporating lotions, and the patient should be scrupulously kept from all excitement of every kind. After the severity of the headache is over, and the con- gestion is evidently ebbing, gentle bodily exercise is often of the greatest value, but the brain ought to be kept at rest for a long time. The headache of inflammatory diseases of the brain and spinal cord requires bromides, chloral, hyoscyamus, and opiates, with cold to the head sometimes, and heat and friction to other parts of the body. When the head- ache is not inflammatory in character, medicines con- taining opium in any form should be withheld, as far as possible, since, from the chronicity of a large proportion 522 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Headache. Head. of the cases, the opium habit becomes easily established. In the chronic cases, however, an occasional paroxysm of great suffering makes the use of opiates, even hypodermi- cally and in full doses, positively demanded. Headaches of Bright's disease are most satisfactorily re- lieved by lessening the product of urea in the body, in proportion to what the kidneys are capable of excreting. This is accomplished by reducing the mental and bodily exercise ; continuous rest, in bed if need be, and freedom from mental annoyances accomplish the best results. Paroxysms, and days of unusual suffering, require the various anodyne medicines already referred to. Many cases of headache cannot be relieved by remov- ing the cause. Often the patient is unable or unwilling to help do this, and often the doctor fails to discover how to do it. While the patient is suffering he asks to be, and ought to be, relieved. Palliatives must be used frequently; the bromides, guarana, valerian, hyoscyamus, cannabis in- dica, caffein, camphor, ether, chloroform, ammonia, and opium, must be employed in various ways and combina- tions. To have to use such remedies, except on the rare occasions of severe seizures of headache, is most unfor- tunate ; on such occasions they ought to be used. A few patients, in order to have any degree of comfort, are, or think they are, obliged to haT e daily recourse to such drugs for many weeks at a time. A proportion of these can be helped by some of the various local applications, regulations, and hygienic influences already referred to, and these should always be tried before medicine. Norman Bridge. cold applications, or, if not seen till after swelling and ecchymosis have taken place, then hot applications con- stitute all that is required. Upon a superficial abrasion some antiseptic should be used. Any ordinary effusion of blood between scalp and bone will be checked, and then reabsorbed, under this treatment. The hair may be cut short or shaved if required ; this should be done if the wound has been in any sense severe. If effusion be very great, and apparently unchecked after prolonged trial with simpler measures, then it would be right to make a free incision, turn out the fluid or solid blood, search for bleeding vessels, twist them or tie them with catgut, cleanse thoroughly, wait till all bleeding has stopped, and then neatly approximate the edges of the incision with fine silk or catgut, with the insertion of a few threads of horse-hair or catgut for drainage, and with a firm compress over all. Of course all this should be done under antiseptic precautions, with clean hands and instruments, etc. Small punctured wounds need only antiseptic occlu- sion after their freedom from foreign matter has been secured. Small instruments and weapons sometimes make small punctures, yet wound a vessel of some size. Nu- merous cases of aneurism of terminal vessels have been reported from such causes. From such a wound haemor- rhage would be free, while it would be easy to recognize whether an artery or a vein, or both, had been injured. If a vein, pressure wrould in most cases suffice; this should be made a part of the antiseptic occlusion, being main- tained by an elastic bandage or by some mechanical de- vice. But if an artery be w7ounded and such pressure be in- sufficient, it should be included in a deep suture or oc- cluded by acupressure. This might need to be done on cither side of the cut, which should then be cleaned and occluded as before. In other cases it might be well to clip off the hair, shave the part, and enlarge the opening so that the bleeding vessel may be caught and secured. Extensive lacerations or complicated incised wounds are often received, by which large skin flaps are torn up and the periosteum stripped rudely off, and yet with only temporary concussion or " stunning." In such cases the attendant should satisfy himself that the bone has received no such injury as may call for operative interference. He should first check haemor- rhage, next shave the parts, and then, with sponge and forceps, address himself to removing every particle of dirt and every loose hair. Shreds of tissue whose vitality is doubtful had best be removed. It then only remains to close the wound. If periosteum have been torn and raised, it is best to readapt the torn edges with fine cat- gut sutures. Then the superficial wroifnd edges are care- fully approximated by silk or catgut sutures, continuous or interrupted. At each angle a stitch may be omitted for the escape of serum, or a few catgut threads may be inserted for capillary drainage. In the dressing of such wounds, gentle compression should be so exerted as to compel approximation of raw surfaces. For small wounds collodion makes a very ser- viceable application, the parts being first thoroughly dried and dusted with iodoform. When a moist dressing is used about the scalp or hairy face, the writer usually prefers a glycerine dressing ; that is, some such preparation as boro- glyceride, sublimate-glycerin fide Antiseptics in Sur- gery, vol. i., p. 262), or iodoform and glycerine, since whatever serum exudes from the wound will be readily taken up, and the dressing cannot dry and so stick to the parts that its removal will be very unpleasant to the pa- tient. For all dressings about the head, the writer esteems naphthalin very highly, since it seems to be particularly prophylactic against erysipelas ; the latter- being more common after head injuries than after those of any other part of the body (vol. i., p. 264). Should there be any special reason to fear inflammation, as meningitis, an ice-bag may be applied outside the dressing. Cases occasionally occur where some part, or nearly the whole, of the scalp has been torn off or torn loose, as by machinery or " scalping." If the patient be seen in HEAD, WOUNDS OF. Certain features in the anat- omy of the skull are of great surgical importance w'hen considering the nature and occurrence of wounds of its component bony parts and of injury to the brain. The periosteum of the cranium-called usually the pericrani- um-is not thick, but is strong and resistant. Except over the sutures and the great foramina, it can be easily stripped off, or even made to glide over the bone ; though in the aged its connection with the underlying bone is more firm. It is nourished principally by vessels from the bone. The internal periosteum of the cavity of the cranium is the dura mater, wfliich is thicker and tougher than the pericranium. Concerning the cranial bones themselves, it should be remembered that the diploe ex- ists only during middle life, and is not to be found in the very young or very old. The amount of space which the frontal sinus may occupy should be always borne in mind. Of great importance are the connections which the veins of the superficial soft parts enjoy with the deep sinuses and the veins of the diploe through the emissaria Santorini. The most important of these anastomoses arc: 1, Among the occipital veins, which connect w ith the lateral sinus through the mastoid foramen ; 2, along and around the interparietal suture, especially its poste- rior extremity, where numerous openings connect with the superior longitudinal sinus; 3, the ophthalmic veins, ac- cording to Sesemann's investigations, empty into the cavernous siuus as well as into the facial veins. It will thus be seen that the sinuses of the brain have their over- flow outlets, or " waste weirs," in abundance. Never- theless, this freedom of venous connection enhances ma- terially the danger from pyaemic or thrombotic trouble in cases of erysipelas or phlegmon of the external soft parts. It will be well, at the very outset, to give here the great- est possible prominence to the classical dictum (so often ascribed to Sir Astley Cooper, but really clearly enunci- ated by Hippocrates) : ' ' No injury to the, head is too slight to be despised, nor too severe to be despaired of." There is a great temptation to ignore trivial scalp-wounds, to in- sufficiently cleanse them, or to carelessly dress them. If nothing else teaches the danger of carelessness in these cases, the experience gathered from the sword-duels of German students should be convincing, since each year several deaths are caused by comparatively trivial scalp- or face-wounds. Superficial Wounds.-Bruises and contusions need only slight attention besides rest; evaporating lotions, 523 Head. Head. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. time an effort should be made to replace the loose por- tion. Astonishing successes have been reported in such cases, and the case must be very severe which does not justify a trial. The general rules given above are suffi- cient to guide the reparative effort; perfect cleansing, proper antisepsis, accurate approximation, and judicious pressure constituting the important canons of treatment. Should the effort partially succeed or fail, if the loss of substance be not too great, a plastic operation may be at- tempted ; otherwise the bare or raw surface must be kept clean, and healthy granulations stimulated by such dry applications as zinc oxide or boric acid, or compresses soaked in solution of potassium chlorate. The healing process may be further hastened by skin- or sponge-graft- ing (q. v.). No case of this kind, which is not speedily and primarily fatal, need be despaired of. The soft parts about the head and face possess great reparative and recuperative power, and pieces which have been severed may yet unite by adhesion if properly and quickly reapplied. Thus, by bites and by various acci- dents, portions of the nose and ears may be nearly or quite detached. Unless the circumstances be very unpropitious the attempt should be made to restore them. Careful cleansing and perfect approximation are here, as else- where, essential to success. Ragged lacerations of the lips and cheeks may some- times be cleaned and sewed up ; at other times it will be best to trim or pare their edges, and then neatly close the wound, this procedure causing less scar or disfigurement. It may happen that we are called upon to deal with parts which have already become inflamed, or, perhaps, erysipelatous. In such case we should proceed as follows: The hair or beard should be closely removed. If the appearance of the part or the general condition of the patient indicate any septic process, the wound should be opened, its interior freely exposed to examination, and a most painstaking disinfection of its entire surface made. Foul spots or suppurating surfaces should be treated with an eight-per-cent, solution of zinc chloride, new openings made for drainage at the most dependent parts, and, ac- cording to circumstances, the edges reunited or the whole left open to close by second intention, putrefying and ne- crotic tissue being removed with knife, scissors, or curette. Abscesses should be laid freely open and their cavities disinfected. If erysipelas have supervened, the whole scalp may be covered with antiseptic poultices, or it may be anointed with a five-per-cent, ointment of naphthalin, pencilled with a five-per-cent, glycerine solution of tri- chlorphenol, or the old-fashioned white-lead paint, rubbed up with a little turpentine, may be employed. Few sur- geons would feel justified in making ice applications in such a case unless cerebral complications were extremely severe. It will of course be remembered, in the light of the vascular connection between the scalp and deeper parts (vide above), that all cases of erysipelas of the head are at least serious. With reference to later results of former injuries in the way of granulating or indolent ulcers, caries, necrosis, etc., there are no indications calling for different treat- ment than that generally resorted to for similar condi- tions elsewhere about the body. A healthy ulcer may be covered by skin- or sponge-grafts, or by a plastic opera- tion ; an unhealthy one should be first made healthy. All dead or dying bone should be removed with curette or chisel, and its surface allowed either to heal by granula- tion or covered by a plastic operation. The soft parts about the head and face are, if possible, more vascular than in other parts of the body. This means, on the one hand, that life may be lost by neglect or from ignorance. Thus, within a short time, the writer has seen a drunken man so completely exsanguinated by haemorrhage from a superficial scalp wound only two centimetres long, that it was with the greatest difficulty and care that he was recalled to life. On the other hand, by virtue of this excessive vascularity, reparative pro- cesses go on more rapidly ; and, provided that proper precautions have been taken, it is the rule for most ex- tensive solutions of continuity to heal per primam. Superficial gunshot wounds should be treated on general principles. It must be remembered that a bullet may not only pursue a most tortuous track, but may carry in foreign matter. Such a wound should either receive primary antiseptic occlusion, without the slightest ex- ploration or disturbance, or its track must be carefully cleansed and drained, being laid open for this purpose if necessary. After it has been interfered with or explored it differs in nowise from other wounds, so far as indica- tions for treatment are concerned. There is seldom any positive indication for removal of a bullet, save the anx- iety of the patient, and this of course is a minor consider- ation. Deep Wounds with Injuries to the Bones.-Like all other wounds, these call at first for haemostasis, then for perfect cleanliness, and then for removal of the hair in the neighborhood. This completed, exact exploration should be made. Should it appear that underneath a small external lesion extensive damage is concealed, then by free incision the whole must be exposed to touch, if not to sight. According to the extent of these deeper le- sions the superficial wound, as thus extended, should or should not be reunited. It may happen that one or more pieces of the external table, or of the malar or other bones, may be chipped off or entirely separated from their bony basis, and held only by their connections with the periosteum and soft parts. Not forgetting that they may be still nourished by these connections, it is, on the whole, the safest plan to remove them, leaving if possible the periosteum. But should a prominent process of bone be thus detached from its seat, e.g., a part of the supra-orbital ridge or margin of the orbit, or even the mastoid process (and such cases have been reported), it would only be proper to make every effort to save it. Such a fragment is to be held in place by pressure, by stitches in the periosteum, or by drilling and suturing with catgut or silver wire. Pieces of bone that lie quite loose must be unhesitatingly re- moved, even if dura mater or brain be thereby exposed. Haemorrhage from a denuded bone surface, and oozing from a deep wound, may be commonly checked by ice- water or hot water and pressure. Once checked, it is not likely to recur after the wound is protected from the air and dressed with suitable compression. Aside from leaden projectiles, a great variety of foreign bodies may not only injure the cranial bones and those of the face, but parts of them may even become embedded or disappear from sight: workmen's pointed tools, knife- blades, bayonets, sword or foil points, arrowheads, hatchet or tomahawk points, pieces of glass, splinters or chips of wood, etc. The deeper they penetrate the greater the gravity of the case; the greater also the possi- bility of perforation or depression of the inner table of the skull. Thus fatal injury of the brain is not so rare in connection with a wound of the orbit, and the condyle of the inferior maxilla has been forced through into the cavity of the cranium. By means of a wound in the oro- pharynx, death, with literally no external injury, has been caused. In all these cases the indications for treatment are general, yet explicit. Obviously, removal of a foreign body is called for in almost every case, and this should be accomplished with the least possible disturbance. The only exception would probably be when it has totally dis- appeared within the brain-substance. If simple traction be insufficient to dislodge it, enlargement of the external wound and instrumental aid must be resorted to. Strong forceps, a pointed elevatorium, the chisel and gouge, the trephine, or even the surgical engine may be called for. Thus the writer has had to resect almost the entire upper jaw to get away a piece of wood which had been deeply driven into the skull as it flew off from a circular saw. The more recent the case the better, as a rule, the results. If a pointed object have penetrated the cranium, it should be removed by traction in the direction of its line of en- trance, so that further injury to the brain or its coverings may be avoided. In such a case it would, in many cases, be well to trephine at the site of its entrance into the skull, in order to remove any depressed bone, and to smoothly round off the opening; by means of the free opening thus made haemorrhage can be more easily checked. 524 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Head. Head. In every case in which solution of continuity of the ex- ternal table has taken place, the attendant should bear in mind what a vantage ground the diploe offers for the lodgment of septic germs, and for the development of inflammatory and septic thrombotic processes which may greatly militate against the safety of the patient; and he should in such cases omit no precaution which may tend to avert their destructive tendency. Rigid antisepsis, or, if it can be secured, rigid asepsis, must be our motto ; without it no such wound can be properly treated. The possible remote consequences of a blow on the head should not be lost sight of. Inflammatory hyper- trophy of the bone may be the result, or caries or necro- sis may ensue. These latter may be limited to the part injured, or may be very wide-spread, affecting one table or both, and even involving the whole vertex. Extensive destruction of the inner table alone has been known, and Saviard's celebrated case proved that the entire vertex might separate, since in his patient, two years after a blow, the whole skull-cap came away. Not to speak of other bone lesions, we must also remember the remote results of haemorrhage, as when a clot organizes into a cyst, etc. (yide Brain, Tumors of). For every reason, then, we should endeavor to diagnose at the time, if pos- sible, the nature of the injury, and«to meet the indication at once, in order that untoward after-consequences may be avoided. Fractures of the Vault of the Skull.-These are usually direct, the result of the force applied, whether the head have been struck, or whether the patient have fallen upon it, and they consist at one time of a depres- man sustaining injury, as by a kick of a horse, on the right side, is a little later found to have paralysis of the same side of the body ; the explanation being fracture of the left side of the skull by contre-coup, with rupture of vessels and formation of a clot (or even rupture of vessels without lesion of the bone), with paralysis consequently on the side opposite the clot as an ordinary compression symptom. There is no limit to the pecu- liarities of fracture by contre-covp, save that it is never de- pressed. Concerning the di- agnosis of fractures of the vertex, it is not paradoxical to say that it is easy in proportion to the severity of the case, and most difficult when the injury is most trivial. The merest novice may recognize the or- dinary compound fracture at a glance, while the expert may be at a loss in some cases of simple linear fissure. Doubtless many cases of concussion of the brain following head injury are accompanied by some fissuring of one or both tables, yet, while we may suspect this, there is no way of proving it. Even a compound fracture is sometimes overlooked when the broken bone lies deep under the temporal muscle. Mistakes occur in the opposite direction also ; thus mere extravasation of blood has been mistaken for fracture with depression, and pre-existing abnormal depressions have been deemed to be the result of recent violence. The importance of fracture about the skull is subor- dinate to the importance of the presence or absence of Fig. 1599. Fig. 1598. sion (in a yielding skull, akin to green-stick fracture), at another of an abrupt perforation, of a linear, a stellate, or a comminuted fracture. Fractures may here, as else- where, also be simple or compound. If the fracture be fissured the fissure may be short, or may pursue a long devious line, even to the base of the skull, extending through two or three bones. The comminuted fracture is usually less extensive as far as lines of cleavage are con- cerned. Fractures of the vertex also involve either one or both of the tables. Thus we often have fracture of the external table alone, and fracture of the inner table without visible lesion of the outer is known. Displace- ment may occur outward or inward. The lines of fract- ure visible on the outside of a given skull are seldom any index as to what may be found on its inner surface. Figs. 1598 and 1599, from Hewett's monograph in Holmes' " Surgery," third edition, illustrate this fact; they represent respectively the outer and inner aspects of a vertex thus injured. A. large number of similar illus- trations may be found in their appropriate places in the " Surgical History of the Civil War." On the other hand, Fig. 1600, from Bergmann, will give an idea of the extent of some fractures of this kind. There is further the possibility of fracture by contre- coup. By this term is meant fracture by violence trans- mitted by the arched construction of the skull to a point more or less opposite to that injured. It is known that in cracking a cocoanut, for instance, the shell is not al- ways broken at just the point where the hammer strikes it, but often at some other place. So a blow on the right side of the head may cause fracture of the left side, or in both places. Thus may be explained those cases where a Fig. 1600. compression symptoms. Along with a simple fracture of the vertex may happen a rupture of some vessel, and the formation of a clot of such size as to determine a fatal ending ; on the other hand, we may have a compound comminuted fracture with a minimum of compression or cerebral disturbance. We need, then, to diagnose the intra cranial lesions with greater exactness, if possible, than those of the bone. For the diagnostic signs and 525 Head. Head. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. symptoms of compression, the reader is referred to the article Brain, Compression of (vol. i.). When after in- jury to the head such evidences of compression are no- ticed as are there detailed, no matter whether they ap- pear at once, indicating depressed bone, after a few hours, as from a blood-clot, or after a few days, as when caused by pus resulting from purulent meningitis, then there is sufficient justification for exploration, and this usually means the employment of the trephine. After all, in theory at least, it is not difficult to decide on the appropriate course in a given case. In cases of concussion without serious external lesion, we are called on to do but little. If a scalp wound be present, it should be first utilized for purposes of exploration and then closed, as already advised. In cases of contusion of the brain, unless external indications are sufficient, wre must pursue a tentative policy. Later, if circumstances call for it, the trephine may be employed. But in cases of distinct compression the trephine is almost always indi- cated. To be sure, its proper application may call for anatomical knowledge of the construction of the brain, of high order; nevertheless, this is no contra-indication to operate, it simply calls for expert skill. American surgeons are not yet quite a unit on the sub- ject of early trephining, or what may be called the early exploratory use of the trephine. A few-very few-of the most conservative still hold that it is employed too often by competent surgeons, but their number is dimin- ishing. On the other hand, the majority hold that, in- asmuch as the operation is, per se, when properly (anti- septically) performed, one of very small danger, we are likely to gain more than we shall lose by employing it for purposes of exploration when in doubt. Personally, the writer thoroughly believes in and advises operation when it seems as if any benefit, either in a diagnostic or therapeutic way, may be gained. But before finally de- ciding on instrumental interference, valuable hints may be gathered from external incision and exploration. The indication for the trephine may be in this way placed be- yond the limits of doubt. The writer would then advise, in all but the most plain and typical cases, the following order of procedures in cases of serious injury to the head: 1. Careful external examination and consideration of the general condition of the patient. 2. Exploration with the finger by means of suitable in- cisions, provided the cerebral condition be other than manifest concussion. 3. Exploratory or therapeutic use of the trephine ac- cording to the revelations of the second procedure, or when concussion and contusion symptoms give way to those of compression. In a very excellent monograph on the surgery of the brain, Dr. Roberts, of Philadelphia, has given a ' ' sylla- bus of the treatment of fractures of the cranium," which is so concise that it would seem to the reader's best inter- est to quote it here. " Closed Fissured Fractures.-1. No evident depression, no brain symptoms: No operation. 2. No evident de- pression, with brain symptoms : Incise scalp and tre- phine. 3. With evident depression, no brain symptoms : Incise scalp and possibly trephine. 4. With evident de- pression, with brain symptoms: Incise scalp and tre- phine. " Closed Comminuted Fractures.-5. No evident depres- sion, no brain symptoms: Incise scalp and possibly tre- phine. 6. No evident depression, with brain symptoms: Incise scalp and trephine. 1. With evident depression, no brain symptoms; Same. 8. With evident depression, with brain symptoms : Same. " Open Fissured Fractures.-9. No evident depression, no brain symptoms: No operation, but treat wound. 10. No evident depression, with brain sympoms ; Tre- phine. 11. With evident depression, no brain symp- toms : Possibly trephine. 12. With evident depression, with brain symptoms : Trephine. " Open Comminuted Fractures.-13. No evident depres- sion, no brain symptoms : Probably trephine. 14. No evident depression, with brain symptoms: Trephine. 15. With evident depression, no brain symptoms: Tre- phine. 16. With evident depression, with brain symp- toms : Trephine. " Punctured and Gunshot Fractures.-11. In all cases and under all circumstances : Trephine. " Note.-In classes 3 and 11,1 should be inclined to tre- phine if the depression was marked, or the fissures suffl. ciently multiple to approach the character of a commin- uted fracture. In classes 5 and 13. I should trephine, unless the comminution was found to be inconsiderable." Guided by such aphorisms as these, it would seem as if the practitioner should be much less likely to err than when actuated by the teaching of a certain past era, and of men who are passing away, that the trephine should never be used unless its application seems, even to the novice, plainly and unmistakably necessary. For the details of the operation the reader is referred to the article under the heading Trephining. Wounds of the Orbit.-Those involving the eye or its adnexa are discussed under Eye, Wounds of ; while those which do not injure the globe are to be treated on general principles already laid down. We would simply remind the practitioner, that in case of a penetrating wound of the orbit of this character there is necessity for adequate provision for drainage, otherwise pus may in filtrate or burrow into localities where its presence would be most undesirable. Wounds of Intra-cranial Vessels and Sinuses.- These most often involve the longitudinal and transverse sinuses and the middle meningeal artery. Wounds of these channels have also occurred during the operation of trephining, and have not been fatal ; in fact, in more than one case the effect was rather that of a venesection, and was consequently good. If, by a small punctured wound, a superficial sinus be penetrated, an antiseptic compress may be sufficient to check bleeding ; over this an ice- cold application should be made. The cases are numer- ous in which recovery has followed this simple measure. Death is unusual in such cases, and results rather from other complications, such as injury to the brain, partial escape of blood into the cranial cavity, septic processes, or air embolism. Volkmann has lost a case by entrance of air into a sinus during extirpation of a sarcoma from the bone and dura mater. But under most conditions this would not happen. Wounds of the cavernous sinus through the orbit have always been fatal. A splinter of bone or a foreign body having perforated a sinus wall, the blood may escape at once or only after its removal. These cases are very rare. Haemorrhage may be checked by antiseptic tampons with ice applica- tions, or the sinus walls may be sewed together with fine catgut or silk, as has been done in one notable case by Dr. C. T. Parkes. Provided they do not prove rapidly fatal, these sinus wounds usually heal well, with only a thickening of walls ; but entire obliteration of the chan- nel, should it occur, would be of no great import, as Schellmann's researches have proved. The principal danger comes from softening of thrombi. Wounds of the middle meningeal artery may be rec- ognized sometimes by the supervention of compression symptoms, even though there be no external lesion indi- cating them. Among causes of the injury maybe men- tioned: Direct wound by sharp objects; laceration by projectiles or bone spicula ; rupture by changes in rela tive situation of neighboring bones; rupture without fracture of bones, occurring especially on the side oppo- site the injury. Rupture having occurred, commotion may retard the formation of clot, but it will form sooner or later. It may even putrefy without visible exposure to the air. Symptoms of this accident are : An interval of con- sciousness following injury before supervention of som- nolence, sopor, and coma-these are sometimes preceded by irritation symptoms, and the compression symptoms may occur at any time after haemorrhage begins, from fifteen minutes up to eleven days; hemiplegia on the side opposite the injury, the artery being right over the motor centres for the opposite arm and leg ; changes in the pulse, infrequency and hardness ; slow, embarrassed, stertorous respiration ; vomiting ; loss of reaction to light 526 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Head. Head. of the pupil on the same side as the clot; occasional unilateral impairment of sensation ; aphasia ; disordered bladder and rectum; rise in temperature. If the first four of these symptoms be present, the diagnosis may be regarded as sufficiently accurate to justify operation. The gradual supervention of aphasia indicates exten- sion anteriorly of the clot, disorders of sensation its extension posteriorly, while paralysis of the third pair means that it has extended toward the base of the brain. Numerous cases of penetrating wounds with lesion of this vessel have been reported. Not infrequently it has required a ligature during removal of fragments after se- vere injury. During our civil war the common carotid wras seven times ligated for this same purpose, with three recoveries ; while now, twenty years later, probably no competent surgeon would hesitate to trephine over its course. A case of Parker's will be instructive in this connection. In this there was no external wound of soft parts; nevertheless he trephined over the artery on one side, but found no lesion ; he then trephined over the ar- tery on the other side, but finding no coagulum outside the dura, and noticing that this was discolored and dis- tended, he incised it and removed a considerable amount of blood. In three days the patient became conscious, and afterward quickly recovered. Symptoms of compression, supervening with varying rapidity, not improbably without external wound, would justify exploration by means of the trephine. The opera- tion of trephining, with proper antiseptic precautions (see Antiseptics in Surgery, vol. i.), is by no means a serious or hazardous one. In trephining with the purpose of finding the artery in question, the point of the instru- ment should be applied an inch and a fourth to an inch and a half back of the external angle of the orbit. Otherwise the instrument should be kept away from this spot. It should be borne in mind that sometimes the ves- sel lies in a very shallow groove on the under side of the bone, sometimes in a deep groove, and sometimes in a complete bony canal. The instrument must, therefore, be worked with gentleness and care (vide Trephining). If a satisfactory cause of the compression be not dis- covered on one side, it will be well to take a hint from the case mentioned above, and, remembering the possi- bility of fracture by contre-coup and lesion of the vessel on the other side, to explore there also. Certainly cases of compression are usually desperate enough to justify any search which may reveal the cause and permit its removal. Wounds of vessels in the brain call for treatment only ■when diagnosed, and the circumstances which permit diagnosis will also at once indicate the proper thing to do. Could haemorrhage in the subdural space be diag- nosed, it would be good practice to trephine, open the dura, and wash out the extravasated blood. One such case was reported during our war (Gross: Am. Jour. Med. Set., July, 1873). Injuries to the cerebral portion of the internal carotid are much rarer than those to the meningeal. Longmore relates how a bullet penetrated, in one case, through the orbit into the petrous bone and lodged there, leading later to erosion of this vessel and fatal haemorrhage. Some in- jury of this kind might, if not rapidly fatal, lead to the formation of an arterio-venous aneurism, calling for liga- tion of the common trunk. Wounds of Cranial Nerves.-The treatment of in- juries to these nerves cannot be other than symptomatic. Should a depressed fragment or a foreign body press upon a nerve-trunk, removal of the same would meet the prin- cipal indication, and, provided the injury were not too severe in other respects, the nerve might regain some or all of its function. Sometimes, after bruising or contu- sion of a terminal branch, e.g., the infra-orbital, there will ensue so violent a neuralgia as to call for section or exsection of the nerve on the proximal side of the injury. If it be certain that a nerve-trunk outside the cranium has been severed, and if the locality of the lesion be reason- ably accessible, it would be good practice to cut down upon it and unite the severed ends with a fine catgut suture. Wounds of Brain-substance.-Since these are by necessity complicated by those of external parts, we can draw no abrupt therapeutical distinctions. Obviously, if antiseptic measures are indicated for more superficial in- juries, they are vitally essential here. The majority of these wounds are inflicted by firearms, and we wish here to emphasize what is elsewhere in this Handbook de- tailed, viz., the futility-nay, even the homicidal effect -of careless or ineffectual probing for bullets. From time to time in current literature the writer has denounced this practice as vigorously as he could. The array of cases set forth by German military surgeons, in which most dangerous wounds-such as, when treated by old methods of promiscuous bullet-hunting, were surely fa- tal-primarily and antiseptically occluded, and never probed nor investigated, have gone on to speedy recovery ; this array should be most convincing as to the merits of this practice. Gunshot wounds of the cranial cavity virtually always call for the trephine ; but with elevation of depressed bone, attention to bleeding, and smoothing off the edges of the bone wound, the indications are fairly met in the majority of cases. Blood-clot is always to be removed, and the source of the haemorrhage attended to; a discolored, pout- ing dura may justify incision and exploration ; while in the effort to remove pieces of bone which have been detached and driven into the brain, the bullet may be found and also removed. But the idea of introducing a probe into the brain through a small penetrating wound of the skull is one which must be abhorrent to every modern surgeon. Random exploration of the brain is never justifiable, and the circumstances which would seem to call for the in- troduction of the probe through its bony roof would call much more loudly for the use of the trephine. More- over, many recorded cases prove with what apparent free- dom from serious consequences patients may recover with such foreign bodies as bullets in their brains. The safest rule, then, to follow is to abstain from all operative measures for the removal of missiles when indications are ob- scure, or such as not to promise a compensating advantage. Traumatic Abscess of the Brain.-By this term is meant abscess formation supervening on injury, as dis- tinct from those cases where the cause of the abscess is uncertain or unknown. Such traumatic abscesses are more likely to result from gunshot injury than from any other, though they may follow a simple contused wound of the exterior. The symptoms of cerebral abscess, often much resembling those of compression, have been already con- sidered (vide Brain, Abscess of). We wish here only to put in a plea, not only for the exploratory use of the trephine when there is good reason to suspect abscess, but of the aspirating needle as well. A small needle, of the common aspirator set, may be employed, or in lieu thereof a hypodermic-syringe needle. A reasonable knowledge of cerebral anatomy will indicate how far it may be introduced in every direction without touching the vital ganglia at the base of the brain, while up to this limit it may be cautiously introduced without any fear of harm. The writer has several times had occasion to thus explore the brain-substance, and has never seen harm follow nor had occasion to regret it. Should the pres- ence of pus be thus revealed the aspirator should be dis- engaged, and the needle used as a guide or director upon which to pass a small knife, perhaps a tenotome, and by thus making a freer opening, not only permit escape of pus, but the introduction of a drainage-tube and careful washing out of the cavity. This operative procedure, though bold and radical, is not half so dangerous as to permit the abscess to take its own course, and will in the future fully justify itself. Hernia Cerebri.-When from a recent wound, or one of a few days' standing, protrusion of brain-sub- stance-hernia cerebri-takes place, it may seem doubtful whether it would be better to excise the protruding mass or to endeavor to repress it by suitable pressure. Of course, the careful practitioner will dress all fresh cases with such a judicious amount of pressure as shall guard against this condition ; nevertheless, he may be called on to treat it after it has occurred. If the hernial mass has 527 Head. Health-Resorts. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. begun to slough there can be no question ; excision by ligature, elastic or otherwise, or by the knife, must be practised, and haemorrhage carefully watched for and checked. When the mass is small and appears healthy, gentle and continuous pressure, as by an elastic outside bandage, will usually coax back into the cranium that which belongs there. After complete reduction a lead or caoutchouc plate may be adapted to the shape of the part and applied externally as a part of the bandage tech- nique. An abscess may underlie the hernial mass ; this is to be discovered and treated as above. Adams has reported a case of irreducible hernia cerebri, in which he succeeded in covering the hernial mass with a flap of skin by a plastic operation, and Kusmin has re- ported another similar case, excepting that he resorted to skin-grafting. Purulent Meningitis. - When compression symp- toms supervene several days after injury, there is fre- quently good reason to suspect the presence of pus. This maybe in circumscribed collection, i.e., abscess, which has already been spoken of, or it may mean purulent or sup- purative meningitis. This accession of compression symptoms always, or nearly always, justifies the explora- tory use of the trephine. Should it prove to mean com- pression from suppurative meningitis, there is no reason why the arachnoid cavity should not be washed out, but every reason why it should. In other words, it should be treated just as purulent peritonitis is now treated by some of the most advanced surgeons, that is, by washing out and draining the cavity. Recovery will not always follow this procedure, but it will in a fair proportion of cases, which are inevitably doomed if some such measure be not instituted. Irritative Lesions following Head Injuries.- These are mostly to be grouped under two classes, con- vulsive (epileptic) and mental disturbances (mania, de- mentia, etc.). This hardly seems the appropriate place in which to discuss these at length, the pathological le- sions being so varied, including depression of the skull, cystic formations, abscess, etc. Nevertheless there is each year a stronger tendency, on the part of advanced sur- geons, to explore these cases when any external scar or depression may indicate rudely a point of attack. The element of risk is small, the prospect of at least alleviation sufficiently hopeful, in conjunction with the otherwise hopeless nature of the case, to justify the attempt, and besides, the degree of success attending these efforts is affording more and more encouragement. In cases of this general nature the exact condition is yet, in individual instances, too uncertain to permit of more than general operative directions. Those which have not already been given in this article can be found in their appropriate places elsewhere in these volumes. This paragraph has been made, therefore, suggestive rather than explicit. Wounds of the Head during Birth.-With refer- ence to injuries to the foetal head during artificial or nat- ural delivery, it is necessary to add but little. Even large extravasations of blood are usually absorbed ; in ex- treme cases, after waiting a few days, it might be well to incise, turn out the clot, and sew up. Excoriations and bruises made by instruments need only conventional treatment. Fatal phlegmonous inflammation has been known to result from injury done by forceps ; hence the advisability of antiseptic precautions and attention to de- tail. Symptoms and appearances arising from compres- sion caused by the forceps will commonly subside as the head resumes its shape. Should positive fracture take place, it will probably run its course uninfluenced by therapeutic measures. Perfect rest and cool applications would constitute about all that could be done. The prognosis must be based on the amount of injury. Roswell Park. Analysis (Walton).-One pint contains : Old Spring, 85° F. Prof. Wm. E. Aikin, M.D. New Spring, 88° F. Prof. Wm. E. Aikin, M.D. Grains. Grains. Carbonate of magnesia 0.156 0.246 Carbonate of iron 0.009 0.034 Carbonate of lime 2.238 2.340 Chloride of potassium 0.029 0.032 Chloride of sodium 0.034 0.036 Sulphate of potassa 0.276 0.316 Sulphate of magnesia 0.906 0.924 Sulphate of iron... 0.022 0.013 Sulphate of lime 3.165 0.158 Sulphate of ammonia 0.029 0.029 Iodine trace trace Bromine trace Silicic acid 0.237 0.228 Organic acid, probably crenic... 0.107 0.109 Total 4.208 4.465 Cub. in. Cub. in. Carbonic acid gas 0.58 0.60 Therapeutic Properties.-These waters have an assured reputation for efficacy in the treatment of scrofu- lous ulcerations and other persistent skin affections. They are described as being diuretic, diaphoretic, and alterative, and are generally used both externally and internally. These springs are situated in a valley at the summit of the Warm Springs Mountain. Within a few miles are the Falling Springs, a fall of water one hundred yards in breadth and one hundred and fifty feet in height, and near by are the Cascades. Accommodations are furnished by the Healing Springs Hotel. G. B. F. HEALTH, PUBLIC, LAWS REGULATING. Sanitary laws are the product of a high degree of civilization, and in general are of quite recent adoption. This appears clearly from the fact that such organizations as Boards of Health have in few instances been established longer than twenty-five years. The general subject of health regula- tions involves an investigation into matters purely sani tary, but it will not be practicable to treat under this title any phase of the subject except the legal. It will, therefore, be the object to state some of the legal principles which all civilized communities put in force to protect themselves in matters of public health. There are inherent, in every political community, certain rights and powers which are often called in general terms " police powers." Prominent among such powers is the right to make rules and regulations concerning health, the abatement of nuisances, and the like. It is, and must be, the right of every community to pro- tect itself, and this sentiment of self-preservation is su perior to all constitutions, or, perhaps, is better stated to be presupposed by all constitutions. Laws may be adopted which will break up trades and occupations, or which will take private property for public uses, and this may be done under cover of the necessities of public health, or by virtue of the police powers of the State. It cannot be successfully contended that such laws are unconstitutional, for the opposite has been many times declared. The rights of the few must yield to the necessities of the many, and this rule is embedded in the common as well as in the statutory law. It must not be supposed, however, that the rights of the private citizen are thereby unduly endangered. Private property cannot be taken for public uses with- out just compensation, in matters of public health any more than in other cases. Where personal rights seem to be invaded under the plea of public necessities, the courts have been, and always will be, jealous to see that the one is properly protected against any unjust demands of the many. No one can, however, rightfully complain of in- vaded rights, or successfully call upon the courts to help him, who, for instance, maintains what is a nuisance per se. Any person, for example, has the right to abate the nuisance of a dead body kept unburied until putrefaction ensues. Individual powers may be summarily abridged in cases of this kind by any one. In the vast majority of HEALING SPRINGS. Location and Post-office, Healing Springs, Bath County, Va. Access.-By Chesapeake & Ohio Railway to Coving- ton, thence sixteen miles by stage to the springs. 528 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Head. Healtli-Kesorts. cases, however, the point to be decided is whether the public, through boards of health or other similar organi- zations, has the right to interfere with what are not nuisances per se, such, for instance, as a mill-dam on a running stream which has become unhealthy to the sur- rounding neighborhood. In matters like this the powers of health boards are for regulation, not destruction. It would not be legal for the board to issue an order directing the summary remo- val of the mill-dam. The usual course of protection in such cases is to procure an injunction from a court pre- venting any interference by the Board of Health until the rights of the citizen and the public can be carefully considered and adjudicated. If the result sustains the Board of Health in its action, no one can properly say that his interests have been abridged "without due pro- cess of law." The legal presumption in all health mat- ters is that the Board of Health is acting within the law. There have been, in some recent cases, a remarkable tendency to invoke the supposed irresistible power of "public health" to destroy whole trades, and the courts have stepped in to protect private rights. Two instances of this character are connected with New York legisla- tion. The Legislature, in 1885, prohibited the manufacture and sale of oleomargarine. In 1886 the law was declared unconstitutional, on the ground that an entire branch of trade and manufacture could not be prohibited for any alleged health reasons when the article was not necessar- ily harmful. The Legislature shortly before this passed a law declar- ing that cigar-making could not be carried on in certain tenement-houses, but the Court of Appeals pronounced the law unconstitutional, because the health issue was a mere subterfuge, and the result of the law was to deprive certain persons of their property without just compensa- tion, while others were unaffected. It does not seem, therefore, that there is any real ground to fear the unlawful abridgment of personal or property rights under any existing health legislation. The true ground for fear is, rather, that the health laws are not stringent enough, and that the public is not edu- cated sufficiently to sustain laws which look to the pre- vention of disease. It is noticeable that there are not only frequent outcries against regulations which, in the careful and conscientious judgment of experts, are neces- sary for the preservation of health, but also that the leg- islatures are unwilling to vote the money necessary to secure the proper execution of health laws. An in- stance of the first kind is found in the tremendous oppo- sition shown, in 1885, toward the enforcement of the vac- cination laws by almost the entire French Canadian population of Montreal; and an illustration of the second is found in the stinted and utterly inadequate appropria- tions made in New York for the work of the State Board of Health. There are now, in about twenty-five of the States, regu- larly organized Boards of Health, with more or less gen- eral powers. A summary of the duties of the New York State Board of Health is given in the last report of the Executive Com- mittee, and is as follows ; To take cognizance of the in- terests of life and health among the people of the State. To make inquiries in respect to the causes of disease, es- pecially epidemics. To investigate the effects of locali- ties, employments, and other conditions upon the public health. To supervise the State system of registration of births, marriages, and deaths, and the registration of prevalent diseases. To prepare forms for obtaining and preserving such records. To insure the faithful registra- tion of the same in the several counties, and in the Cen- tral Bureau of Vital Statistics at the capital of the State. To prepare forms with proper coupons attached for, and to prescribe rules regarding, the issue and use of transfer permits to be issued by local boards of health for the transportation of dead bodies for burial beyond the limits of the county where the death occurs. To secure compli- ance with these rules on the part of every common carrier or person in charge of vessels, railroad trains, or vehicles. And to examine and report upon nuisances affecting the security of life and health in any locality where the peo- ple, unable to gain redress from their local officials, seek the aid of the State Board of Health by petition to the Governor. In addition to these statutory duties, which are com- prehensive enough to require the best executive ability and the profoundest sanitary and medical knowledge, the extremely important matter of food and drug adultera- tion is entrusted to these State boards. This latter sub- ject is treated under a separate article, and will not be touched upon here. The actual application of health laws to the individual comes, in most cases, however, from local boards of health in the cities and towns. These organizations have the right to make regulations and rules on health matters, and have powers which are in many cases very sweeping. There is, however, rarely an instance of oppression no- ticed, and the only fault, in most cases, is a too great leniency. Health legislation of a really scientific character is of only a few years' growth, hardly more than ten, and there is much still to be done in securing the necessary data to base legislation upon, and in educating the public to the needs of the case. Few public questions exceed in im- portance that of the public health Henry A. Riley. HEALTH-RESORTS. The subject which is to be briefly considered in the present article is unquestion- ably one of great importance to the physician, and is one demanding his most careful attention. That it is one which excites especial interest at the present time is abundantly proven by the frequency with which works devoted to its consideration, and occasionally to its eluci- dation, are issued by the medical press. The alleviation or cure of disease by resort to what may justly be re- garded as in a pre-eminent degree nature's own remedies, to wit, a change of climatic surroundings combined with, or not combined with, the employment of those powerful medicinal adjuncts supplied by the waters of mineral springs and of the ocean, is a subject which for centuries past has occupied the attention of mankind, and in par- ticular of the medical profession. In evidence of this fact may be adduced the frequently cited apothegm of Hippocrates (Epidemics, vi., §5), Vnv neranei/Seiv <rvp.<popov ewl toIcti /j.aKpo'iai vovn^p-aatv. " Change of climate (lit. of land) is profitable in long-lasting illnesses. " References to various health-resorts, for the most part places lying by the sea or possessing sources of mineral waters, are famil- iar to readers of classical literature. Baiae, celebrated for its sea- and sulphur-baths, and for its mild and sunny climate, was, perhaps, the best known, as it was the most fashionable, of such resorts in " classical" days.* Doctor Hermann Weber tells us that sea-voyages, also, were recommended by Aretaeus and Celsus in cases of pulmo- nary phthisis; that a species of "high-altitude" cure, combined with a "milk-cure," was adopted by Galen in such cases ; while the elder Pliny gave the preference to a sojourn in the pine-woods, when compared with the other climatic remedies just mentioned, as a means of combat- ing the disease in question. Consideration of these facts may well lead one to exclaim that, even in the domain of climato-therapeutics, " there is no new thing under the sun." Nevertheless, the devotion of general attention to the study of climate as applied to the treatment of dis- ease is in reality a comparatively new thing among mem- bers of the medical profession, and no more satisfactory proofs of the genuine progress now making in the scien- tific study of palliative, curative, and preventive thera- peutics can be found than are the interest which climato- therapeutics excites in our own days, and the character of at least a fairly large share of the literary pro- ductions devoted to this subject. That many such pro- ductions should be more or less superficial and unscien- tific is no more than should reasonably be expected, * Cf. the following expressions selected from the writings of four cele- brated Roman poets of this period : " Felices Bai®," " principes Bai®," " Baiani soles," " zEmula Baianis Altini litora villis," " Fumida Baia- rum stagna tepentis aquae," " Sacris Baiarum proxima lymphis," " Mihi Baias Musa supervacuas Antonius . . . facit," etc. 529 Heal th-Resorts. Health-Resorts. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. when regard is had to the daily increasing demand for works of this class; and, while the student of climato- therapeutics may w'ell become wearied and impatient at the very multitude of the publications, both large and small, which now claim his attention, and may often be tempted to exclaim that ' ' of making many books there is no end ; " nevertheless he will do well to consider that amid this Babel of conflicting tongues some voices are worthy of careful attention, and that the foundations of a truly scientific system of medical climatology are, at least, in- dicated in the works of a few of the best informed and most patient students of the subject. To a number of works of this class reference has already been made in the article entitled Climate, while other valuable and trustworthy publications will be found mentioned in the course of articles describing individual health-resorts. Since writing the general article on Climate referred to, I have had the pleasure of reading the essay by Dr. Fonssagrives, bearing on the same subject, and published in the " Dictionnaire Encyclopedique des Sciences Medi- cales" (First Series, vol. xviii.) ; an essay which I cannot too highly recommend to the attention of those who desire to obtain clear ideas respecting the study of climate as applied to the treatment of disease, and in particular re- specting the proper method of pursuing such study in order to establish medical climatology upon a firm and truly scientific basis, and thus to render it as fruitful as possible in therapeutic results. Careful and detailed ob- servation, together with full reports respecting the cli- matic factors and the therapeutic results of sojourn at each individual resort are, as is pointed out by Dr. Fons- sagrives, the first essentials in the proper study of this important subject, and should precede all attempts at classification ; and he very justly deprecates the attempts at premature classification, which, together with preju- dices, both lay and professional, have done so much to hinder the growth of this infant science, and to postpone the day when it shall become of the greatest possible practical utility in the alleviation, cure, and prevention of disease. The objects set before him by the writer of the present article are : I. A brief discussion of the effects produced upon the human organism by the separate climatic factors, which, variously combined, go to make up the different varieties of climate. II. The presenting of brief remarks concerning the -classification of climates and the geographical distribu- tion of different varieties of climate. III. A brief discussion of the adaptability of special climates to the treatment of special diseases. IV. The discussion of qualifications other than those of a purely climatological character which should be pos- sessed by any place aspiring to be considered as worthily occupying a position within the category of health-resorts of the first class. With health-resorts chiefly remarkable as possessing fa- cilities for the use of mineral waters the present article has but little to do. A few such places will, indeed, be referred to under Section III., but the entire department of mineral springs and of mineral-spring resorts is outside the do- main covered by the writer's contributions to the Hand- book, having, at his own request, been assigned by the editor to other contributors. I. Physiological and Pathological Effects of Climate.-In discussing the effects produced upon the hu- man organism by different varieties of climate, it is mani- fest that we are considering the physiological and patho- logical effects of the separate climatic factors (see article Climate) variously combined. Unfortunately the data upon which such consideration should be based are as yet too few in number to carry the conviction that this fun- damental portion of the study of climate, as applied to man, has been established upon a scientific basis. In Parkes's "Practical Hygiene," Weber's "Treatise on Climato-therapy " (in Ziemssen's " Handbook of General Therapeutics)," Dr. Fonssagrives's article on "Climate" (" Diet. Encycloped. des Sc. Med.)," etc., the reader will find this subject discussed at considerable length. In the present article we shall merely attempt to lay before him a brief epitome of what has been said in these longer and more exhaustive treatises, touching upon the physiological and pathological effects produced by most of the climatic factors mentioned on page 186 of vol. ii. of the Hand- book, and discussing each factor in the order there given. 1. Temperature.-The tendency of increased tempera- ture seems to be to augment the activity of the- skin, to diminish the activity of the kidneys, to reduce the fre- quency of the pulse, to diminish the respiratory activity of the lungs. These results of this tendency are observed in different degrees in different persons, and the effects of increased heat are, for the most part, observable only when such increase is considerable in amount. Extreme heat of the atmosphere seems to exert " a depressing in- fluence, lessening the nervous activity, the great func- tions of digestion, respiration, sanguification, and directly or indirectly, the formation and destruction of tissues " (Parkes). Its effect in elevating above the normal the temperature of the body is well known, and will be found discussed in the article entitled Heatstroke. Nature's safety-valve against the dangerous effects produced by extreme elevation of atmospheric temperature lies in the increased functional activity of the skin mentioned •above. Evaporation from a freely perspiring skin tends, of course, to reduce the body temperature. A freely act- ing skin also performs vicariously the functions of the other eliminating organs, whose activity is in a measure reduced by elevation of the atmospheric and of the body temperature. Cold being nothing more or less than a relative absence of heat, it is manifest that the tendency of a reduction of the atmospheric temperature will be to produce effects upon the human organism exactly opposite to those pro- duced by elevation of temperature. Concerning varia- bility in temperature it may be remarked that such vari- ability, when moderate in its degree, usually exerts a healthfully stimulating effect upon the human system. For most persons a variability indicated by an average nycthemeral range of about ten or fifteen degrees Fahren- heit may be considered as conducive to health. Changes of temperature which are extreme in range and rapid in their onset are apt to " play fast and loose," as it were, with the various functional activities of the human or- ganism, calling now upon one, now upon another, elimi- nating organ to exercise its special function to the utmost limits of its capacity, and, at short notice, to act vicari- ously for one or more of the others. 2. Humidity.-Moist air is a better conductor of heat than is dry air. Extreme degrees of heat and of cold are better borne when the air is dry than they are when it is moist. The same may be said of variations of tempera- ture. Evaporation from the skin and lungs is accelerated by dryness, retarded by dampness, of the atmosphere. Moist heat exercises a debilitating effect upon the human system : it is thought to have a soothing effect upon the mucous membrane of the respiratory tract. Moisture combined with cold increases the functional activity of the kidneys and predisposes to catarrhal affections of the respiratory and genito urinary tracts. Moisture combined with heat favors decomposition and the multiplication of various forms of germ life in the atmosphere. Extreme dryness of the air, whether it be cold or hot, is unfavor- able to both these processes. So far as the functional ac- tivity of the skin is concerned, the relative humidity of the atmosphere is alone worthy of consideration in esti- mating the effects upon the human system exerted by moist and by dry air respectively ; but, by the student of climato-physiology and climato-therapeutics, the relative humidity of the atmosphere must always be considered in connection with its temperature. For information respecting the comparative importance of relative and of absolute humidity in estimating the effects of moist and of dry air upon the functions of the respiratory mucous membrane, the reader is referred to the general article on Climate (vol. ii., p. 187), and to that upon Davos (vol. ii., p. 359). 3. Wind.-Winds vary in their effects according to the humidity and temperature of the air which is in motion, 530 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Health-ICeNortN. Heal th-Resorts. and in proportion to the velocity of that motion. Cold dry winds are stimulating, that is to say, they are irritat- ing. When very cold and very violent they are apt to prove much too irritating, even for persons possessing the strongest and most robust constitutions. Cold damp winds are noxious to all. Cold air in motion abstracts heat from the body more rapidly than cold still air. Heat is less felt by the body when the air is in motion than when it is still, be the atmosphere either dry or moist. Aside from their direct action upon the human organism, all winds, both warm and cold, moist and dry, undoubtedly fulfil an important sanitary function to dwellers in large cities, or in densely populated regions, by reason of their acting literally as ventilating forces to clear the atmosphere of stagnating organic impurities. 4. Rainfall.-A fall of rain exerts per se no direct in- fluence upon the human organism. There is no neces- sary connection between the total annual rainfall of a climate and its average humidity. 5. Cloudiness.-The presence of clouds in the sky ex- erts no direct influence upon the human organism, except so far as it tends to obscure the sun's rays. The precise effect of unobstructed sunlight upon organic life is as yet imperfectly understood ; but in general it may be said that we have good grounds for believing the metabolism of tissue to be favored in a marked degree by direct and powerful sunlight. Sunlight is stimulating and tonic in its influence upon the nervous system. The value of the cheering effect produced upon the mind of an invalid by an abundance of bright and vivid sunshine can hardly be overestimated ; although it is true that occasional in- stances may be found, among persons who have been little accustomed to this great boon of nature, in which a pro- longed and unbroken succession of cloudless days exerts a sort of depressing, and at the same time irritating effect upon the mind, by reason of the very monotony of such succession. These persons weary of the glare of light characteristic of most regions in which such prolonged cloudless weather prevails, and would fain have it more frequently tempered by the clouds to which, when at home, they are so much better accustomed. The con- verse of this is notoriously true, and the mental, nay, sometimes the physical, depression exerted by a long suc- cession of cloudy days upon the native of a generally sunny clime, is equally, and even more marked. Some of the good effects produced by direct sunshine seem to de- pend upon the radiant heat accompanying the brilliant light, and there are persons in whom the cheering effect of sunlight is especially dependent upon the contingency of its being accompanied by a fairly considerable de- gree of such direct or radiant heat. Dr. Parkes, in his treatise on hygiene, when discussing the direct action of hot sunlight upon the skin, tells us that despite its drying effect, we do not yet know whether it tends to increase or to diminish perspiration; but " on the whole," he says, "it seems probable that a physio- logical effect adverse to perspiration is produced by the direct rays of the sun." The bearing of this question upon the risk from sunstroke, in the case of a person ex- posed to a very hot sun, is important. It is at least equally important that the very high temperature in the sun, as compared with the shade, should not be lost sight of in any attempt to account for the sunstroke of a per- son so exposed. 6. Atmospheric Pressure.-The tendency of a diminu- tion in atmospheric density is to accelerate the pulse and respiration, to lessen the spirometric capacity of the lungs, to increase the evaporation of water from the skin and lungs, and to lessen its excretion by the kidneys. An increase in the atmospheric density naturally tends to pro- duce physiological effects exactly opposite to those just specified. Diminished atmospheric pressure tends to cause a determination of blood to the venous, increased pressure to cause a determination to the arterial, system. The physiological effects produced by alterations in the atmospheric pressure have hitherto been observed only in instances where those under observation have been per- sons subjected to rather sudden alterations of pressure (as in the case of those ascending in ballopns, climbing moun- tains of considerable altitude, or descending in diving- bells, or into caissons, etc.), or else these effects have been estimated from a comparison made between the physiological functions of persons habitually dwelling at considerable elevations above sea-level and those of in- habitants of lower-lying regions. Concerning the physiological effects of the minor vari- ations of pressure which occur as meteorological phenom- ena in the climate of any one place, we know next to nothing. For the present, therefore, the factor of at- mospheric pressure may be disregarded in estimating the climatic effects of all health-resorts, excepting only those which lie at a considerable elevation above sea-level (see article Mountain Resorts). The physiological effects produced by variations in the electrical condition of the atmosphere are as yet by far too imperfectly understood to justify an attempt at their consideration in this place. For a discussion of the chemical composition of the atmosphere in its bearing upon health, see article entitled Air. II. Classification and Geographical Distribu- tion of Climates.-The classification of climates ac- cording to rules based upon the accurate valuation of their meteorological factors is yet to be made ; that is to say, any truly scientific classification, definite in the value of its terms, and therefore capable of being ex- actly understood, does not, up to the present time, exist. For lack of it all writers upon climatology, and in par- ticular upon medical climatology, are greatly hampered in their work ; while it is certainly not too much to say that their readers are frequently not a little puzzled to grasp the meaning of what is said, and find it well-nigh impossible to retain any considerable portion of it in their memories. Surely it is high time that everything possi- ble should be done to remedy this fundamental defect, and probably no better way to remedy it can be found than that suggested by Dr. Fonssagrives. The terms cold, temperate, warm, very dry, dry, moist, etc., should have their value fixed within certain limits of the scale (ther- mometric, hygrometric, etc.); these limits should be estab- lished, and the choice of the leading meteorological factors calling for consideration in the classification should also be determined and agreed upon by an international congress. There is nothing impracticable in this idea, and its adop- tion cannot but facilitate the establishment of clima- tology upon a scientific basis. Probably Dr. Fonssa- grives is right in implying, as he does, that several centuries must pass before climatology shall have become an elaborate science. He is certainly right in cautioning against premature attempts at classification, and in urging the study of local climates (as opposed to regional, still more so to zonal, climates) as the proper field for meteor- ological and medical investigation. Nevertheless, he justly urges the importance of an authoritative determi- nation of the value of the terms which must be used in describing any particular local climate. Respecting the geographical distribution of climates we have little to say beyond a mere acquiescence in the opinion expressed by Dr. Fonssagrives, that in the present state of our knowl- edge its consideration is of no practical importance to those who study climate from a medical point* of view. Re- gional and zonal distribution, based upon a system of rather coarse classification, are indeed matters of impor- tance to the student of physical geography, of botany, zoology, or comparative ethnology, and have value for him who studies the geographical distribution of endemic diseases ; but for him who considers climate as a thera- peutic agent, and whose classification must therefore be based upon the study of local climates, any attempt to group such climates according to their geographical dis- tribution is as yet premature. " Medical climatology," says Fonssagrives, " has been hitherto the docile slave of geography ; in my opinion it should free itself." To facilitate the discussion of the next section of this article (Section III.), in which we have promised to consider briefly the adaptability of special climates to the treat- ment of special diseases, it is necessary that we should adopt some temporary scheme of classification. We se- lect, therefore, the scheme propounded by Dr. Hermann 531 Heal tli-Reports. Health-Resorts. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Weber (op. cit.), as being on the whole the most con- venient. Dr. Weber separates all climates into two great classes, viz., those of (A) sea, island, and coast climates, and of (B) inland climates. Equability and humidity characterize the former, vari- ability and dryness the latter, of these two classes. Such, at least, is the general rule in this respect; but so mani- fold are the exceptions to this rule that the reader must be cautioned against allowing himself to consider it as of universal application. Class A is further divided by Dr. Weber as follows :-1, Moist; 2, moderately moist; 3, dry climates ; while these three divisions are again subdivided upon a basis of tem- perature, separating each one of them into a warmer and a cooler variety. Class B Dr. Weber divides into .-1, Mountain climates, and, 2, lowland climates; and the second of these two di- visions he again divides, first upon a basis of humidity, into dry and moderately moist lowland climates; and, finally, both the dry and the moderately moist subdivis- ions are a second time divided by him, into a warmer and a cooler variety. Examples of these many varieties of climate are given by Dr. Weber, and we shall cite a few of these examples, selecting, for the most part, the names of such health- resorts as have received, or are likely to receive, special and detailed mention elsewhere in this Handbook. 1. Moist and warm island and coast climates:-Madeira, Azores, Sandwich Islands, Bermudas, Barbadoes, Florida [at least its most southern portion], 2. Moist and cool island and coast climates :-The Heb- rides, Orkney, and Shetland Islands. 3. Moderately moist and warm island and coast cli- mates :-Mogador, Algiers, Ajaccio, Palermo, Pegli, Biar- ritz, Arcachon, Nervi. 4. Moderately moist and cool island and coast climates: -Dr. Weber divides the health-resorts mentioned under this heading into two classes, comprising respectively those suitable for winter and for summer residence. As types of the former he specifies Bournemouth, the Isle of Wight, and other points along the English southwest coast, etc. [Atlantic City and Cape May may be added to this list.] Types of the summer resorts of this class it is hardly necessary to specify. 5. Dry coast climates :-As explained by Dr. Weber, it is with places possessing warm as well as dry climates that we have chiefly to deal when considering this class of dry coast stations. Types of this class are numerous, a large proportion of such resorts lying scattered all along the Mediterranean coasts of Spain, France, Italy, etc. Among places thus situated, Dr. Weber specifies Ali- cante, Valencia, Barcelona, the Western Riviera, Hyeres, Alexandria, Syracuse and Catania, Amalfi, Salerno, and the islands of Ischia, Capri, and Malta. Other stations of the same class, alluded to by the author in question, are Cape Town and Port Natal in South Africa ; Ade- laide, Sydney, Melbourne, and Perth, on the Australian coast. [To these may be added the coast stations of Southern California.] 6. Mountain and " high-altitude " climates :-Here be- long Davos, Denver, Colorado Springs, theEngadine, etc., and a host of mountain resorts of more moderate eleva- tion. Under this category, and in a subdivision headed " Voralpenclima," or climate of the Alpine foot-hills, Dr. Weber mentions such resorts as Arco, Meran, Botzen, the Italian lakes, and a large number of the less elevated sta- tions in Switzerland. [Asheville, N. C., is, perhaps, the best type of a resort of this class which is to be found in the United States.] 7. Warm, dry lowland climates:-Egypt and Nubia are specified by Dr. Weber. [The lowland portion of Arizona may perhaps be added.] 8. Cold, dry lowland climates:-It is unnecessary to specify types of this class. 9. Moderately moist, warm lowland climates :-Rome, Pisa, and Pau are specified by Dr. Weber. [Thomasville, Aiken, Atlanta, and other similarly situated inland sta- tions of our own Southern States, some of them more, some of them less, elevated above sea-level, but none of them belonging within the category of mountain re- sorts, may be classed under this heading. Strictly speak- ing, these places belong in a separate class, which might be called that of the moderately dry warm inland climates of low or medium elevation above sea-level.] 10. Moderately moist, cool lowland climates: - No types of this class need be given. III. Adaptability of Special Climates to the Treatment of Special Diseases.-This section of our subject together with the section next following are the two which, as indicated by their respective headings, should be those of greatest practical value to readers of this article. Brevity here, as elsewhere throughout its course, must be our rule; judicial accuracy is unfortu- nately impossible in the present embryonic condition of the science of climato-therapeutics, and amid the as yet very considerable diversity of opinion existing among students of this subject. Fortunately the day has gone by when it was considered enough in the case of a certain given disease to prescribe a certain class of health-resorts, possessing in common what was supposed to be a certain definite variety of climate. A more careful and detailed study of the varying symptoms of each disease, a better understanding of the pathological conditions characteris- tic of different stages of one and the same disease, a more discriminating attention paid to the physiological and pathological idiosyncrasies of the individual patient (or to what is called the " constitution" of the sick man), to- gether with a somewhat better comprehension of the cli- matic effects of the separate meteorological factors upon the human organism-all have combined to raise the practice of climato-therapeutics to a higher plane. Ex- perience has opened the eyes of the medical profession to their former errors, and has demonstrated that the selection of a health-resort can by no means be made by "rule of thumb." Experience has yet much to teach us before that day shall arrive when serious, it may be fatal, errors in the determination of this important question will be as rare as formerly they were frequent in occur- rence. The three great desiderata in hastening the ad- vent of this day are :-1. A more thoughtful, conscien- tious, and painstaking consideration of the precise pathological condition of the individual patient, and of his constitutional peculiarities. 2. A more careful study of the effects produced upon the human organism, both in health and in disease, by variations in each and all of the meteorological factors of climate. 3. The detailed study of these factors as they exist in the climate of each place which experience has proved to be, or analogy has led us to regard as likely to be, well suited for use as a health- resort. The two former of these three desiderata call simply for increased carefulness and critical power in clinical work, supplemented by physical and physiolog- ical experimentation upon animals. They are in the hands of the practising physician and of the physiologist. The third and last has its foundation in detailed and long-continued meteorological observations. Concerning the importance, the essential importance, of full meteoro- logical data in studying climate in its relations to health and disease, quite enough has been said in the article en- titled Climate. The writer trusts that the day will soon come when failure to present full and reliable data of this kind will in every instance be regarded as tanta- mount to confession of its worthlessness when occurring in the statements of persons advocating the claims of any health-resort. Already the value of such statistics is so widely acknowledged that nearly every health-resort is able to present a modicum of figures in support of its claims; but unfortunately such small samples of local meteorology are not always well selected, while by reason of their very brevity they may serve only to mislead. Short tables and figures for temperature, etc., derived from brief periods of observation, generally mark the place whence they come as a new resort. Their presen- tation is commendable as testifying to an appreciation of the value of figures, and as an earnest of fuller data yet to come. The newest resort may, of course, be the best, and a spot where thermometer and barometer are quite 532 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heal tli-Resorts. Health-Resorts. (b) When expectoration is scanty: In winter-Warm, moist climates ; as Madeira, Pau [Bermudas, Nassau, Ja- maica, etc.]. In summer-[Isle of Wight and English south-coast resorts generally, Newport]/ 2. Chronic Bronchitis, with Cardiac Complications or Emphysema.-The climatic conditions should be the same as in the case of uncomplicated bronchitis, except that "high-altitude" resorts (such as Colorado Springs and the higher lying portions of Arizona) are to be avoided. In some cases of this class the summer mountain resorts would also be contra-indicated. (See article Mountain Resorts ; also see report of certain cases where resort to comparatively low elevations proved fatal to patients having slight or previously unsuspected heart disease, in a paper read before the American Climatological Society, in 1886, by Dr. A. L. Loomis.) 3. Simple Laryngeal Catarrh.-The climatic conditions indicated are those found useful in the case of bronchial catarrh. [The same may be said, of course, respecting obstinate cases of pharyngeal catarrh without serious laryngeal implication. It would be well if a larger num- ber of cases of this kind availed themselves of the bene- fits of climatic treatment, especially when we consider the important causal relation borne by this form of catarrhal disease to chronic aural affections, and the too often un- satisfactory treatment of such cases, during the winter season amid adverse climatic surroundings.] 4. Bronchiectasis.-In winter-Warm and moderately dry resorts, such as the Western Riviera, Hy^res, Ajaccio, Palermo, Algiers [and many of the Florida resorts]. In spring and autumn-Baden-Baden, Bex, Montreux [Me- ran, Old Point Comfort, Cape May, Atlantic City, Lake- wood]. In summer-Mountain resorts of moderate ele- vation ; or sea-side resorts, such as those on the southeast and east coasts of England [Long Branch, Fire Island, etc.]. 5. Catarrhal Asthma without Cardiac Complications.-• " Generally quickly relieved at ' high-altitude' resorts, al- though in certain instances, where the affection is accom- panied by general debility, warmer climates have a more beneficial effect; those of them that are dry, in cases where expectoration is free ; those of them that are mod- erately moist (Arcachon), or moist (Pau, Pisa), in cases where it is scanty " (Weber, loc. cit.). 6. Phthisis.-(See also articles on Climatic Relations of Consumption, and Mountain Resorts.) (a) Catarrh of the Apex:-In winter-The Riviera, Ajac- cio, Palermo, Algiers, Cairo [Arco, Aiken, Thomasville, Florida resorts (especially those lying inland), San Diego, Santa Barbara, Asheville, Atlanta, etc.], Davos, theEnga- dine, Colorado, Gorbersdorf. In spring-Bex, Montreux, Pallanza, etc. [Charleston, Old Point Comfort, Atlanta, Aiken, etc.] In summer-Mountain climates and the cooler sea climates. [For the entire year-Colorado Springs, San Diego, Santa Barbara, Denver, Asheville, etc.] Sea-voyages may also be recommended in such cases. (b) Chronic Pneumonia of the Apex requires similar climatic treatment, but the treatment must be more pro- longed. Places specified above as typical representatives of resorts good all the year round are especially desir- able for such cases. (c) Unabsorbed Pleuritic Effusions:-Dr. Weber rec- ommends mild sea-coast stations, such as Ventnor and the English southwest coast, and also "high-altitude" re- sorts, the latter especially for cases of longer standing in which all acute symptoms have disappeared. (d) Caseous Phthisis:-During the earlier and active stage of caseation^ while fever is present, sea-side resorts are recommended by Dr. Weber • the warmer ones (such as Algiers, Palermo, Ajaccio, Mogador, and Tangiers) during the winter season, the cooler ones during the warm months ; at which latter season he also recommends resort to mountain stations of moderate elevation. Later on in the history of the disease, when cavities have formed and fever has ceased, he prefers " high-altitude " to warm sea- coast stations; that is, provided the cavities formed be not of large size. (e) General Catarrhal Pneumonia, without any Con- unknown may be an El Dorado of climato-therapeutics; but too much cannot be said to impress upon the advo- cates of the special merits of any resort that the fuller the data they present, and the longer the period of observa- vations represented by such data, the more convincing will be the proofs they can give for their faith in such merits. The indulgence of the general reader is craved for the frequent reiteration of this opinion, as the writer in penning the present article and the general article on Climate, to which it is supplementary, has in mind a twofold object:-first, to assist the average general prac- titioner in selecting suitable resorts for his patients, and in learning how to read and estimate the merits of the multitude of publications upon climato-therapeutics now claiming his attention; second, to impress upon those specially interested in climatology and climato-therapeu- tics the value of that method which, in his opinion, is the true one to be followed, in order to establish medical climatology upon a scientific and solid foundation, and thereby to render it most serviceable to those whose in- terest in it is of a purely practical nature. The general practitioner cannot fairly expect to find in this article a complete guide as to the best choice of a health-resort for any given case of illness. For the most part such in- formation on climato-therapeutics as the writer is able to give will be found scattered through the various accounts of individual resorts, while more detailed information of the same kind will be found in the standard works upon climate and climato-therapeutics, which are referred to in the course of such articles, in the present article, and in the general article on Climate. An account of the climato-therapy of special forms of disease belongs also most properly to the section on treatment accompanying articles describing such special forms ; and, in some in- stances at least, it will there be found. We shall do little more in this place than to present an epitome of what has been said on this subject in Dr. Weber's most excellent treatise upon "Climato-therapeu- tics " (under the heading " Use of Climatic Resorts in the Treatment and Prevention of Pathological Conditions "), feeling sure that in the present imperfect state of the science of climato-therapeutics we cannot do better than to avail ourselves of the remarks made by so celebrated an authority, in constructing that brief index of health- resorts which the reader has a right to look for under this section of our subject. Accordingly we give below a list comprising many of those pathological conditions which call for climatic treatment, and containing under each heading the names of certain health-resorts likely to be found beneficial in each such condition. We shall not at- tempt to quote the names of all the places mentioned by Dr. Weber ; but, in the main, we shall follow his scheme, and shall add in brackets the names of a few places which are either not specified by him at all, or else are not given under the special heading which is for the moment under consideration. We shall not follow Dr. Weber's Scheme exactly, but shall rather use it as a framework upon which to con- struct our own ; and we regret that, except in the in- stance just mentioned of the introduction of bracketed passages, it will be impossible to indicate with precision how far we have deviated from our type by omission or by the insertion of original matter. Consequently the authority of Dr. Weber can by no means be claimed for this index portion of our article, taken as a whole ; while, at the same time, the writer must acknowledge his in- debtedness to him for the plan or scheme here followed, as well as for very many of the statements therein contained. 1. Bronchial Catarrh, including Chronic Bronchitis, without Cardiac Complications or Emphysema.-(a) When expectoration is profuse: In winter-Dry and warm cli- mates, e.g., Egypt, the Riviera. [Arizona and San Antonio, Tex., may, perhaps, be added to this list, although pos- sessing less equable climates than those of Egypt and the Riviera; Thomasville, Aiken, and Augusta may also be added.] In summer-Seaside or mountain resorts [Col- orado Springs, Asheville, St. Paul, Minn., San Diego, Cal., etc.]. 533 Heal Hi-Resorts. Health-Resorts. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. siderable Loss of Lung-tissue:-In winter-Dr. Weber recommends warm coast resorts, like those on the Riviera or like Madeira ; the former when expectoration is abun- dant, the latter when it is scanty in amount. He also advises resort to places protected from the wind and sur- rounded by pine woods like, Arcachon [Aiken, Thomas- ville, etc.]. In summer-Inland resorts of moderate elevation are recommended by Dr. Weber, except after subsidence of the more acute conditions, when he con- siders "high-altitude" resorts likely to prove most bene- ficial. (/) General and Progressing Phthisis, with Formation of Cavities :-In such cases but little can be hoped for from climatic treatment. Such is the opinion of Dr. Weber, and such the common opinion. " High-altitude " resorts, Dr. Weber tells us, are not to be recommended, while easy accessibility of any resort is a great desider- atum, and warm, sunny, sheltered sea-side places, like Mentone, he regards as those most desirable. (g) Acute Tubercular Phthisis:-Short journeys or none should be undertaken. Next to nothing can be hoped for from climatic treatment. (h) Tendency to Haemoptysis :-In haemorrhagic cases, when not too far advanced, Dr. Weber prefers high alti- tudes to low-lying inland resorts, and quotes Drs. Denison and Solly, of Colorado, and Dr. Spengler, of Davos, in support of this position. Haemoptysis, he says, is an ac- cident which occurs less frequently at "high-altitude" stations than at those of lower elevation. " Sea-voyages and sea-side resorts are not excluded" by the presence of this tendency to haemorrhage. (i) Profuse Sweating is a symptom of phthisis es- pecially likely to be alleviated at "high-altitude" sta- tions. (f) Diarrhoea of Phthisis, when no ulceration of the bowels is present, is best alleviated by resort to high alti- tudes ; is less apt to be checked at dry sea-side stations, and is aggravated by a warm and damp climate. The same is true of anorexia and of general debility. (&) Tubercular Laryngitis:-Occasionally healed, when in an early stage, by moist and. warm sea-side climates, or by a voyage in tropical seas. "High-altitude" resorts contra-indicated. (I) Non-progressing Phthisis, without fever, contra- indicates moist, warm climates. High altitudes are ad- visable unless the loss of lung-tissue has been very great. At first change of climate is desirable (e.g., Egypt, Nubia, some warm and dry sea-side resort, etc., in winter ; a cool coast station, or a mountain resort of greater or less elevation, in summer); later on the patient is recom- mended by Dr. Weber to select for permanent residence any spot which he has found to agree well with him. (m) Prophylaxis against Phthisis :-Change of climate, sea-side resorts, and "high altitudes" all recommended ; the latter especially for children having defective thoracic development. 7. Scrofula.-Sea-side resorts, sea-voyages, and "high- altitude " resorts. The two former preferable to the latter. 8. Rheumatism and Gout.-Warmth, dryness, and abundance of sunshine are the climatic factors indicated [Egypt, Alicante, the Riviera, Aiken, Thomasville, in- land Florida stations, etc.]. When recourse is had to sea-side stations the tendency of sea-air to produce con- stipation is a thing to be guarded against, and to be reme- died, if necessary, by mild medication (Weber). 9. Cardiac Affections.-The same climatic treatment as was just recommended for rheumatism and gout; " high altitudes " to be avoided, as a rule. (See remarks under Bronchitis with Cardiac Complications.) Dr. Weber specially warns his readers against the risk from apoplexy attending a resort to "high altitudes" in the case of a patient giving symptoms of atheromatous degeneration of the arteries. 10. Renal Diseases.-Warm, dry climates in winter ; in summer, dryness and medium elevation above sea-level, are recommended by Dr. Weber. 11. Genito-Urinary Organs, Chronic Catarrh of.- Warm and moderately dry climates. A long sea-voyage is sometimes useful, on account chiefly of the enforced and protracted rest involved. 12. Digestive Apparatus, Diseases of.-Mere travelling, without special regard to the climate of the resorts visited, is often beneficial. High altitudes benefit some cases. When occurring in elderly persons these affections call for treatment by resort to a warm, dry, and sunny climate in winter, while in summer mountain resorts of medium elevation or cool sea-side resorts are beneficial. (But see under Cardiac Affections, and Chronic Bron- chitis with Cardiac Complications.) The usefulness of many mineral-spring resorts in cases of this kind will, of course, be borne in mind [Mentone, Algiers, St. Au- gustine, the Bermudas, etc., in winter; Vichy, Carlsbad, Ems, Ischl, Richfield Springs, Saratoga, etc., in summer], 13. Diseases of the Nervous System.- (a) Mental Depression :-Travelling is often very bene ficial. Egypt, Southern Italy, Sicily, and Spain are speci- fied by Dr. Weber among regions to be visited during the winter season. [Algiers, Greece, and Palestine may be added to this list.] Travelling in the mountains is bene- ficial during the summer. (See, however, remarks under subsections 2 and 9.) Dr. Weber tells us also that he has often found a winter passed at Rome useful in such cases. [The writer doubts the expediency of this plan in all cases, because of the prevalence of rainy weather at Rome during the mid-winter season. A sirocco wind in Rome or a wet January day is anything but cheering. So far as mere climate is concerned, Colorado Springs, Aiken, Thomasville, and the Florida resorts should be beneficial in winter, but the constant sight of invalids at such places would hardly be cheering to the mentally depressed; and unquestionably, in the point of possessing facilities for mental distraction, the United States health-resorts are, and probably always will be, vastly inferior to most of those in Europe. Mental distraction is the great desider- atum in a case of mental depression, and special stress is very properly laid upon this point by Dr. Weber, Whose selection of health-resorts for cases of this variety is based upon this consideration. The sirocco winds are about the only blemish, so far as concerns the pathologi- cal condition in question, in the climate of the Mediterra- nean Basin, but they do blow occasionally at all stations situated along its shores ; and it would be well for the invalid to counteract their depressing effect, so far as pos- sible, by resorting at mid-winter to the sunniest and dri- est stations, such as those in Egypt or along the Spanish coast-to pass December, February, and March at Rome, or in Greece or Sicily ; visit the Riviera in April or No- vember, and Northern Italy in May. A trip to Southern California in winter, and to Colorado in summer, might be useful in such cases.] (b) Mental Exhaustion from Overwork, etc. :-The cli- mato-therapy of this condition is about the same as that found beneficial to cases of mental depression. A sea- voyage is often serviceable to the overworked business man, because he is, for the time being, completely cut off from business surroundings and from business news. High altitudes are often beneficial to this class of cases, provided they retain a fair amount of physical strength. (See, however, remarks under subsections 2, 9, and 12.) (c) Hypochondriasis :-Climatic treatment the same as that for mental depression. (rt) Symptoms pertaining to that Condition which has been happily termed "the Borderland of Insanity":- Frequent change of scene and travelling under the guidance and with the companionship of a physician are often beneficial. High altitudes sometimes hurtful, some- times helpful. 4 (0 Hysteria:-Choice of climate is very difficult in these cases. The Western Riviera is frequently bad for them. Perhaps the best choice would be that having for its basis the adoption of a place where the climate, the " habitual weather," is known to be identical with what- ever variety of weather experience has proved to suit the patient best when he is at home. (/) Neuralgia :-The Western Riviera is often bad for these cases. The cause of the neuralgia is the key to the choice of a health-resort. 534 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Health-Resorts. Health-Resorts. (g) Nervous Asthma:-In these cases also the climatic conditions of the Western Riviera sometimes prove de- cidedly deleterious. There is no rule for the selection of a health-resort in a case of nervous asthma. Some pa- tients are benefited by resort to the sea-coast; some by re- sort to the mountains. [Bethlehem, N. IL, Fire Island, Block Island, and the higher points in the Catskill Mountains, and in the Adirondacks, Asheville, Colorado Springs, etc., may be suggested as resorts worthy of trial in these cases.] 14. Locomotor Ataxy.-Dryness, sunshine, and warmth appear to be indicated. Dr. Weber recommends Egypt, Algiers, and Palermo in the winter season, Rome and Naples in autumn and spring, Ischia and Capri in sum- mer. This treatment, continued for several years and combined with yachting, seems to have caused decided and lasting improvement in two of his cases. These pa- tients passed a portion of their time (during the summer) in England, so that it is difficult to judge how far the climatic factors of dryness and sunshineare to be credited with the improvement observed. 15. Diabetes Mellitus.-Sunshine, moderate dryness, and moderate warmth are indicated as good adjuncts to medicinal treatment. " The psychical conditions call for especial attention " (Weber). [Florida resorts, Aiken, Thomasville, Southern California, Mentone and similar Riviera resorts, Alexandria, Cairo, Algiers, etc.] 16. Basedow's Disease and other Similar Affections of the Vaso-motor Apparatus.-Dr. Weber recommends that ex- tremes of heat and of cold be avoided ; places having moderately warm, moderately dry, and equable climates are the best. Social opportunities and facilities for amuse- ment and distraction are desirable ; but all excitement is to be avoided. He commends mountain stations of moderate elevation for the summer season, but goes on to say that excellent results, in his experience, have been obtained where the patients in the early stages of the affection took up their residence for a considerable length of time at such places as St. Moritz, Pontresina, the Bel Alp, the Ma- deraner Valley, and the Righi-of which five points the first three certainly belong within the category of " high- altitude " stations, while the last two (elevation about 5,000 feet) can hardly be considered stations of moderate elevation. 17. Chlorosis.-Sunshine and facilities for abundant out-of-door exercise of a nature not liable to cause over- fatigue. In winter-Pallanza, Meran, Montreux [Aiken, Thomasville, Florida resorts, Southern California, Lake- wood, etc.] ; sea-side resorts, when sea-air does not dis- agree with the patient, such asVentnor, Bournemouth, Brighton, the Eastern and Western Rivieras. In sum- mer-Mountain resorts of various degrees of altitude, ac- cording to the presence or absence of concomitant heart lesions, etc. ; sea-side stations of the cooler class, such as Folkestone, Eastbourne, Lowestoft, Scarborough [Block Island, Nantucket, etc.]. In slight cases, and for those who have in great measure recovered, Dr. Weber recom- mends Florence in the spring, Rome in winter and spring, Naples in autumn, winter, and spring, Castellamare, Sor- rento, Ischia, and Capri in autumn and spring. 18. Anaemia due to other Causes.-Sea-air is advisable when amenorrheea is present, and deleterious when men- orrhagia exists. In anaemia resulting from malarial dis- ease mountain resorts and the drier sea-side stations prove beneficial. 19. Leucocythmmia and Lymphadenoma. - Advanced cases are but little helped by climatic treatment. Dr. Weber reports two cases of this kind (probably not far advanced) which seemed to have derived benefit from a long yacht voyage, combined with occasional landings and sojourn in Egypt and Algiers. 20. Convalescence from Acute Diseases.-After whoop- ing-cough and diphtheria sea-air is most beneficial; after scarlatina and typhoid fever warm and sunny spots are to be chosen, whether they be inland or sea-side resorts. The resort first selected should lie as little distant as pos- sible from the patient's home. Dr. J. Burney Yeo gives his voice decidedly against either sea-side or mountain resorts in the early stage of convalescence from any debilitating febrile affection, re- garding both as too exciting, too stimulating ; and he pre- fers " pure, unexciting country-air, in a locality where the patient can be thoroughly protected from cold winds, and where he can ' bathe in the sunshine or slumber in the shade. ' " 21. Disturbances in the Nervous System, in the Cir- culation, etc., attending the Two Principal "Climacteric Periods"-Dr. Weber expresses the opinion that the disturbances which are alluded to under this head- ing, and which are commonly regarded as belonging properly to the period of the menopause, also (less frequently, to be sure, yet oftener than is supposed by many) occur as phenomena attendant upon the period of puberty. He tells us that, in his opinion, such disturb- ances sometimes attend in both sexes the two principal climacteric periods-that of commencing senile decline, and that of the entry upon full organic maturity. These conditions of disturbed balance in the animal economy he thinks may often be beneficially treated by a resort to the expedient of travel, by having recourse to change of scene and of climatic surroundings. In summer the sea- side resorts and places of moderate elevation among the mountains, in the colder months the sunny and moder- ately dry winter stations, he regards as places of sojourn likely to prove beneficial under these temporary condi- tions of disturbed balance; and, in addition to whathq terms the " officinal " resorts, he specifies Home, the Bay of Naples, Sicily, Spain, Palestine, and Greece as good places to be visited under these circumstances. This point is mentioned because, to the present writer, it seems likely to be of occasional service, at least in the practice of neurological and gynaecological specialists. It is, however, precisely one of those ideas, or suggestions, which is liable to be exaggerated, and to be abused through that mischievous over-nicety in diagnosis which is one of those errors against which all physicians should be on their guard. 22. Conditions of Retarded Development.-For these Dr. Weber advises sea-air, and both the higher and less ele- vated mountain resorts. 23. Senile Changes, both Functional and Organic.-Evi- dences of simple senility, whether occurring in due season or prematurely, are said by Dr. Weber to be not infre- quently mistaken for the symptoms of some illness, and, for the most part, to be treated to no purpose by the use of drugs. Low temperatures, cold winds, rapidly occurring changes of weather, and a high degree of relative humid- ity in the atmosphere, are badly borne. In winter warm, sunny, dry climates are indicated, such as Cannes, Nice, Mentone, San Remo, Pegli, Algiers, Palermo [Florida re- sorts], or the lower-lying Alpine stations (such as Pal- lanza, Meran, Montreux, Lugano) may be useful. ' ' High- altitude " stations are to be avoided at all seasons, but in summer mountain resorts of moderate elevation may be chosen. Respecting the relative value of sea-side and of mountain resorts, the following opinion is expressed by Dr. J. Burney Yeo ("Climate and Health-Resorts," p. 48): "Speaking within very wide limits, mountain- air is less suitable to persons advanced in years than sea air. The very stimulus to muscular exertion which mountain-air produces is, to persons much past middle life, often a pitfall and a snare. Q,ui va doucejnent, va loin, is especially applicable to this period of life, and the state of feverish activity which is sometimes induced in aged persons in the mountains is not by any means for their good." Dr. Weber recommends moderate exercise both of body and mind, in order to combat a tendency to torpor of all the functions which is apt to be characteristic of old age. * In pursuance of this idea he wisely recommends for this class of persons a sojourn at such resorts as Naples, * Cf. the following passage in Cicero's De Senectute:-" Utemlum exercitationibus modicis. . . . Nec vero corpori soli subveniendum est, sed menti atque animo multo niagis. Nam hwc quoque, nisi tam- quam lumini oleum instilles, exstinguuntur senectute." (Physical exercise should be taken in moderation. . . . Nor must the body only be helped along in this way, but the mind and the spirit much more ; for these also, unless you pour oil into them as you would into a lamp, are quenched out by old age. 535 Health-Resorts. Hearing. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Rome, Florence, and Venice; adding to the list the names of several places which are hardly to be considered as common health-resorts, but which (as being great cen- tres of art and of civilization) may be veritable health-pre- serving resorts and life-prolonging resorts for those persons now under consideration-to wit, Paris, Dresden, Berlin, London, and Munich. He also speaks of the benefits derived by old Londoners from temporary sojourn at Brighton and Folkestone, and of the usefulness of short visits to London on the part of elderly persons who ha- bitually reside in the country districts of England, and in the smaller English towns (" Bewohner der Provinzen "); and he commends the benefits derivable from simple change of scene in general. IV. General Qualifications (not Climatic) Proper to a Good Health-resort, etc.-A good health-resort, in addition to its peculiar climatic qualifications, should be also a place provided with an abundant supply of good drinking-water, and having an efficient system of drain- age and sewerage. Its hotels or boarding-houses should also be properly plumbed and ventilated, and should, of course, provide an abundance of good food-that is, of food suitable in its nature and suitable in its method of preparation for the use of invalids. Too often, alas, these most important matters are in a measure neglected or for- gotten ; such is the case, not only at a number of our own American health-resorts, but also at many of those in Europe ; and, in consequence, a very large number of places whose climatic features would render them excep- tionally desirable resorts are to-day practically useless to the invalid. Nay, more than this, they may prove, and not infrequently do prove, positively detrimental, occa- sionally even fatal, to those who risk a residence amid their unhygienic surroundings. Plenty of pure air and an abundance of really good food and of wholesome wa- ter are necessities to the invalid. The exchange of bad climate, combined with good hygiene, for good climate, associated with bad hygiene, is a poor one. The nature of the soil is a matter of importance, both as influencing the local humidity of the atmosphere and as facilitating or hindering the introduction and proper maintenance of an efficient system of drainage. The ignorance and the ra- pacity of landlords is usually to blame for the long contin- uance of hygienic defects at any resort, and it is to be hoped that as time goes on such defects will become less and less frequent, until they shall be as rare as now they are com- mon. Meantime, in the case of any particular resort pos- sessing such defects, the invalid will do well to avoid it until assured on competent authority that they have been removed. The duty of the physician in this matter is perfectly clear-he should be extremely cautious how he places confidence in the pamphlets, etc., which extol the merits of any resort, should read them very critically, and should be on his guard against statements which appear likely to have been colored by self-interest or by ignorant and "provincial" enthusiasm. The establishment of good " sanatoria," or hotels under medical management, is, perhaps, desirable for the con- venience of certain classes of invalids ; but a really good hotel under "lay" management, and a competent "local practitioner " living in the neighborhood, is an arrange- ment which answers usually quite as well. The entrance of methods peculiar to "quackery" of one sort or an- other within the walls of sanatoria is a thing not un- known. Facilities for mental occupation and for suitable out-of-door exercise (riding, driving, etc.) are important features of any health-resort. Reference was made just now to the " local practitioner." Of his presence we are always assured ; of his competence, perhaps, we who re- side in large cities are too prone to form an unfavorable opinion. The lesson of " Doctor Antonio " should not be forgot- ten, and the invalid and the physician who sends him to any particular resort should both bear in mind that a man's talent and learning is not always proportionate to the size of the town in which he resides, and that (par- ticularly in matters pertaining to local hygiene, to local endemics, to special local types in the manifestation of disease, and to local risks to health in general) the " local physician " should be, and often is, a better judge and a wiser counsellor than can easily be the case with his distant brother practitioner. In this connection it may be well to remark that the larger and more prominent health- resorts should afford a good field for the specialist, inas- much as his services are liable to be a convenience, or even a necessity, to many resorting thither; and inas- much as he is likely, in carrying out a regimen of internal medication or of topical applications, to be unhampered by adverse climatic surroundings. The violence of the contest between good medication or suitable local applica- tions, on the one hand, and bad and unsuitable weather, on the other, is, in his case, reduced to a minimum ; and his success should therefore be raised to a maximum. Finally, it is worthy of mention that easy accessibility is a strong point in favor of any health-resort, and it is hardly necessary to remind the reader that in a case of grave and debilitating illness it will be advisable for the patient to break the journey by stopping at one or more intermediate stations. In going from a colder to a warmer climate, or from a lower- to a higher-lying sta- tion, it is not infrequently advisable to do so by degrees, stopping at intermediate points. This plan it is espe- cially advisable that the patient shall follow who is re- turning from a warm and equable climate to one which is decidedly cooler and more variable. Abrupt and sud- den descents from great elevations are also at times to be avoided. In this matter "peu d pea faut," as Dr. Fonssagrives says, adopting the expression from a dic- tum of Ambroise Pare respecting the change from bad to good habits of living. The various subjects relating to the qualifications proper to a good climatic health-resort, to the effects of different varieties of climate upon different pathological conditions, and to the rules which should be followed in estimating the yalue of different climatic " cures," have now been treated, so far as the limits of a handbook article will allow. The rule of brevity laid down by the writer in the early part of the article may have seemed to some readers to have been too closely followed in some sections, and to have been unduly relaxed in others ; but if it shall appear, upon careful consideration, that the relaxings of the rule were no greater than was necessary in order to make clear the meaning, while the instances of its closer following were only such as were demanded in the interests of justifiable condensation, and that, upon the whole, this contribution to the Handbook has subserved the purpose of imparting practical instruction in the choice of health-resorts, and of laying down such rules for the study of climato-therapeutics as shall tend to establish this infant science upon a solid foundation-■ it is certain that its presentation will not have been made altogether in vain. Huntington Richards. HEARING, PHYSIOLOGY OF. Definition.-Hear- ing is the faculty of the perception of sound. This faculty depends upon the proper reception and transmission of sound vibrations through the medium of the external and middle ear, and the action of these vibrations in the in- ternal ear upon the terminal organs of the auditory nerve, which convey the impressions of sound to the portions of the brain where they are perceived. The impression of sound may be produced upon the auditory nerve by certain forms of irritation without the intervention of the ear, and it may originate in the brain, as, for example, in dreams and hallucinal insanity. These latter impressions are to be distinguished from the normal memory of sounds. The psychical and pathological phenomena of hearing are elsewhere discussed. The present article deals with the normal physiological transmission and perception of sound. Owing to the extreme minuteness and delicacy of the internal and middle ears, the func- tions of their several parts are imperfectly understood, and there are many conflicting theories and experiments regarding them. Where such is the case, an effort will be made to state fairly the different views which appear the most plausible and let the reader balance them. Hearing comprises a conception of the character of sound-its intensity or volume, pitch, timbre or quality. 536 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Health-Resorts. Hearing. duration, direction, distance, variety, its influence upon reflex action, etc. The function of the ear is also in part to make sound more perfect, to increase vibrations by resonance, and to resolve complex sound vibrations into simpler ones, called " pendulum vibrations " (Helmholtz). A " good ear " is a conventional expression, implying not so much acuteness of hearing as accurate discrimination between different sounds, especially musical notes. A moderately deaf person may sometimes retain a better ' ' ear for music " than one whose hearing is more acute but without discrimination. This difference is partly a result of mental cultivation, but principally of functional delicacy of the ear itself. Normally, sound is not men- tally referred to the ear itself, but is projected to a dis- tance from the body. Before discussing the physiological effects of sound, it is well to briefly review its principal physical phenomena. Sound is a form of wave-motion in which the mole- cules vibrate to and fro horizontally. When an elastic body is struck its molecules alternately approach and re- cede from each other with a velocity which depends upon the form, size, and molecular composition of the body, and they impart their motion through contact with any other surrounding body or elastic medium, such as air. Sound waves are in part reflected in passing from a rarer to a denser medium. Sound vibrations originating in a solid body are easily taken up by the air, with an increase in the amplitude of the molecular movement, owing to the greater elasticity Harmony.-When two tones are simultaneously pro- duced, if their wave-lengths stand to each other in the ratio of simple multiples, so that while the low note makes one vibration the high note makes two, three, or four, etc., the notes are said to be in harmony or concord, and the result is consonance. The intervals between cer- tain tones are expressed by very simple ratios, which are easiest and pleasantest to hear. They are the ratios of the notes of the human voice in ordinary speaking and singing. The simplest ratio is f, and to this the name " octave " is given ; the higher note in this case has double Fig. 1602. the number of vibrations of the lower. Notes are in ac- cord when several tones meet which have consonant in- tervals. If the wave-lengths do not stand in the ratio of simple multiples, interference results-that is, whenever the crests of the two waves coincide the sound is inten- sified, and where the hollow of one wave corresponds in point of time with the crest of another the sounu is dimin- ished (Figs. 1602, 1603). Beats.-These variations in tonal intensity are called "beats." The beats are heard more frequently as the difference between the number of vibrations of the two tones is increased. If the beats occur at long intervals, they are perceived as distinctly isolated. Dissonance.-If beats occur in rapid succession, they produce a whirring, unharmonious sound, or dissonance, which is often distressing and may even be painful to hear. Dissonance in- creases with the frequency of beats up to thirty-three per second, which rate is the most disagreeable to the ear. After this maximum, dissonance de- creases and approaches harmony or consonance. If beats occur more rapid- ly than one hundred and thirty-three per second, they become fused and are no longer separately distinguishable. If beats occur frequently anyone can detect them, but if they occur very seldom they are less readily deter- mined by an uneducated ear. Two tones of respectively thirty-three and thirty-four vibrations are once increased in a second by meeting of their wave-crests, and once di- minished through interference. Such minute differences help us in part to discriminate between different sounds (Wundt). Dissonance may be due to intermission in the perception of sounds, as well as to beats. The pitch of a sound is the rate or period of the vibra- Fig. 1601.-Tuning-fork Registering its Vibrations. (Ranke.) A, The fork; b, needle; B, B, tracing-paper ; c, d, curve of vibrations of the needle. of the air ; but the extent of this movement is dimin- ished again on passing from the air to solid or fluid media. Membranes.-If, however, a tense membrane be inter- posed between the air and a fluid or solid medium, so that it is free to vibrate, the aerial vibrations lose little or none of their intensity. It will be seen, from a review of the anatomy of the middle ear (see below), that these physi- cal conditions are exactly fulfilled. Were it not for the membranes of the middle ear, the sound waves would lose intensity, in passing from the air to the bones, and lymph, to such an extent as to become for the most part inaudible. Tuning-forks.-The vibrations of an elastic body which give rise to sound waves are made graphic by a simple apparatus. A needle is attached to an arm of a tuning- fork, at a right angle (Fig. 1601). Every movement of the fork is communicated to the needle, and if a piece of smoked glass or card-board be moved past the needle with a uniform velocity, regulated by clock-work, a tracing of the vibrations of the needle is scratched upon it. The tracing records the number of vibrations occurring in a given time, and their extent or amplitude. Such a curve is very simple, and its analogy to the curve of motion of a pendulum, or metal rod with one end fixed, led Helm- holtz to describe this form of vibration as " pendulum vi- bration." The form of pendulum vibration-no matter what its velocity-is uniform, and like other pendulum vibrations, but the curve produced by the combination of several such vibrations of different velocities may take any shape (Fig. 1602). A tone, technically speaking, is a sound produced by a simple pendulum vibration (Helmholtz). Fig. 1603.-Curves Produced by Vibrations of Different Velocities and Amplitude. The black line indicates the curve produced by the com- bination of two different tones marked by dotted lines. (Wundt.) tions producing it. The pitch is higher the more frequent the vibrations become, and, conversely, it is lower the less frequent they become in a second. A noise is distinguished from a tone by the irregularity 537 Hearing. Hearing. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of its vibrations. It has also been defined as a rapid change of different sound perceptions. No absolute line can be drawn between noises and musical sounds com- posed of tones, for in many noises there is a pitch which indicates that, among the many vibrations composing them, there is a periodicity with fixed intervals. Helm- holtz regards a noise as an irregular mass of tones whose vibrations interfere with each other. Wundt differs from this view, on the ground that the shrill noises are pitched above tones, and he argues for a separate perception of noise. Disharmony.-When the variety of vibrations is great, and their intervals are irregular and out of proportion, they produce discordance, dissonance, or disharmony. Dissonance may be partial, due to the interference of certain partial tones which form beats while the main tones are normal. If this effect be very slight, it pro- duces an effect of unrest and melancholy. The amplitude of the vibrations of a sound determines its intensity, which we recognize as a degree of loudness. The greater the amplitude of vibration the louder the sound produced, and conversely. The intensity of a tone is proportional to the square of the amplitude of the vi- bration of the sounding body. It is generally stated to be inversely proportional to the square of the distance of the source of the sound from the ear. (Vierordt and others do not regard this formula as exact.) The sounds of the voice and of musical instruments are all composed of many simple tones, whose vibrations reach the ear simultaneously. The simpler and more regular the vibrations, the purer the tone. Among these mon illustration of this principle is produced by singing a single note over the stretched wires of a piano with the dampers raised. The quality, timbre, tone-color (Klangfarbe), musical color are expressions used to denote the property by which we discriminate between the sounds of the same note when produced by different instruments, as the flute, horn, violin, human voice. The quality of a note de- pends upon the number, variety, and intensity of its various harmonic overtones. For a given instrument these overtones are characteristic. Even tuning-forks are said to have feeble overtones. The limits of audibility are not very accurately defined. Sound impulses which occur with a rapidity of less than sixteen per second (Helmholtz and many others) may be separately distinguished as single dull impulses, beats, or puffs; but if their frequency equals or exceeds sixteen per second they are perceived only as being continuous. On the other hand, when sonorous vibrations reach a certain frequency, their amplitude is so small as not to affect the ear. Sometimes the fundamental tone is in- audible, while the overtones produced by more rapid vibrations can be heard. The number of vibrations per second which produce audible tones is variously esti- mated by different observers. Helmholtz, Despretz, Tyndall, and others agree in fixing the limits of audi- bility at 16 and 38,000 vibrations per second, or a range of about eleven octaves. Despretz estimates the highest note of a violin at 38,016 ; this is painful to the ear. But few of these notes-those only between 40 and 4,000, or, in round numbers, seven octaves (Ranke, Tyndall)-can be employed in music. Many persons with normal ears can hear a tone higher with one ear than the other. The musical limit is attained where the power of the ear to unite vibrations to a tone ceases (Helmholtz). Ob- viously this varies very greatly in different individuals. An ingenious adjustable whistle has been devised by Galton for testing the maximum number of vibrations audible by human and other ears. When screwed up to its highest pitch the whistle gives eighty-four thousand vi- brations per second. Galton finds that when the limit of hearing for high notes is approached the sound becomes fainter, and after the limit is passed it is succeeded by a feeling akin to vertigo. The power of hearing shrill notes has nothing to do with acuteness of hearing, " any more than a wide range of the key-board of a piano has to do with the sound of the individual strings." It is rare for anyone to hear vibrations which are more rapid than thirty-five thousand per second. Some people never hear the squeak of a bat or a mouse, or the chirrup of a cricket, or even a house-sparrow. Some persons can hear grave more readily than acute notes, and a trained ear can distinguish half vibrations which an ordinary ear cannot do. Thus some cars are not disturbed by hearing a half-note flat or sharp, while others experience a pain- ful feeling. The exact discrimination of musical pitch is confined within narrow limits, especially for high notes (Wundt). Practised musicians will distinguish between notes the difference of which is not greater than 1 in 1,000 (Power). The Anatomy of the Ear.-The anatomy of the external ear is elsewhere described, in vol. i., pp. 417- 443. The anatomy of the internal ear, or labyrinth, is de- tailed in vol. ii., pp. 562-567. The Anatomy of the Middle Ear is as follows: The middle ear, or tympanum, is situated in the petrous por- tion of the temporal bone, where it is secure from injury. It is an irregular cavity presenting six sides for examina- tion. The roof is a thin plate of bone which separates Fig. 1605.-Oblong Resonator. (Helmholtz.) Fig. 1604.-Spherical Resonator. (Helmholtz.) simple tones forming a compound series, one is of greater intensity-that is, its vibrations are of greater amplitude than the vibrations of the other tones of the series, or "tone picture." This tone is called the fundamental tone, ground tone, or key-note, and it determines the pitch of the whole series. The remaining notes of the series are all weaker. They are called "overtones" ("upper tones"), and their number and intensity vary greatly in different instruments. The fundamental tone is not always the most intense (Kanke). If the overtones are of too high pitch, or too numer- ous, they overwhelm the fundamental tone, and the re- sult is a hollow or "tinkling" sound. The overtones are separated and analyzed by means of resonators. Resonators are of various kinds. Those used largely by Ludwig and Helmholtz are hollow spheres of different sizes, open at one pole to admit the vibrations of the air, and having an open tube at the opposite pole for insertion in the external ear. Each sphere has only unharmonic overtones of its own, so that when complex vibrations reach it, among which occurs either the fundamental tone of the sphere or some simple multiple of it, as the octave, the air contained in the sphere is thrown into sympathetic vibration, and alone intensifies the fundamental tone. Thus each sphere separates its own fundamental tone from the various vibrations brought to it, and a complex sound can be analyzed. Analyzing apparatus may also be made of stretched strings or membranes. When a compound tone is sounded near, the string which is in unison with the fundamental tone will be thrown into violent vibra- tion. At the same time certain other strings will vibrate less extensively in unison with the overtones. A com- 538 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hearing;. Hearing. the tympanum from the cavity of the brain. The floor is narrowed by the approaching walls, and is formed by a thin plate of bone which overlies the jugular fossa. The external wall is partly bony, but it contains a large ori- fice, which is closed by the membrana tympani. The inner wall presents an uneven surface formed by the ridge of the aquseductus Fallopii, the promontory, and the pyr- amid (see Ear, Anat, of Labyrinth, vol. ii., p. 563), be- sides two orifices, the fenestra ovalis and fenestra ro- tunda. The fenestra ovalis is in the upper part of the inner wall, just beneath a bony ridge which covers the aque- meatus auditorius externus, at an angle of forty to fifty five degrees (Fig. 1606, C). It measures 9.5 to 10 mm. by 8 mm. in diameter (Kessel). It is 0.1 mm. thick, and its superficial area is about 50 sq. mm. The long axis is directed from behind and above, downward and forward ; the short axis, from before and above, downward and backward. The membrane is retracted toward the tympa- num by the handle of the malleus, which is attached over Fig. 1608.-Tympanic Cavity Opened from Above. (Helmholtz.) e. g, Ligamentum externum; m, head of the malleus ; i, the body of the anvil; bi, the end of its short process; Tu, entrance to the Eustachian tube; St, stirrup ; AC.st., tendon of stapedius muscle; T.t., tendon of tensor tympani muscle; Ch. T, chorda tympani nerve; Sp.t., spina tympanica major: C.m., strong tendinous fibres stretching from the short process of the anvil to the posterior wall of tympanum. Fig. 1606.-The Middle Ear (left). (After Ranke.) Magnified «/i- External auditory canal; C, membrana tympani; H\ malleus; 8. stapes; LS, ligamentum superius. more than half of the long diameter of the membrane (see below, Ossicula) (Fig. 1607, M). It is thus drawn into the shape of a cone with a broad base (Fig. 1606, (7), the apex or umbilicus being a little below the centre of the membrane (Figs. 1607, 1609). The membrane is composed of three layers : a middle fibrous layer and an outer and inner layer, derived re- spectively from the investments of the meatus and the tympanum. The fibres of the middle layer, or substantia propria, are radiating (external) and circular (internal). The radiating fibres proceed from the insertion of the handle of the malleus toward the periphery (Figs. 1607, 1609), where the circular fibres become more and more duct of Fallopius, that transmits the portio dura of the seventh nerve. It leads into the vestibule, but it is closed by the stapes and its ligaments (see Ear, Anat, of Laby- rinth, vol. ii., p. 562). Below this fenestra is the prom- ontory, or tuber cochleae, upon which lies the tympanic plexus. The fenestra rotunda is beneath and behind the promontory. It leads into the scala tympani, and it is closed by a delicate membrane (see Ear, Anat, of Laby- rinth, vol. ii., p. 563). The posterior wall communicates above with the mastoid cells, through one large and sev- eral small orifices. The anterior wall is in close proxim- Fig. 1609.-The Left Membrana Tympani and Ossicula seen from the Meatus. (After Ranke.) Diagrammatic : a, Head of malleus, which joins the body of the incus b at the joint e ; d, long process of incus project- ing backward and downward; c, d, membrana Schrapnelli; ax, ax, axis of rotation of malleus and incus. Fig. 1607.-Left Membrana Tympani and Ossicula seen from Within. (Landois.) Diagrammatic : .If, manubrium ; T, insertion of tensor tympani muscle ; A, head; IF, long process of malleus ; a, incus ; K, short process ; I, long process of incus; /S', plate of stapes. Ax, Ax, axis of rotation of malleus and incus ; S, " cogged-wheel " arrangement between head of malleus and incus. dense. Owing to the peculiar interlacement of these two sets of fibres, toward the periphery the radiating fibres are curved, and the margin of the membrane is bowed a little outward (Quain). There are a few additional fibres of irregular arrangement. The inner layer of the membrana tympani is composed of a delicate layer of squamous epithelium. At the upper part of the membrana tympani the bony ring presents the small notch of Rivinus, which is filled ity to the carotid artery. It contains the orifice of the Eustachian tube, in the upper part of which lies a small muscle, the tensor tympani. The membrana tympani is an irregular elliptical disk, fixed obliquely in a bony groove at the inner end of the 539 Hearing. Hearing. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by connective tissue forming the membrana flaccida Schrapnelli (Fig. 1609, c, d). If the planes of the two tympanic membranes were prolonged anteriorly, they would meet at an angle of 130°. The tympanic mem- brane has numerous nerves, vessels, and lymphatics. Its normal color is gray, and it is sufficiently transparent to admit of a view of the handle of the malleus from the. meatus. At the anterior and lower part a cone of light is distinctly re- flected from the external surface of the membrane (see Ear, Exami- nation of, vol. ii., p. 573). The Ossicula. The upper part of the tym- panic cavity is occupied by three small bones, the ossicula auditus, which are so articulated as to form a chain of communication be- tween the membrana tympani and fenestra ovalis. The bones are of very irregular shape, but they have been named, from fan- cied resemblance, (1) the hammer, malleus ; (2) the anvil, incus ; (3) the stirrup, stapes. The incus is articulated with the malleus and stapes ; the malleus is joined to the membrana tympani, and the stapes is fastened into tlie fenes- tra ovalis. The malleus and in- cus are placed nearly vertically, and the stapes horizontally. The malleus presents a round head, or capitulum, covered in part by cartilage, which fits into a corresponding groove in the incus, forming a movable articulation (Figs. 1606, 1607). Below the head is a narrow neck, or cervix, and a second enlargement giving attachment to three processes : a long process (p. gracilis), largely ligamentous, which extends obliquely downward and forward ; a short pro- cess (p. brevis), which projects outward (in the natural position) toward the upper part of the membrana tympani (Fig. 1610, P.E. - Fig. 1611, Ml); a handle, or manubrium, which is twisted and tapering, and which passes down- ward, forward, and inward between the middle and inner layers of the membrana tympani (Figs. 1607, 1608, 1610, 1611). It is attached to the fibrous layer of the membrana tym- pani by its perioste- um and by fibrous cartilaginous tissue (Quain). The incus has a body which presents a concave articulation for the head of the malleus, with which bone it forms a joint completed by articu- lar cartilage and syno- vial membrane. From the body proceed : (1) a short process (crus breve), which projects backward and gives attachment to a liga- ment which connects it with the posterior wall of the tympanum in front of the mastoid cells ; (2) a long process (crus longum), which passes vertically down behind the handle of the malleus. At its tip the long process presents a constriction and a flattened tubercle covered by cartilage, the os lenticulare, or Sylvian ossicle. The stapes closely resembles a stirrup. The head is directed outward, and presents a depression for articula- tion with the os lenticulare. The base fits into the fenes- tra ovalis, by an articulation which has been described (see Ear, Anat, of Labyrinth, vol. ii., p. 562). The head and base are connected by two crura, which, with the base, form a triangle filled by a thin membrane. The ligaments of the tympanum are three : (1) The an- terior ligament of the malleus, which connects the ante- Fig. 1612.-Right Tympanic Membrane from Within. X Jk. Tt. ten- sor tympani muscle ; Mcp, head of malleus ; *, handle of malleus ; Jb, short, JI. long, process of incus; Jpl, lenticular process: 1, chorda tympani; 2, septum tubas; 3, Eustachian tube ; 4, membrana tympani. Fig. 1610.-The Incus and Malleus. (After Helmholtz.) T.t., insertion of tensor tympani muscle in the mal- leus ; P.E.. processus gra- cilis ; b, cog-like tooth of the incus; a,a, axis of rotation of the two bones. rior tympanic wall with the base of the processus gracilis (Fig. 1606, Fig. 1611, Ml) and the anterior part of the body of the malleus ; (2) the suspensory ligament of the malleus, which passes outward and downward from the roof of the tympanum to the head of the malleus and controls its outward movement (Quain) ; (3) the posterior ligament of the incus, which extends from the crus breve backward toward the posterior wall (Quain). Arnold and others describe a superior ligament, attaching the body of the incus to the roof of the tympanum, but its existence is not generally admitted. The muscles of the tympanum are two : (1) The tensor tympani lies in an osseous groove above the Eustachian tube (Fig. 1612, Tt). It arises from Fig. 1611.-The Ossicula. (After Henle.) Jf, malleus; J, incus; S, stapes; ifcp, head of malleus ; Me, neck ; if I, processus gra- cilis ; Mm, manubrium; Jc, head; Jb, crus breve; JI, long process of incus; Jpl, os lenticulare ; Sep, head of stapes. Fig. 1613.-Peculiar Pear-shaped Body Found in the Middle Ear. the cartilaginous end of the Eustachian tube, a portion of the sphenoid bone, and upper part of the Eustachian orifice, and proceeds through the Eustachian tube to the tympanum, where, in front of the fenestra ovalis, it curves over the processus cochlearis, and is inserted a little be- 540 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hearing. Hearing. low the processus brevis of the malleus, and spreads out over the anterior border of the maligns for some distance. A small part of the muscle is inserted into the processus cochlearis on the external surface of the petrous bone (Zuckerkandl: Arch. f. Ohrenhk., xx., 2). The muscle is 2.2 centimetres long. It has a strong sheath. (2) The stapedius lies in the descending part of the aquaeductus Fallopii, and passes out of the eminentia pyramidalis forward to the head of the stapes and Syl- vian ossicle, where it is inserted posteriorly. A spicula of bone is sometimes found in the tendon of this muscle. The tympanum is lined with columnar, ciliated epithe- lium (Wendt, Troltsch), excepting over the surfaces of the membranes, ossicula, and muscles, where it is tessel- lated (Sterling, Kessel). Peculiar capsulated, striated corpuscles are described by Politzer and Kessel as exist- ing in the mucous lining of the tympanum.* General, Sketch of the Mechanism of Hearing. -The outer ear and middle ear receive and carry the waves of sound. The labyrinth, or internal ear, with the terminal organs of the auditory nerve, analyze the waves and translate them into nerve irritation. The auditory nerve transfers the irritation to the brain-cells associated with its origin, where the perception of sound takes place. The waves of sound pass into the external auditory meatus, either directly or in part, by reflection from the irregular surface of the external ear, which is adapted to receive and concentrate waves coming from many differ- ent angles. At the bottom of the meatus the waves strike the membrana tympani nearly perpendicularly, and cause it to vibrate. Its movements are transmitted from the inner side by the ossicula. These bones vibrate probably to some extent individually, but chiefly as a whole, and through the stapes they convey the waves through the fenestra ovalis, and set the lymph of the labyrinth into vibration. The air contained in the middle ear is also set in motion by the vibrations of the membrana tympani and the ossicula, and its movements are communicated to the fenestra rotunda. Thence they pass to the lymph con- tained in the scala tympani of the cochlea. This latter mode of transmission is, however, of secondary impor- tance, and may even play no part in communicating im- pressions of sound to the nerve of hearing. Each vibra- tion communicated by the stapes through the fenestra ovalis to the perilymph travels as a wave over the vesti- bule, semi-circular canals, and all parts of the labyrinth, and sets the endolymph in vibration, which in turn is sup- posed to communicate its motion to the hair-cells of the maculae and cristae. The waves of the vestibule pass to the scala vestibuli of the cochlea, ascend to the cupola, and descend through the scala tympani to the fenestra rotunda, where they meet with any vibrations of the tympanic cavity. While traversing the cochlea the vibra- tions in some manner affect the organ of Corti, and gen- erate an irritation in the terminal cells of the cochlear branch of the nervus auditorius. This irritation is trans- ferred to the cerebral auditory centres by the nerve, and here finally the consciousness of sound results. Functions of the External Ear.-The influence of the external ear in the physiology of hearing is disputed. In man, hearing is not impaired by its removal or dis- placement, and acuteness of hearing does not depend upon its size or shape. In birds, and some reptiles which hear acutely, it is absent or rudimentary. From its peculiar shape in man, it must reflect almost as many sound-waves away from the meatus as toward it. Its dimensions are too small to reflect the waves of noises (Mach). There can be no doubt, however, from experi- ments made by Burnett, of Philadelphia, that the auricle aids materially in conveying to the auditory canal some of the more delicate sounds which would otherwise not be perceived. The haematomata which frequently occur in the external ears of the chronic insane, and the aural deformities among idiots, do not usually impair hearing. Filling all the irregularities of the external ear with wax (Schneider) is said to somewhat dampen sounds which strike the ear obliquely. Wild animals, whose safety depends upon the speed of their flight, often keep their ears moving back and forth, to intercept sounds which warn of approaching danger. A horse turns one ear forward to intercept sounds from in front, and the other backward to catch a word from his master. Among wild animals the external ears never droop, except in the elephant (Darwin). Those few per- sons who can move their external ears slightly do not find that the movement influences acuteness or range of hearing. People who are " hard of hearing " seem to de- rive some aid by pressing the external ear forward, and adding the palm of the hand to the receiving surface. At the same time the concha may be raised by the thumb, which straightens the canal a little. In one hundred cases in which the angle of the external ear with the head was measured (Buchanan), the majority of persons heard bet- ter when the ear stood out far from the head. Darwin and Haeckel suggested that evolution has rendered the ex- ternal ear useless to man. The theory is advanced that since sound-waves reach the external ear from all direc- tions, those which strike the surface least obliquely will be less apt to be reflected. The waves which strike the surface of the ear perpendicularly to its tangent of curva- ture at any point are transmitted directly through the solid tissues. Such waves lose so greatly in intensity as to be almost useless (Huxley). The ears are used by animals for emotional expression when angered or excited. In animals which fight with the teeth the ears can be laid back flat against the skull, to prevent their being seized and bitten off. The capital made by phrenologists out of the size and shape of the ears is without foundation. The ears are very vascular, and they are easily congested in blushing. One ear may become congested while the other is pale. In ancient times it was thought that the pinna influenced sexual de- sire, and it was excised in criminals (Sexton : Med. Rec., April 5, 1884). Functions of the Meatus Auditorius Externus.-The external auditory canal, or meatus, is a slightly curved (slightly spiral) tube, which can be readily straightened by drawing the external ear upward and backward. It is 3 to 3.25 ctm. long, 8 to 9 mm. high, and 6 to 8 mm. broad at its opening, which is directed externally. The inner end of the tube is closed by the membrana tympani, which is seen on straightening the tube. The outer third of the canal wall is round and cartilaginous ; the inner two- thirds are narrower, oval, and bony. The canal is lined throughout by squamous epithelium prolonged from the cutaneous layer of the external ear. The lining also con- tains a number of soft fine hairs, sebaceous and cerumi- nous glands, which latter secrete a waxy, sticky sub- stance called cerumen. These glands number from one thousand to two thousand (Buchanan). Cerumen, or " wax," is yellow, and has a strong, pecu- liar odor. It is poorly soluble in water. Its composition is ten per cent, water, twenty-six per cent, free fat, olein and margarin, fifty-two per cent, potassium soap of fatty acids, twelve per cent, insoluble matter. There are pres- ent an albuminate, a bitter principle soluble in water, pigment, and traces of calcium and sodium (Petrequin). The cerumen is mixed with desquamated epithelium and hairs. It does not cover the tympanic membrane, but accu- .mulates at the orifice of the canal. The hairs and ceru- men prevent dust and insects from entering, and they are said to prevent changes of temperature in the canal, which would occur from rapid renewal of the air. The normal temperature of the canal is 0.3° C. less than that of the rectum (Mendel), but it varies considerably (Eitelberg, Ztschr.f. Ohrenhk., xiii., s. 28). It is said to be an index of cerebral temperature in disease (Istamanoff, "Pfliiger's Arch.," 1886, p. 113). In many animals which dive (birds, etc.) the meatus can be closed at will by a valve. In man certain movements of the jaw narrow the meatus. The curved shape of the canal prevents particles of sand and the like from falling directly upon the membrana tympani. Sometimes coarse hairs fill the concha and the * A micro-photograph of one of these bodies may be seen in the Amer- ican Journal of Otology, vol. iv., July 1, 1882 : "Micro-photograph of a Peculiar Pear-shaped Body Found in the Middle Ear," by Albert H. Buck, M.D., New York. The accompanying engraving (Fig. 1613) is copied from a photo-lithographic copy of the original. 541 Hearing. Hearing. ' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mouth of the canal, but they do not appear to interfere with hearing to any extent. Rarely, hairs may reach to the membrana tympani and cause a disagreeable sensa- tion or sound by scratching it (Kessel ; Weir, " Trans. Amer. Otol. Soc.," 3d year). Roughness of the meatus, due to accumulated cerumen or hairs, etc., checks the transmission or reflection of rapid vibrations which strike the canal wall obliquely (Galton). The nerves of the meatus are derived from the auriculo- temporal branch of the trigeminus, and probably from the ramus auricularis of the vagus (Arnold ; Troltsch ; Quain and Fox think, the latter only supplies the pinna). There is a region near the centre of the canal which, when touched, often causes acute pain, and may occasion vomiting and fainting. Coughing-the " ear-cough "- frequently occurs in the same manner (Roosa, loc. cit., p. 202 ; Fox, Brit. Med. Jour., 1869, p. 650). The evi- dence is conflicting regarding the influence of stimulation of the sympathetic nerve upon the blood-vessels of the ear (Berthold, Ztschr.f. Ohrenhh., xii., s. 172). Electric stimulation of the third branch of the trigeminus causes congestion of the aural vessels and salivation (Hirschner, Centralb., 1832, s. 654). The column of air contained in the external meatus acts as a resonator (Lucae, Verhdlg. d. Phys. Ger. zu Berlin, No. 9, 1883). Ordinarily sounds are not much affected by this air, but a tone of the same pitch with that of the meatus produces a shrill, disagree- able sound. Certain high tones resound in the external meatus, but they fail to do so when the meatus is artifi- cially prolonged, or when the tension of the membrana tympani is increased (Helmholtz). The direction of sounds entering the external meatus modifies their distinctness. This is especially true of high notes. Some persons cannot hear a mosquito buzz until it flies directly past the orifice of the meatus, when a sudden "ping" is experienced (Galton). Those waves which enter in the direction of the long axis of the canal are most distinctly transmitted ; hence, turning the head at various angles enables us to judge from what direction the sound waves are most intense, even when one ear is employed alone, although the use of both ears makes the estimation easier. The slight difference in nearness to the source of the sound existing between the two ears is of less moment in estimating a distant sound. A note sounded directly in front of or behind the body in the median plane is usually in either case referred to the front (Kessel ; Tarchanoff, St. Peters. Med. Woch., No. 43, 1878; Rayleigh, Nature, xiv., p. 32). If sounded at either side of the median plane it is properly referred to the direction of its source when the conditions are nor- mal. It is easier to judge of the direction of noises than of music (Rayleigh). Waves of sound are reflected from the membrana tympani, and they may thus slightly interfere with those entering the meatus (Malini). Accumulated cerumen may interfere with the w'aves, or it may adhere to and dampen the tympanic membrane. Mach found that when the entire meatus was filled with solid wax sound was well conducted. Various appliances have been de- vised for conducting the sound directly from the sound- ing body to the tympanic membrane. Schmiedekam em- ployed metal rods for this purpose. Rubber tubes plugged at either end with ivory knobs are also used. When the meatus is filled with water the direction of sounds cannot be accurately determined. E. Weber argues from this that the degree of vibration of the tympanic membrane helps to locate sounds, rather than the angle at which the sound strikes the tympanic membrane. But Schmiedekam says the perception of direction is also lost if air is kept in the meatus while the head is placed under water. Accu- rate perception of the direction of sound is necessarily a psychic phenomenon, based upon the memory of accu- mulated experiences with the causes and effects of similar sounds. If its source has not previously been determined, the same note, sounded with increasing intensity, will be referred to a nearer and nearer source. Conduction of sound through the bones of the head takes place to a limited extent. Fishes are said to hear entirely in this manner. It is probable, however, that impressions of sound are conveyed to their labyrinths through the medium of a columella, similar to that which exists in the sea-turtle. Politaer thinks that such vibrations affect the ear by passing through the membrana tympani and ossicula, rather than by passing directly to the bony laby- rinth. Yet such vibrations are perceived even when the middle ear is destroyed. It must be remembered, how- ever, that so long as the foot-plate of the stirrup remains in situ, impressions of sound may be communicated by it to the labyrinthine structures. A tuning-fork no longer heard when held in front of a partially closed ear be- comes again audible when held between the teeth, and when inaudible there, it is again heard when passed into the meatus (Rinne), the cartilaginous portion of which is even a better conductor than bone. E. H. Weber first showed that a tuning-fork is heard louder when held against the mastoid, if the external meatus is closed to prevent dispersion. Audiphones are instruments made to improve conduc- tion through bony media. A typical one is a broad fan of vulcanized rubber, which, may be bent by a cord into a curved surface which receives sound waves from many angles. If the margin of the fan be pressed against the teeth, the aerial vibrations are transmitted through the cranium from an extensive surface. Functions of the Membrana Tympani.-The mem- brana tympani readily takes up the vibrations from the air in the external meatus. It possibly also receives them from the bony ring in which it is fixed. The angle which it forms with the long axis of the external auditory canal enables a greater number of vibrations to be reflected upon it from the walls of the canal. Its peculiar cone- shape, with the apex not in the mathematical centre, its oval contour, together with its inequality in thickness at various parts, and the unsymmetrical attachment of the handle of the malleus, all combine to prevent the mem- brane from being thrown into excessive vibration, since no two of its fibres are under the same degree of tension. This prevents it from having a strong fundamental note of its own, which would greatly impair hearing by sound- ing very loud and continuously. The existence of a fun- damental tone for the membrane is disputed. Hensen says that there is such a tone, with not over seven hundred vibrations. But the tension of the membrane is con- stantly varied, so that it responds to any sound without necessarily calling forth its own fundamental note. The membrane vibrates in toto in transverse vibrations, which are adapted in number and extent to those of the air. The membrane is almost inelastic, and the total excursion of which it is normally capable is 0.07 millimetre (Helm- holtz). Schrapnell's membrane yields a little more than do the other portions. Mach suggests that the membrane vi- brates better for high tones when previously set in motion by deeper ones. The mass of the membrane is so small that the extent of its sympathetic vibrations is also small, and they are further dampened by the action of the tensor tympani and the malleus. Painful tones are due to sym- pathetic vibrations which are not completely dampened (Helmholtz). Kessel says that separate parts of the mem- brane vibrate in response to certain tones. Hensen says that for some noises the posterior fibres vibrate longer than the anterior. If particles of fine sand are dropped upon the membrana tympani they are set in motion by its vibra- tions. The more lax the membrane the more forcibly are they rejected when a loud sound causes the vibrations (Savart, Muller). Increased tension of the membrane di- minishes the amplitude of its vibrationsand renders hear- ing less acute. If sound be equally conducted through the external meatus, and by a catheter through the Eus- tachian tube to both sides of the membrane, its vibrations are lessened in extent (Mach, Kessel). When perforations exist in the membrane, hearing may be more or less af- fected according to the size of the opening. Perforations of moderate size impair hearing very little. In some cases of extensive perforation the hearing for sounds of high pitch becomes very acute, owing to the direct effect of the sound waves upon the stapes. Toynbee devised an artificial membrana tympani consisting of a small, thin, metallic plate attached to a rod which enabled it to be inserted in the place of the real membrana tympani. 542 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hearing. Hearing. Such instruments are in use among certain classes of the deaf. Even a plug of cotton may be of service in replac- ing to some extent the normal tympanic membrane. Thickening, stiffening, or unusual dryness of the mem- brane alters the character and intensity of sounds. An idea of the degree of tension of the membrana tympani is conveyed to the brain, and we are thus assisted in estimat- ing the distance of a sound by its loudness (Draper), which affects the tension, and in estimating the direction of the sound by the angle and force with which it strikes the membrane as the head is moved. If the membrane is pressed either outward or inward to any considerable extent, it gives rise to very acute pain. (See article Cais- son Disease, vol. i. ; and below, Influence of Occupa- tion.) The reflection from the tympanic membrane has been mentioned above. The membrane transmits vibra- tions to the handle of the malleus and to the air in the tympanum. Its tension is regulated by the relative press- ure existing between the air in the tympanum and the air in the meatus externus, and by the tensor tympani muscle. Function of the Tensor Tympani Muscle.-Contraction of this muscle increases the range of hearing for high notes to from three to five thousand additional vibrations. It is contracted by reflex stimulation when loud tones or shrill noises strike the membrana tympani. When such a sound is anticipated, as the near report of a gun, some per- sons can voluntarily contract this muscle (Roosa, loc. cit., p. 255 ; Blake). Such voluntary contraction, or a tetanic contraction, causes a crackling sound or " muscle tone." The stimulus to contraction may come from the nervus acusticus by reflection in some manner, or from the sen- sitive nerves of the external ear (Harless). Stimulation of the trigeminus contracts the tensor tympani, and the endolymph rises in the superior vertical canal (C. Lud- wig, Politzer). The action of the muscle in contracting is to draw the membrana tympani inward through its in- sertion below the processus brevis, and over the anterior border of the malleus without turning the malleus much upon its transverse axis. The action of this muscle also presses the stapes more deeply into the fenestra ovalis, and consequently increases the intra-labyrinthine press- ure. When the muscle is relaxed the normal elasticity of the parts restores their equilibrium. The effect of the muscle upon the membrana tympani is, therefore, to act as a damper to prevent too extensive oscillations, di- minish sympathetic vibrations, and attune the fibres of the membrane to proper vibratory accommodation. The muscle is relaxed during the continuance of a prolonged note, but it contracts at the commencement of every sound or noise (Foster, Hensen). The tendon of the muscle has been successfully divided for relief of per- manent contracture of the membrana tympani. The full contraction of the muscle prevents the hearing of tones deeper than seventy vibrations (Schapringer). Paralysis of the muscle causes difficulty in hearing and produces buzzing noises (Romberg). The function of the air in the tympanum is to regulate the tension upon the membrana tympani. It also isolates the ossicula from surrounding solid walls which would disperse their vibrations. It admits of the bulging of the membrane of the fenestra rotunda into the tympanum, when the stapes presses against the lymph of the laby- rinth. The air of the tympanum reaches it through the Eustachian tube. When the supply is cut off, as it often is by catarrhal inflammation of the tube, etc., the air is slowly absorbed by the blood-vessels, or is forced out through the tube by vibrations. A partial vacuum is pro- duced in the tympanum, and the tension of the membrana tympani is, therefore, increased, because it is forced in- ward by external atmospheric pressure. This condition, which causes disagreeable subjective sensations, ringing, buzzing, etc., is often relieved by catheterization of the Eustachian tube or. by the use of the Politzer bag. (See Ear, Diseases of, vol. ii.) The functions of the Eustachian tube are to admit of the periodical renewal of air in the middle ear, and to afford an outlet for discharges-mucus, epithelium, granular detritus, etc. It is lined by ciliated epithelium, which facilitates the latter object. There is much discussion as to when and how this tube is opened. It is said that if it were constantly open, forced inspiration would suck out the air from the tym- panum, and the reverberations of the voice in the pharynx would be conveyed with too great intensity to the mem- brana tympani (autophony). By many (Ranke, Mach, Kessel, and others) the movements of the pharynx, yawning, making inspiratory efforts (Valsalva), pronounc- ing certain words, as "Huk" (Gruber), but especially swallowing, are said to open the Eustachian tube, while between these actions it remains closed. In some animals it is permanently open. A tuning-fork held inside of the mouth sounds feebly, unless the Eustachian tube is open. Lucae says, that in the first part of deglutition and in phonation the levator veli palatini forms an eminence by its thick, contracting belly, which narrows the entrance to the canal, but the contraction of the tensor veli palatini opens the canal toward the end of deglutition. A manometer placed in the external meatus is made to move by swallowing (Politzer). Riidinger and Hensen say that the canal is always open, but that it is very nar- row, except in swallowing. Swallowing may produce a crackling, hissing sound, which is due to separation of the adhesive walls of the Eustachian tube. Lucae and Schwartze describe a movement of the membrana tym- pani synchronous with respiration, which could not occur if the Eustachian canal were closed. The function of the ossicula is to transmit vibrations from the membrana tympani to the labyrinthine fluid. They may also serve as dampers to the membrane (See- beck). They afford attachment to the muscles of the middle ear, which alter the tension of the drum membrane and of the foot-plate of the stirrup in the oval window. They may be capable of slight individual vibration, but. in so far as hearing is concerned they vibrate as one bone (Helmholtz). Their attachments are too loose, and their dimensions are too small as compared with wave- lengths of sound, to favor the molecular propagation of waves (Helmholtz). In birds and reptiles there is but a single bone. If their mobility be lessened by adhesions, hearing is impaired. Their movements resemble those of levers. The membrana tympani being firmly attached to the handle of the malleus causes it to swing with it at the same rate. As the handle of the malleus moves inward its head moves outward. The head turns about a small arc on its axis, the axis-band (Helmholtz). In so doing it causes the head of the incus to move with it, the axis of rotation of the latter ossicle running through its short process. This action causes the long process of the incus to move inward, and to swing through an arc equal to about two-thirds of that described by the handle of the malleus, because the handle of the malleus is 9.5 mm. long, whereas the long process of the incus is only 6.5 mm. long. The extent of movement is consequently lessened, but its force is increased. The malleus and incus form an angular lever, whose fulcrum is at the ligamentous attachment of the short process of the incus to the posterior wall of the tympanum, and they rotate in a plane vertical to the membrana tympani. The long process of the incus is so fixed, at almost a right angle to the stapes, through the Sylvian ossicle (or interarticular cartilage), that in vibrating it must push this bone into, and pull it out of, the fenestra ovalis. If the air in the tympanum be suddenly condensed the malleus and mem- brana tympani move outward, but the incus does not fol- low so rapidly, because the malleus moves away from it; hence the stapes cannot be torn out of its socket (Landois). The loss of the malleus is said not to destroy the cone- shape of the membrane (Gruber, Monatschr. f. Ohrenhk., No. 5, 1877). The vibrations of the membrane are reduced to one- fourth of their intensity in passing to the malleus (Buck). Mach, Kessel, and Buck have studied the vibrations of the ossicula by means of various ingenious devices, such as placing shining particles upon the bones, which reflect light as they swing to and fro, etc. If the incus and malleus be lost, the stapes may still be set in motion by sound waves. Resistance is no longer offered to very 543 Hearing. Hearing. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. high notes, and it is said (Blake) that vibrations up to 80,000 can be heard. Loss of the stapes causes marked deafness. The functions of the stapedius muscle are disputed. In contracting it is said to draw obliquely on the head of the stapes (Henle, Lucae, Politzer), drawing the anterior end outward and pressing the posterior end inward. This makes the annular ligament that surrounds the stapes tenser, and consequently tends to make the stapes more fixed (Henle, Landois, Huxley). The muscle therefore counteracts too intense shocks that come from the incus to the stapes, and relaxes pressure on the labyrinthine fluid and membrane of the fenestra rotunda. Lucae says the muscle lessens the power of hearing for all musical potes, but increases the power for notes of over 10,000 vibrations-an effect opposite to that produced by the contraction of the tensor tympani. Toynbee regards the stapedius as a lever to move the stapes out of the fenestra and give it more freedom to vibrate. The stapes is supplied by a branch from the nervus facialis (Politzer and others). Double paralysis of the facial nerve causes increased sensitiveness to sounds, be- cause the stapes vibrates with increased freedom (Roux). Rarely, in paralysis of the stapedius, low notes are heard at greater distance than upon the sound side (Lucae, Moos). Irritation of the orbicularis palpebrarum, or of the skin in front of the meatus externus, causes contrac- tion of the stapedius. It contracts when the eyelids are forcibly closed. Tenotomy has been successfully per- formed for tetanic contraction of this muscle, produced by reflex irritation from the eyelids (Habermann, Prag. Med. Woch., No. 44, 1884). Function of the Membrane of the Fenestra Rotunda, or Secondary Tympanic Membrane.-When a loud sound causes extensive vibration, the stapes presses forcibly against the lymph of the labyrinth. This lymph is prac- tically incompressible, but the membrane of the fenestra rotunda yields a little and is pressed by the lymph toward the tympanic cavity. The function of the labyrinthine fluid is to transmit vi- brations from the stapes to the important structures in the cochlea, and also probably to afford a medium for the free vibration of otoliths and hair-cells. Although itself incompressible, it can compress the blood-vessels lining the aquaeductus cochleae and semicircular canals (Buck), and gain a little space in this manner, as well as by press- ing outward the membrane of the fenestra rotunda. It has been suggested that the fluid forms currents which brush past the hair-cells and cause them to sway and vi- brate. (This view is not indorsed by others.) (Buck.) The function of the otoliths is disputed. Tyndall says that " owing to their weight they prolong evanescent vi- brations which might otherwise not be perceived." It is also believed that they strike against the hair-cells and intensify their vibrations. This they have been seen to do in crustaceans, as the mysis (Hensen, Huxley, Martin). Others think they act as dampers (Foster, Waldeyer). Haase says that the otoliths and membrana tectoria to- gether transmit vibrations. The functions of the cochlea are to estimate the pitch and quality or musical character of tones (see Ear, Anat, of Labyrinth, vol. ii., p. 565). It serves to spread out the fibres of the cochlear branch of the auditory nerve upon a membranous lamina, which is insulated upon its two surfaces by fluid. The membranous spiral lamina receives the vibrations of the fluid as transmitted to it by the foot-plate of the stirrup, and probably also through the cranial bones (see Ear, Anat, of Labyrinth, vol. ii., pp. 563, 566). Functions of the Membrana Basilaris.-The radiating fibres composing this membrane exhibit a regular grada- tion in length and tension. They are compared to the strings of a harp or piano, and Helmholtz advances the theory that each fibre is attuned to vibrate in unison with a note of a definite pitch. Thus the membrane acts like a resonator in resolving complex sounds into their com- ponent tones. It further communicates its vibrations to the corresponding cells in the organ of Corti. Experi- ments are conflicting which have been made to determine which part of the membrana basilaris responds to high notes, and which to low notes. According to Moos, de- struction of the cupola near which the fibres of the mem- brane are longest causes deafness to deeper tones only. Conversely, progressive disease which advances from the middle ear may first cause deafness for the higher notes, because the fibres of the membrane are shorter near the base of the cochlea, which is first invaded (see Ear, Anat, of Labyrinth, vol. ii., p. 565). But Baginsky's experi- ments upon dogs give directly opposite results ("Berl. Akad. Sitzgdber.," xxiii., June 14, 1883). There are enough fibres in the membrane to correspond to every audible simple tone (Tyndall). Curious instances are re- corded of deafness for certain isolated notes in the scale, which suggest the phenomenon of color blindness. Such cases have occurred from blows upon the head, and from hearing loud steam whistles close at hand. Prolonged sounding of one note wearies the ear, so that hearing for that particular note becomes less acute. A case has been recently observed in which notes of a definite pitch were always perceived as sounding a half-note higher. The f unction of the rods of Corti is probably to take up the vibrations from the labyrinthine fluid and the fibres of the membrana basilaris, and transfer them as a nerve irritation to the terminal filaments of the auditory nerve. They, too, vary in length and span, and their number is sufficient to allow four hundred or more rods to each oc- tave within the musical scale. Some observers hold that each rod vibrates in unison with a particular tone (Mi- vart). The rods, as well as the fibres of the membrana basilaris, are pressed upon by cell-bodies not especially adapted for vibration, which mar act as dampers. Function of the Hair-cells.-Waldeyer and others take the view that the hair-cells are the only end organs or terminal apparatus of the organ of hearing. Tyndall (loc. cit., p. 59) says that they "readily yield up evanescent motion, while they are eminently fitted for transmission of continuous vibrations." Sonorous vibrations in fluid which are not felt by the hand immersed alone may be felt by the hand holding a rod. Others claim that the hair-cells are not numerous enough, and do not vary suf- ficiently in length, for the work attributed to them. They are absent in birds which can distinguish and imitate pitch (mocking-birds). Function of the Membrana Tectoria.-By many this membrane is regarded merely as a damper to check ex- cessive vibrations of the hair-cells, and it is supposed by others that it vibrates en masse with the cells, rods of Corti, and basement membrane. Buck suggests (loc. cit., pp. 14, 15) that this soft membrane is not a damper, but that particular hair-cells vibrating in response to certain notes throw off the membrane and strike their tips against its overhanging surface, thus intensifying their irritation without injuring themselves. The functions of the nervus auditorius are to convey to the brain impressions of sound, and possibly also of equilibrium (see Canals, below). It is supposed that each terminal fibre conveys impressions of its own set of vi- brations to the brain after their analysis in the cochlea. Waves of sound have no effect upon the nerve alone, independently of its terminal filaments, but it can be stimulated mechanically and by electricity. When the galvanic current is closed at the cathode a tone is produced. A feebler tone results when the current is opened (Pryer, Hartmann). A paradoxical reaction re- sults where galvanic stimulation of one ear affects the other ear in an opposite manner. Pathologically, the sensibility of the nerve may become greatly increased (hyperakusis), or painful (acoustic hyperalgia). (See Hysteria and Insanity.) Its sensibility, on the other hand, may become greatly diminished. The function of the semi-circular canals is disputed. It is supposed that when the head is turned currents are produced in these fluids which have a relation to the di- rection and extent of movements of the head (Breuer). The currents flow past the terminal hair-cells in the mac- ula? and cristae, and the canals of the opposite sides are possibly paired in their action (Crum-Brown). If the fluid in the canals presses unequally upon their walls as 544 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hearing. Hearing. the head is moved, it may convey an impression to the end organs of the ampullae of the degree of the move- ment, and assist in determining the relative position of the individual in space (Mach, Goltz). This action has been classed as a separate sense (Leydig. Cyon). The results of experiments made upon animals-pigeons, guinea-pigs, and the like-have been very contradictory, but partial removal or injury of the canals, in many in- stances, produces curious movements and disturbances of equilibrium and co-ordination (Flourens), without impair- ment of hearing. Pendulum-like or rotatory movements of the head occur in the plane of the injured canal (Cyon, Hensen, Vulpian, Landois, Breuer). Section of the au- ditory nerve produces the same result (Bechterew). If all the canals are removed, the animal cannot stand, and the movements may become exaggerated. In man, lesion of the canals is accompanied by dizzi- ness and tinnitus aurium (Moos, Zeitschr. f. Ohrenhk., xi.,s. 234). (See Meniere's Disease.) Other experiments show that pressure on the canals causes irregular move- ments, which cease or change direction when the canals are cut (Bornhardt). Boettcher (Arch. f. Ohrenhk., 1874) says that the symptoms referred to are produced by in- flammation of the dura mater, or by some brain lesion. Certainly some animals operated upon have completely recovered, where care was taken to avoid hajmorrhage, and others have first exhibited the peculiar movements several weeks after the canals were cut (Boettcher). Hensen has attempted to show a definite relation be- tween the impressions of the ampullae and special groups of muscles. He also thinks that they are concerned in the secretion of endolymph, but their lining-cells are of the pavement variety. Buck suggests that the canals may be useful to protect the ductus cochlearis and organ of Corti from over-pressure from vibrations, because the abundant vascular tissue which the former contain is capable of some degree of compression (loc. cit., p. 16). Stimulation of both the nervus acusticus and the audi- tory nucleus, as well as destruction of both labyrinths, causes associated movements of the eyeballs, while sec- tion of these nerves causes disappearance of nystagmus (Cyon). Chloroform and various other drugs enfeeble or support the movements by their action upon the cerebral centre. Electrodes in the external auditory meatus cause vertigo. Munk conducted curious experiments by confin- ing the heads of pigeons in fixed positions at different an- gles of torsion and lateral flexion for months at a time, to see whether permanent abnormal positions of the canals would produce any symptoms. In some cases abnormal movements were observed, similar to those made when the canals are excised. They may have been due, how- ever, to the prolonged muscular constraint. It is also supposed that the canals, through the extensive associated reflex movements of the head and eyeballs, assist in de- termining the distance and direction of sounds, so that wild animals are enabled to look at once toward the source of a dangerous sound (Hogyes, 1880; P. McBride, Jour. Anat, and Phys., 1883, xvii., 2). Functions of other parts of the internal ear are not defi- nitely established. The vestibular nerve distinguishes intensity, but gives no impression of tone, melody, or har- mony (Huxley). The ampullae and saccules perceive com- plex noises as single impulses. The duration of perception of sound is usually very brief, but the jarring, tingling, ringing, etc., sensations in the ears which are felt after exposure to a sudden loud noise, or to long-continued noises, such as are heard near waterfalls, in mills, boiler-factories, in long journeys by rail, etc., last for a considerable time after their produc- tion-even for many hours. These continued sounds have a character of their own, and do not resemble the original noises in pitch or intensity. The duration of the sensation of sound, like that of light, does, however, last a little longer than the actual wave movement causing it. Real ' ' after-hearing " of sounds is very rare. The rhythm and general impres- sions of music and of various sounds continue indefinitely in the mind, but the musical air which "runs in the head " is not actually heard by the ear after its produc- tion. On the other hand, the atmosphere is so full of vi- brations that absolute silence is rarely found (Fechner, loc. cit., p. 212). Persons going suddenly into a very noisy place are at first distracted by the number and va- riety of sonorous impressions. A certain amount of tol- eration or weariness (see above) is soon acquired, and by directing the attention to a particular note, it may be singled out from many others by a good ear. The leader of an orchestra can tell which one of many violins is at fault. Roosa investigated the supposed improvement of hearing of deaf persons in a noise, and he believes that it does not occur except for particular notes and with certain diseases of the middle ear where bone-conduction is bet- ter than that through the air. The evidence is conflicting in this matter. The ticks of a pendulum are audible as distinct sounds until they reach one hundred in a second (Helmholtz). Attempts to mentally estimate the duration of a given sound are very inaccurate (Horing, Mach). Beats are better perceived by the ear than by any other sense (Vierordt). Experiments have been made to determine how many separate vibrations are necessary to excite the sense of hearing a certain tone (Exner, Arch, des Ges. Phys., xiii., s. 228 ; Mach ; Konig). A tone of sixty-four vibrations and its octave each required about seventeen vibrations to be heard, and they were heard louder with thirty-eight to fifty-one vibrations. The time required between hearing and perceiving sounds and giving a signal is 0.12 to 0.18 second. Higher tones require slightly less time than deeper ones. Noises are heard quickest (Kries and Auerbach, Arch.f. Anat. u. Physiol., 1877). The subjective sensations of sound have been referred to in part, such as the " muscle sounds," referable to the ten- sor tympani and the stapedius, and the sound of the sepa- ration of the adhesive walls of the Eustachian tube. Sen- sations of sounds originating in the ear itself are called " entotic " sounds, or "tinnitus aurium." The greater part of such sounds originate in the tympanum. Among the causes of entotic sounds not previously mentioned are : local vascular dilatation, aneurisms (Herzog, Monatsch. f Ohrenhk., No. 8, 1881), obstructions to the circulation, systolic murmurs, contraction of the palatine muscles in yawning, forcible depression of the jaw, forcing air into the tympanum by violently blowing the nose, catarrhs and local inflammations of the ear, circulatory disturb- ances produced by quinine, salicylic acid, etc. Extreme morbid excitation of the auditory nerve may be a cause of great discomfort and even pain, and, if long continued, may lead to suicide (Troltsch). Such sensations are com- mon among the insane, and they are greatly accen- tuated by the imagination. Some entotic sounds are im- proved by the effect of external sounds, others are made worse (Lucae, "Verhdl. d. phys. Ges. zu Berlin," No. 10, 1883-84). The reflexes connected with hearing have been discussed in part (see Functions of Tensor Tympani, Stapedius, and Canals). Unexpected or loud sounds may cause move- ments of the entire body, and even convulsions (Brown-Se- quard) and vertigo. Some rasping sounds cause sensations in the dental nerves ("setting the teeth on edge"), saliva- tion (Kirke), rigors, etc. Those who are profoundly af- fected mentally by impressive music describe a peculiar tingling, pleasurable sensation which travels down the spine and may be felt in the extremities. This sensation is more or less controlled by the will, and it is intensified by giving entire attention to the music. Paroxysmal hiccough may be stopped by a loud unexpected noise (see article Hiccough). Hearing may be affected through local irritation of facial muscles, as in an exceptional case of intermittent deafness accompanying the use of strongly pinching eyeglasses (Moos, Zeitschr. f. Ohrenhk., xii., s. 101); through the central nerve organs in abdominal visceral diseases, fevers, etc. (disordered nerve nutrition), insolation, dental caries (Hilton), etc. Sudden fright has been known to make the young incurably deaf (Wilde). Acoustic hyperaesthesia occurs in hysteria, fevers, azo- 545 Hearing. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. turia, etc., from some causes that would be expected to produce anaesthesia. The psycho-acoustic centre of the brain is situated in the temporo-sphenoidal region, upon both sides, but it seems to be more active on the left side. It exhibits crossed action through a bundle of projection fibres, which pass between the temporo-sphenoidal region and the thala- mus and internal geniculate body (v. Monakow, Arch. f. Psych., xii.). If the temporo-sphenoidal region be excised deafness is said to result (Munk, " Berl. Akad. Sitzgaber," 1884, xxiv., s. 1). Atrophy of this region is said to occur after long-continued deafness (Huguenin). Partial left-side injury to the region causes "word- deafness" (surditas verbalis, Giraudeau, Rev. de Med., 1882-85) or " word-blindness'' (cajcitas verbalis) for cer- tain words. The words sound like a confused noise, with- out meaning (Kussmaul). In left-handed persons the centre is on the opposite side (Westphal). Auditory de- lusions among the insane may be due to stimulation of this centre. Dry gangrene of the ear constantly occurs from section of the restiform bodies (Brown-Sequard, Lancet, vol. i., 1869, p. 515). Electric irritation of the auditory centre on one side causes elevation of the oppo- site auricle (Ferrier). Munk describes an auditory centre near the fissure of Sylvius, the posterior part of which is devoted to perception of low tones, the anterior to high tones. For the psychic phenomena of sound the reader must be referred to other works. It is sufficient here to recall the well-known effects of enlivening music in cheering troops on the march, or while under the depressing influ- ences of siege, and the profound influence of certain music in exciting the highest emotional centres ; the an- noyance, irritability, mental worry, and even impaired health, occasioned by continued disagreeable noises. In a general way, the deeper tones appear to imply earnest- ness and worth, while the higher tones are more sugges- tive of merriment (Wundt, loc. cit., p. 471). The analyti- cal work of the labyrinth, in resolving complex sounds into simple tones and overtones, enables us to distinguish several musical tones reaching the ear simultaneously, or to blend these impressions in the brain into a harmonious whole (Ranke). Volitional attention directed to hearing causes listening, when we notice very faint sounds. We can even single out soft sounds, and let noisier ones pass unobserved (Carpenter, "Mental Physiology," p. 137). Many of the lower animals are profoundly affected by sounds, but they have no real appreciation of musi- cal harmony (Mivart). The adjustment of the pitch of the voice, and, in fact, the entire mechanism of phona- tion, can only be accomplished by mental auditory con- ception of the tone. Those born deaf are also dumb. (See article Deaf-mutes, vol. ii., p. 363.) A few can be taught to articulate imperfectly, but never with the pre- cision of one whose hearing is normal (Carpenter). The memory of sounds is associated with places, persons (voices), etc., in a marked degree. Revisiting a long-for- gotten place may suddenly recall the exact tones of a voice which has not been heard since childhood. Associations of color with musical sounds are insepara- ble in some persons. The same note may always appear " bright red," whether sounded on the violin, piano, or other instrument. (See article Mental Imagery, in a later volume.) This association is most frequently observed among children, and it is often hereditary. Rarely the as- sociation concerns simply light, without color (Galton). Certain sounds always recall others by association. Sounds conveyed to one ear may at the same time increase the functional activity of the opposite ear. Sounds are nor- mally referred to an origin external to the ear. Under water, or with the ears plugged, they seem to be produced in some part of the ear itself. Among the insane it is com- mon to locate the source of external sounds in the ear itself or elsewhere in the body, so that, in addition to wholly imaginary sounds, they misinterpret external sounds and refer them to voices, etc., within themselves. The influence of occupation on hearing is well known. Early mental training can do much to improve the faculty for discrimination in sounds. Balloonists, divers, boiler- makers, and the like (see Caisson Disease, vol. i.), are very often made deaf to a greater or less degree from the varieties of injury to the ear which they receive. Boiler-makers are frequently deaf, and they become so as a result of concussions of the labyrinth or changes in the articulations of the ossicula (Roosa, loc. cit., pp. 353, 362, 645). Sound-dampers have been devised for the pro- tection of the ear among such as work in constant noise. The effect of age upon acuteness of hearing is familiar. The aged fail to hear high notes, but they often seem un- conscious of deafness so long as the power of hearing low notes remains (Galton). They frequently have tinnitus aurium from alterations in the apparatus of the middle ear, and they lose power over the tympanic muscles (Roosa). Blake gives the following summary of his statistics. From twelve to thirteen years a note of 20,480 vibrations is heard at thirty-four feet, and from eighteen to twenty years it is heard at thirteen to sixteen feet; whereas at the latter age, at thirty-four feet, notes above 18,432 vibrations can- not be heard ; at twenty-eight to thirty years notes above 16,384 vibrations cannot be heard. Infants show con- sciousness of sound from their earliest days, but they do not usually exhibit marked appreciation of particular sounds before the second or third month. They appear to derive impressions of sound earlier when conveyed though solid media, rather than the air. Infants appre- ciate high notes first. Children take a delight in loud noises which they outgrow, while with most persons the enjoyment of music develops later than early childhood. The effect of heredity upon hearing is not very marked. Deaf-mutism is very rarely transmitted, even though both parents are deaf-mutes. Deafness alone seems to be trans- mitted exceptionally (Darwin, "Animals and Plants un- der Domestication"). A. Graham Bell dissents from this view, and by recent statistics shows that crowding deaf- mutes into asylums and allowing their intermarriage is tending to produce a "race of deaf-mutes." Some ani- mals, as white cats, are always deaf (Sexton, Nature, 1883-84, xxiv., 312; Tait, Nature, January 10, 1884). The effect of climate upon hearing is not marked. The density of the air (altitude) and the moisture influence the membrana tympani somewhat, but these factors are of more interest in their influence on the external trans- mission of sound than in any effect upon the ear. The effect of evolution on hearing is noticeable. The ear of a savage, to warn him of approaching enemies, has far more need of accurate perception and intensity and di- rection than of quality. Still, "the preservation of any race never has depended upon such extreme delicacy of hearing " (Mivart). Certain races, like the Chinese, take delight in shrill noises, and have no enjoyment of what others consider music. The character of music which is acceptable to most civilized races seems to be undergoing change. This is no doubt partly due to progress in the number and quality of musical instruments ; witness the change from the use of the flute to the violin or piano as a favor- ite instrument. Hearing with One Ear.-The total abolition of hearing in one ear does not interfere with the perception of the quality of sounds by the normal ear. It affects somewhat the loudness of sounds which are not produced directly opposite and near the normal ear, and it diminishes the accuracy with which the direction of sounds is deter- mined (see above, External Ear). When there is moderate deafness in both ears, treat- ment of one ear sometimes improves the hearing in the opposite ear as well (Eitelberg, Ztschr. f. Ohrenhk., xii., s. 162, 258). Double hearing of one sound may be pro- duced by using different conducting media for each ear. Such binaural sensations are compared to double vision. Bibliography. Helmholtz : Die Mechanik der Gehiirkniicheln u. d. Trommelfells, Pflii- ger's Arch., vol. i. (Mechanism of the Ossicles, etc. Translated by Albert H. Buck and Norman Smith. New York, 1874.) Helmholtz : Sensations of Tone. Trans, by Ellis. Kessel : Anat, of Middle Ear. in Stricker's Histology. Hensen, v. : Physiologic des Gehors, in Hermann's Handbuch, 1880. Wundt: Grundziige der Physiologischen Psychologie, Cap. ix., x., 1880. Munk: Lehrbuch. 546 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hearing. Heart. Retzius: Anatomic ties Ohres. Buck : Diagnosis and Treatment of Ear Diseases, pp. 5, 14 to 16, etc. Darwin : Origin of Species. See Ear and Hearing in index. Darwin : Animals and Plants under Domestication. See Ear and Hear- ing in index. Tyndall: On Sound, pp. 59, 324, etc. Galton : Researches into Human Faculty, p. 375. Crum-Brown : Sense of Rotation, Jr. Anat. u. Phys., viii. Mach, Kessel: Function der Trommelhohle in Tuba, Sitzgaber. d. Wien. Acad.. 3 Abth., 1872. Pryer : Akustiche Untersuchungen. Pryer: Die Grenzung der Tonwahrnehmung. Meniere : Meniere's Disease, Gaz. Med. de Paris, 1861, pp. 29, 55, 88, 239, 279, 597. Roosa : Treatise on Diseases of Ear, 1885. Carpenter: Mental Physiology. Hearing. See index. Ranke : Physiologic, s. 904 to 941. Vierordt: Schall u. Tonstiirke, etc. Tubingen, 1885. Huxley : Anat, of Vertebrates. See Ear and Hearing in index. Landois : Physiology, vol. ii., p. 1043-1077. 1885. Mivart: Genesis -of Species, Ear. See index. Rayleigh : Theory of Sound. 1878. Fick : Die Med. Physik. 1885. Quain : Anatomy, Tympanum. William Gilman Thompson. laminated fibrine, and sometimes these completely fill the sac, especially if it be a small one. Thus the aneu- rism becomes an important factor in the etiology of the fibrinous concretions or heart-clots, which in themselves have such an important pathological significance. When these clots simply occupy the cavity of the aneurism, their presence occasions no disturbance other than that caused by the aneurism itself, which interferes with the effective contraction of the heart muscle. But the aneu- rismal clot, as well as the clot which forms independent of aneurism, renders imminent the great danger of em- bolism if detached fragments of the clot become swept into the arteries of the brain or other organs.* The symptoms of cardiac aneurism vary in definiteness with the extent of the dilatation. If this be considerable, as when the greater part of the anterior or left wall of the left ventricle is involved, the area of praecordial dulness is obviously increased. At the same time the force of the heart's impulse is lessened, and may be diffused. These two circumstances serve to distinguish the enlarge- ment from that produced by cardiac hypertrophy, but cannot serve to distinguish large partial aneurism from general dilatation of the heart or left ventricle. Small aneurisms cause no increase in the area of dulness-those of the septum being particularly inaccessible to the re- sources of percussion and palpitation. They are similarly out of the way of detection by other modes of explora- tion, and may continue until death occurs from some other disease, without having betrayed their presence by any symptom whatever. Aneurism of the left ventricle, however, which may not be extensive enough to increase the area of prsecordial dulness, may so greatly weaken the force of the ventricular systole that the first sound of the heart becomes feeble and indistinct, the apex-beat scarcely perceptible, and the pulse feeble or intermittent. These signs are all the more indicative of aneurism in the absence "of valvular disease, especially mitral, whose symptomatology they closely imitate. The same symp- toms are found in fatty degeneration of the heart, and to these two diseases are common various signs indicative of failing circulation : palpitation, breathlessness on exer- tion, pallor alternating with slight cyanosis, insomnia, irritability and vacillation of temper-the three latter symptoms being due to the imperfect nutrition of the brain. There is no sure mode of distinguishing clinically be- tween aneurism, fibroid disease without aneurism, and fatty degeneration of the heart, when any of the three lesions are extensive enough to cause symptoms at all. It is to be remembered, however, that fatty degeneration is much the most frequent, is less apt to be associated with enlargement of the heart, and is attended by more numerous signs of general organic degeneration, such as flabby, trembling muscles, dimness of eye with arcus senilis, trembling tongue, uncertain gait.f The inter- currence of embolic accidents in the midst of the forego- ing group of symptoms would point strongly to aneu- rism. It must not be forgotten that valvular disease fre- quently coexists with aneurism, and may even be caused by it when the aneurism occupies the upper part of the ventricle adjacent to the valvular orifice, so as to involve this in the dilatation. There is no special treatment for aneurism. The usual treatment for feeble heart-power directed toward re-en- forcement of the contractility of cardiac muscle is indi- cated, but with caution. Thus, digitalis should not be given in large doses, or for long uninterrupted periods, lest the dilated heart rupture under the influence of an energetic ventricular systole. HEART, ANEURISM OF THE. Aneurism of the heart originally meant dilatation of the entire organ.1 To-day the term is limited to the localized pouches which are sometimes formed in one of the walls of the heart, and which vary greatly in size according to their precise situation. Thus, two favorite localities are the apex of the left ventricle, and the uppermost portion of the inter- ventricular septum, just where the muscular tissue is deficient; at these situations the aneurism is necessarily small. But if it occupy the wall of either ventricle or auricle, it may gradually increase in size until nearly the entire wall become involved. Partial aneurism, like general dilatation of the cardiac cavities, always implies such an alteration of the structure of the walls of those cavities as to cause them to yield to the pressure of the blood contained in them. The essential cause of heart aneurism is thus identical with that of arterial aneurism. The lesion of structure is, however, different, as might be expected from the difference of tissue in the heart and arteries. In the latter, non-traumatic aneurism nearly al- ways depends on atheroma ; in the former, upon fibroid disease, the result of a chronic interstitial myocarditis. In 1835 Cruveilhier pointed out that cardiac aneu- rism could be produced by this condition, since the por- tion of the heart-walls thus affected must fail to contract during systole, and then, instead of opposing to the blood- stream a force effectively superior to its own, must give way before the energetic pressure to which it is submitted on all sides.2 More modern researches not only confirm Cruveilhier's view, but tend to deny any other efficient cause for local cardiac aneurism. The initial lesion of the fibroid dis- ease may, however, differ in different cases. Thus, it may sometimes begin in a chronic endocarditis, some- times in a pericarditis, and sometimes in the cardiac muscle itself. The cases originating in endocarditis have sometimes been interpreted as implying ulceration and rupture of the endocardium, and the aneurism has then been assimilated to the false aneurisms of arteries, in which, after rupture of the internal coat of the vessel, blood has become infiltrated between its external tunics. The analogy is, however, false, since in the heart there never is any rupture of the endocardium, and this mem- brane is usually found lining the entire pouch. But sometimes it seems to have been eroded away, and the pouch is hollowed out exclusively in muscular tissue, or even, when the eroding action of the blood has been long continued, the muscular tissue disappears, and the bot- tom of the pouch is formed by the thickened pericardium alone. Cardiac aneurisms, however, follow the law of vascular aneurisms in belonging exclusively to the ar- terial system-that is, to the left side of the heart. This fact is evidently due to the much higher blood-pressure of the arterial system. Fatty degeneration of the heart, which is the main con- dition of spontaneous rupture, does not occasion aneu- rism. The aneurismal pouch is always lined with layers of * Senhouse Kirkes, in his famous memoir, describes a case of cardiac thrombosis dependent upon a large aneurismal pouch in the left ven- tricle, in a yonng woman aged eighteen. Four months before death there was paralysis of the left arm, with subsequent recovery; then of the left leg, and afterward of the right leg, with recovery in both instances; finally complete left hemiplegia occurred, and was followed by convul- sions and death. There were traces of embolism in the right corpus stri- atum, in the spleen, and in the kidneys. t Fothergill gives a picturesque description of the appearance of an old person with fatty degeneration of the heart, in his work on Diseases of the Heart, 547 Heart. Heart. DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Legg. Wick.ham : Bradshawe Lecture. 1883. Pelvet: Des anevrysmes du coeur, 1867. Thurnam : Med. Chir. Trans., 1838. Peacock : Edin. Med. J., 1846. Cruveilhier: Anat. Pathologique, liv. xxi. Schroetter : Ziemssen's Handbuch, Bd. vi. Reynaud : Art. Andvrisme in Nouveau Diction, de Medecine. Turner: Path. Soc., London, 1883. Evart: Ibid., 1880. Peabody : N. Y. Medical Record, 1881. Ingals : Ibid. Talamon: Bull. Soc. Anat., 1879. Morgagni: Epist. xvii. puinam.JacM 1 Morgagni : Epist. Corvisart: Essai sur les mal. du coeur. 1802. 2 Anat. Path., liv. xviii. Bibliography. atrophied heart is frequently pale or fawn-colored ; oc- casionally it is of a deep reddish-brown. The muscular substance being too small for its pericardial covering, the latter is thrown into folds, presenting somewdiat the ap- pearance of a " withered apple. " The coronary vessels, for the same reason, are tortuous and prominent. The muscular fibres, on microscopical examination, are found to be diminished in size and often in number. What is termed "yellow atrophy" of the heart is the result of in- terstitial fatty or fibroid growth. When numerous yellow or brown pigment particles are contained within the muscular fibres, as is frequently the case in the marasmus of old age, the condition is known as "brown atrophy." The consistence of the cardiac walls may be firmer than natural, except in phthisis and other diseases attended with pyrexia, when their fibres may present the appear- ance of fatty degeneration. Etiology.-Congenital atrophy of the heart is more common in women than in men. The causes of the acquired variety are either general or local. The general causes include all those constitutional con- ditions or local diseases which gradually produce emacia- tion, diminish the total amount of blood, or preclude active bodily exercise. Such pre-eminently are stricture of the oesophagus and cancer of the pylorus, the heart in the latter affection becoming smaller than in any other condition. Phthisis, from an analysis of one hundred and seventy-one cases made at the Brompton Hospital, would appear to lessen the weight of the heart in more than one-half its subjects. In cases of diabetes mellitus, prolonged suppuration, or other chronic conditions, as also in diseases of a subacute character, such as typhoid fever, when protracted in their course, the heart shares in the general wasting. Bramwell points out that in un- complicated cases of waxy disease of the kidneys atrophy of the heart is present, while hypertrophy accompanies other varieties of Bright's disease. Atrophy of the heart is regarded by many as a result of general senile decay, but the correctness of this view is denied by Cruveilhier, and Hayden entirely concurs in his opinion. The local causes of atrophy of the heart are : the press- ure of secondary products in the mediastinum, pericar- ditis, chronic effusion into the left pleural cavity, fatty accumulation on the heart, and contractions of the open- ings of the coronary arteries, resulting either from the conditions just enumerated or from disease or malforma- tion of the vessels themselves. Symptoms and Physical Signs.-In typical cases the characteristic phenomena are those of feeble circulation. The area of praecordial dulness is much diminished, and in extreme cases may be completely effaced, the cardiac impulse is limited and extremely feeble, or altogether absent. The sounds are sharp and clear when the struct- ure of the heart is normal, but if it is softened the first sound is dull and scarcely audible. In cases of phthisis the pulmonary second sound is usually more distinct than the aortic ; it may be accentuated. The pulse is small and weak, but wThen the disease is unassociated with an ad- vanced stage of fatty or other tissue-change, it is regular. In phthisical cases it is much more frequent, but when the atrophy is due to chronic wasting disease, unaccom- panied by fever, it may be slower than normal. Diagnosis.-A positive diagnosis of cardiac atrophy is only to be ventured upon when the observer can satisfy himself that the lungs are not emphysematous-a matter of extreme difficulty in some cases. The existence of the disease may be regarded as probable when the above signs and symptoms are present, and are associated with gen- eral emaciation. Prognosis.-This depends entirely upon the etiology of the disease. The condition of the heart itself (in the form which we are here considering) is unimportant, since removal of the antecedent affection, when that can be ac- complished, is followed by a rapid return of the heart to its natural weight and dimensions. Treatment.-The only therapeutic measures indicated in atrophy of the heart are those which are directed to HEART : ANEURISM OF VALVES. A valvular aneu- rism is a cavity in the substance of the valve itself, con- taining pus and other inflammatory products, or blood- clots and debris. The origin seems to be always in endo- carditis of a more or less acute form, of wdiich this is really only one of the possible results. If the process starts on the surface of the valve, ulceration may perforate one layer, after which the blood-pressure dissects away the other, and so dilates the cavity that it may be as large as a pigeon's egg. On the other hand, the process may be- gin in the tissue of the valve and result in perforation of one of the layers from within, after wdiich the blood- pressure acts precisely as in the former case. These aneurisms are generally single, but may be multiple, and seem to be confined to the left heart. Of 23 cases col- lected by Pelvet, in 16 the aneurism was on the mittal, in 7 on the aortic valve. The perforation is almost al- ways found on the side of the valve wdiich is exposed to the highest pressure, the ventricular surface of the mitral, the distal surface of the aortic. The cavity may be lined by a laminated clot. The layer of the valve opposite to that containing the perforation may rupture, and the valve then suddenly become insufficient. The symptoms in such a case might be precisely similar to those of val- vular rupture from any other cause. As may be readily understood, valvular aneurism is of pathological rather than clinical interest, inasmuch as it betrays its presence by no distinctive diagnostic marks. Acute endocarditis can usually be detected, and so also valvular incompetence, but the precise steps which have led from one to the other in any given case must remain highly uncertain. This being the case there is, of course, no special treatment to be recommended other than that suitable to acute endocarditis. It would seem that the affection occasionally becomes chronic when seated in the mitral curtains, and is, therefore, somewdiat less seri- ous than in the semilunar cusps. There is one other and more chronic condition which is sometimes classed as valvular aneurism. A portion of, or the whole valve, namely, may become so modified by inflammatory changes that its tissue generally yields and becomes stretched by the force of the blood-pressure- both layers of the valve remaining in apposition, but be- ing bellied out with the convexity toward the left auricle or ventricle respectively, according as the changes are seated in the mitral or in the aortic valve. Frederick C. Shattuck. HEART, ATROPHY OF. Definition.-A decrease in the weight of the heart, and often in its size, as a con- sequence of wasting of its muscular fibres. The affection may be congenital, in which case the general growth of the body being similarly retarded, the heart will corre- spond in size to the rest of the body, and its walls and cavities will be normally developed. Morbid Anatomy.-Simple atrophy of the heart, the only form to which the foregoing definition will apply, is characterized essentially by a diminution in the weight of the organ. An instance is cited by Bramwell in which the heart of an adult female, w'ho died of cancer of the pylorus, weighed only two ounces, twelve drachms eleven grains. In typical cases the heart looks smaller than natural, but may sometimes appear of normal size when the cavities are relaxed and distended with blood. The color of the 548 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. the removal of the primary disease, when that is possible, and to improving the general nutrition. Alfred L. Loomis. and fix our mind upon, these two sets ot valves separately, to see if any of them are diseased, and if so, to note : both what is the nature of the change which exists in their own structure, and what modifications have been pro- duced by their alteration of form upon the orifices which they close and open. This essential method of proced- ure (coupled with the statement made above regarding the very marked infrequency of diseases of the right cavi- ties), already greatly simplifies the study of the diseased valves. It is practised even by the novice in such inquir- ies ; and when one is seen examining the heart at random -regardless of the above rule, it is clear to the looker-on that he has not mastered the first horn-book lesson upon the subject, and that it is impossible for him to form any accurate conclusions. He may know that the organ is diseased, but he cannot tell where the injury is. Besides this, whoever is desirous of investigating a case of heart disease, must have in addition to his ana- tomical knowledge, fully and clearly in his mind the whole action and reaction in the cavities of the organ dur- ing its systole and diastole ; he must know when and where the current is flowing out, and when and where its passage is estopped-whether at the back gates, or at the front gates, and conversely. For it is when those mus- cular and tendinous strings and cords at the apex, or those semilunar curtains at the base-which open and shut those orifices-are defective, i.e., where they close imperfectly ("insufficiency"), and permit regurgitation when they should not; or when by fibrinous or other deposits upon the valves the orifices are narrowed or roughened ("stenosis"), and thus obstruct the forward flow, and give rise to abnormal, morbid sounds-it is the consideration and explanation of this problem w'hich is his object in every case which becomes the subject of critical inquiry. It is essential then, that besides the full appreciation of the currents and checks in the incessant working of the organ-the onward flow and the movements of the fleshly barriers which suddenly and rhythmically arrest the flow, -he should first know the normal healthy sounds, in order to detect the slightest deviation from them ; and he should localize these deviations-for they are necessarily morbid sounds, and indicate diseased valves.- It being necessary then for the observer to know the cause and rationale of the normal sounds, w'e will state them. It is pretty well agreed that the first sound (rep- resented by the word "lubb") is synchronous with the systole of the organ, and is owing to one or all of three causes : viz., the contraction of the muscular ventricles, the sudden closure of the auriculo -ventricular valves which prevents the blood from regurgitating into either auricle, and the impulsion of the heart against the walls of the chest. At this moment a column of blood is driven through the aorta and pulmonary artery, and the auricles are silently filling with blood from the valveless venae cavae and from the pulmonary veins. That the second sound (represented by the word "dup") is synchronous with the diastole of the organ, and is due to the shutting up of the semilunar valves of the aorta and pulmonary artery. The closure of these valves at this moment prevents the regurgitation of the blood from the aorta and pulmonary artery into the ventricles-when during the diastole of the ventricles these are being filled from the auricles. During the prolonged interval of rest following (which is equal in duration to the first, and twice the length of the second sound), we may suppose that the auricles are still silently pouring their contents into the ventricles-the portals of which are now wide open. During this period of apparent calm the heart-endowed with a high degree of nervous energy derived from the cardiac ganglia of the sympathetic and the pneumogastric, wound round and en- wrapped with concentrically interlaced muscular fibres, layer upon layer as if encased with triple steel, and in- deed the very " cunningest pattern of excelling nature " as respects endurance, strength and force-is preparing, like a wild animal gathering for its spring, for the next systolic paroxysm when its contents will be forced into the delicate meshes of the lungs, and be driven through HEART: DIFFERENTIAL DIAGNOSIS OF ORGANIC VALVULAR DISEASES. I. As it is difficult to retain at all times in the mind the structure, complex opera- tions and functions of the several chambers and valves of the heart, and the nature and cause of the modifications of the sounds they give forth when diseased, we shall there- fore, whilst endeavoring to present a clear and simple ex- position of the subject, make no apology to the readers of the Handbook for the statement or repetition of an oc- casional truism, or of a very elementary and well-known fact. The heart is a machine of exquisite construction, with four chambers and four sets of valves, its cavities inces- santly flooded and emptied, and whilst supplying the motive power to renovate itself as well as the entire body it sometimes works for a century without repair ; yet its mechanism and functions as a great receiving and driving engine-in its healthy action as well as for all purposes of the pathologist-can be grasped and understood by the mental eye if close attention be given to the subject. A knowledge of both its mechanism and functions must be attained as a preliminary step, by any one who pretends to pronounce upon its pathological changes ; but so com- plex are the elements involved-diverse and diametrically opposite operations having to be appreciated and retained at the same time in the mind-that even when thoroughly comprehended, few are enabled to apply their knowledge practically at the bedside. Notwithstanding, we will endeavor to evoke order out of this apparent confusion and difficulty, by means of a generalization which is of great practical use, and which we arrived at many years since, whilst teaching clinical medi- cine to successive classes. This is embodied in a very brief table or formula, which is characterized by exceed- ing simplicity, yet it is competent to the unravelling or interpretation of every uncomplicated case of valvular disease-for its merits are intrinsic, being based upon the relations existing between the mechanism and functions of the organ. The table, which will be developed in the course of this paper, is of instantaneous applicability, and can be used by anyone.1 No allusions will be made in this paper to hypertrophy, dilatation, pericarditis, or other diseases of the organ in- volving its muscular walls, external coverings, or its re- lations to the surrounding viscera. It is almost needless to say that the first effort of one who is desirous of knowing whether the valves and ori- fices of the heart are diseased is, obviously, to notice if there be any derangement, aberration, or change from the normal sounds. He takes care to listen at the base and at the apex, paying separate attention to each point respec- tively ; and also to the condition of the right and the left cavities,-in order, if he does discover any morbid sounds (a modification of the natural being always a morbid sound), that he may isolate and designate the derange- ment or lesion which such morbid sound surely indicates. It simplifies the process very much to know that far the greater number of endocardial lesions or injuries (it is needless to give the figures) are found in the left cavities. He should keep in mind also that the structure of the valves, or curtains at the base of the heart (the semilunar or sigmoid valves of the aorta and pulmonary artery) are analogous in shape, and act similarly and simultaneously. They are placed at their respective gateways with simi- lar intent ; they close and open, give ingress and egress to the column of blood synchronously. The same is true of those at the point or apex (the bicuspid or mitral, and the tricuspid). These, placed between the left and right auricles and ventricles respectively, differ essentially in form and structure from those at the base of the organ,- but they resemble each other in their general shape ; they also open and close simultaneously, and perform analo- gous functions with each other in the economy of the or- gan. So, in making a diagnosis in the case of a heart supposed to be diseased, we address our examination to, 549 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the finest capillary tubes in the remotest tissues of the organism. We will confine our attention at present, whilst attempt- ing to describe the morbid sounds and the lesions they indi- cate, to what takes place in the left cavities,-for what- ever is true of the left is true of the right so far as the circulation of blood is concerned-and we shall simplify matters much by so doing. Now with the first sound (systolic) the blood is being driven through the opened aortic orifice-at which mo- ment the back-gate (the mitral or bicuspid) is shut. So, if we have a deranged or abnormal first sound heard with the greatest intensity at the base of the heart (and it is not a soft, inorganic, anaemic murmur, which is owing .to the thinness of the blood, and which is out of the present question), there is necessarily a narrowing (stenosis) or roughness of the aortic orifice,-an obstruction there by vegetations, atheroma, or other morbid condition pre- venting the natural flow of blood through the aortic ori- fice, and deranging or modifying the natural sound. Hence a deranged first sound at the base of the heart indicates narrowing or obstruction at the orifice-ste- nosis, in other words, of the aortic valves. But suppose this abnormal, first sound has its greatest intensity at the apex of the heart. It must be owing- to this fact: that the back-gate has a chink in it-it is more or less open, in place of being tightly closed as it should be ; the column of blood, instead of meeting with the normal resistance of the closed and perfect mitral valve (bicuspid) in order that it may be propelled through the aorta and reach the utmost boundaries of the tree of life -is leaking back through the defective portals of the mitral,-it is regurgitating into the left auricle; and it gives out to the ear placed over the apex a morbid mur- mur or noise, more or less prolonged, in place of the ordi- nary normal first sound (represented by the word " lubb"). The valve is necessarily defective as a flood-gate ; it is in- capable of close shutting up ; that its mechanism has be- come defective is indisputable, and we pronounce posi- tively upon the subject. So a deranged first sound at the apex indicates insuffi- ciency of the mitral valve, caused by vegetations or other result of endocarditis. We have now disposed of derangements or abnormali- ties (which are always morbid) of the first sound of the heart both at the base and apex. They indicate nothing else but what we have said that they do. Let us now proceed to pronounce upon derangements or abnormalities of the second sound (diastolic), should they be noticed either at base or apex : If the second sound is deranged, its greatest intensity or disturbance being at the base of the heart, it must necessarily indicate the exact opposite condition to that which we stated that derangements of the first sound indicated,-for exactly the reversed condition of affairs is taking place-the semi- lunar valves are shutting now, they were open then. The valves at the base are acting directly contrary to those at the point also ; when one set is shut, the other set is open.* During the second sound we know that the aortic valves are closing, in order to keep the blood tem- porarily from flowing backward into the left ventricle (which is a reservoir of supply). So if there is a morbid second sound (diastolic) at the base, the valves of the aorta are insufficient. The front-gate has not closed tightly; there are vegetations-hardened plaques ot fibrine, or bone, or cartilage which interfere with the integrity or pliancy of the delicate curtains which form this front flood-gate ; and instead of the column of blood in the aorta remaining quiescent for a moment, as it should and does do in a state of health, some of it regurgitates into the dilating ventricle and gives a deranged, morbid sec- ond sound. Therefore a morbid second sound at the base indicates insufficiency of the aortic valves. Now suppose the deranged, morbid second sound has its seat of greatest intensity at the apex, instead of being at the base ; it is very plain then that the back-gate, the mitral or bicuspid orifice, is narrowed, obstructed (ste- nosis), and the blood in passing through makes a noise. Because during the second sound (diastolic) the mitral orifice should be wide open to allow the blood from the auricle to enter noiselessly and fill up the ventricle, other- wise there would be no supply for the next systolic effort of the heart. If the orifice is obstructed or narrowed the blood does not pass through noiselessly as in a state of health-the second sound is abnormal ; there is a mur- mur. A disturbed second sound at the apex indicates then stenosis of the mitral orifice. Our table now is very easily constructed, and being based upon eminently natural and scientific foundations, namely, the physical laws of the heart's structure, func- tions, and actions, it must serve as a ready method, en- abling us, or anyone else-even the most uninstructed,- to make a diagnosis of all the uncomplicated organic dis- eases of the valves at the orifices of all the chambers of the heart. It is necessarily true and correct, and though it may seem very simple, it requires no thought to apply it to any case before us ; nor is it necessary that we should at the time of applying it, understand why it is correct. The formula and the order of the words to be recalled are:- Stenosis. Insufficiency. Insufficiency. Stenosis. For example:- At the Base.-A deranged first sound indicates Stenosis of the aortic, or pulmonary artery valves. A deranged second sound indicates Insufficiency of the aortic, or pulmonary artery valves. At the Apex.-A deranged first sound indicates Insuf- ficiency of the bicuspid, or of the tricuspid valves. A deranged second sound, indicates Stenosis of the bi- cuspid, or of the tricuspid valves. All we have to do is to memorize those words in their order, as a formula, to elucidate at the bedside the val- vular diseases of the heart. Observe what sounds are deranged at the base, then at the apex, and pronounce accordingly. Of course the known relative positions of the four valves must guide us in deciding which of the two valves at the base or at the apex the abnormal murmur pro- ceeds from, so as to distinguish between the valvular de- rangements of the right and left heart. II. The above are what we consider to be the most essential facts with regard to the production and signifi- cance of the sounds and murmurs, heard upon ausculta- tion of the heart, to be recognized and understood by everyone who examines this viscus. Many will content themselves simply with the systolic and diastolic murmurs described above, and not extend their inquiries to the point where the diagnosis requires the consideration of the presystolic, post-systolic, inter- mediate murmurs, and those modified by the complica- tions existing between the diseased valves, the chambers, the muscular structure and the related viscera. But it is incumbent upon us to describe here some im- portant murmurs long known to possess pathological signification, and indicating diseased conditions of great gravity. The characteristic features, the cause and ex- planation-the very existence even-of one or two others have been, and are being daily discussed by some of the ablest observers in our profession, including Skoda, Hoppe, Flint, Broadbent, Hayden, and others. Dr. A. Flint lays special stress upon a "mitral systolic non-regurgitant murmur." He contends that a murmur of the first sound, heard within a limited area at the apex (the mitral regurgitant only can be heard laterally and at the back,) may be due to roughness of the endocardial membrane without mitral incompetency, and, conse- * A third well-known relation may very properly be stated here to com- plete the sketch of these antagonisms and contrasts. This regards the cavities of the organ. The ventricles and auricles are synergetic only with themselves ; when the former are contracting the latter are dilating, and vice versa. 550 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. quently without a mitral regurgitant current. This is the murmur which is present in endocarditis. We can also have murmurs on the right side of the heart indicating stenosis or insufficiency which-though not frequently met with-may coexist with other mur- murs, namely : tricuspid direct, and regurgitant, (the latter not being very uncommon according to Broadbent,) and pulmonic direct, and regurgitant. These are gen- erally consecutive upon other murmurs, result from sec- ondary changes such as hypertrophy, dilatation, etc., and are distinguished, by their anatomical position, a venous or hepatic pulsation, dilatation of the right auricle and the cardiac end of the vena cava ascendens, the quality and pitch of the sounds, etc.-all which are explained with more or less clearness in the several treatises specially de- voted to the subject, and to which we must refer the reader. Mitral Stenosis.-We stated in the first part of this paper that a murmur at the apex, diastolic in time, was indicative of mitral stenosis. This is true, but it is necessary to add that, to speak more strictly, the diagnostic mark of this murmur is its occurrence at the end of the di- astolic period, it is actually terminated by the systole of the heart, so that it is essentially a presystolic murmur. The murmur is caused by the vibrations of the mitral curtains, especially when these curtains are united at their sides, leaving a narrowed orifice through which the mitral direct current of blood flows. It may occur without mitral lesion when there is free aortic regurgitation, be- cause, as explained by Flint, there being blood in the ventricle, when the auricular contraction takes place the mitral curtains are floated out so as to be in contact with each other, and the mitral direct current passing between the curtains throws them into vibration precisely as when the orifice is narrowed. Mitral stenosis, to repeat, is pro- duced by adhesions to each other of the mitral curtains, these forming a funnel-shaped space with the so-called button-hole opening-the curtains not having been made rigid by thickening or calcification. If these conditions be wanting, or if the force of the auricular contractions, as in advanced stages of the disease be wanting, when from dilatation the muscular force of the auricular con- tractions are weakened, the murmur disappears (Flint). So alcohol and digitalis may cause its return. Dr. Broad- bent, in his recent article (Am. J. Med. Sc., Jan., 1886) gives the following concise description of it, which we quote, as it is the most serious of the diseases of the valves, standing next to aortic regurgitation in order of gravity, and may be mistaken for mitral incompetency, which is the least so. According to Broadbent, children are especially liable to mitral stenosis, which gives rise to arterial embolism, great enlargement of the liver, and true hepatic pulsations. Before quoting what follows, we think it just to mention that Traube had long since called a "presystolic" murmur at the apex, a pathognomonic symptom of stenosis of the mitral valve ; and Niemeyer had stated in his "Text-book" (7th ed., 1869) that "if the contracted orifice be not also roughened, if the steno- sis be moderate, if the volume of the blood be reduced, there may be no sound;" . . . and "the second sound of the pulmonary artery is naturally considerably intensified." " The pathognomonic sign of mitral stenosis is usually given as a presystolic murmur heard over a limited area to the inner side of the apex beat. It is not a smooth blowing murmur, but has a rough and vibratory charac- ter, and is often accompanied by a thrill perceptible to the hand at the same spot. Corroborative evidence is af- forded by accentuation of the pulmonary second sound, the result of backward pressure in the pulmonary circu- lation, and, not infrequently, by want of synchronism in the closure of the pulmonary and aortic valves, giving rise to reduplication of the second sound. These are, in effect, the signs in the first stage (he makes three stages), but another important note must be added, viz., that the second sound is audible at and beyond the apex. With such a combination of signs the diagnosis is extremely easy ; a murmur heard near the apex and followed by a first and second sound can only be presystolic. If further aid were wanted, it would be afforded by the character of the murmur, which, as has just been said, differs remark ably from other murmurs ; it is not flowing and smooth, but vibratory, or in some instances rumbling. (Flint calls it vibratory and blubbering, and Niemeyer ' that slight whizzing sound,' or fremissement cataire-being also the most prolonged of the murmurs.) And again, the way in which it runs up to, and suddenly ends in the first sound, which tends to become short and loud, is highly characteristic." The second stage is marked by the disappearance of the second sound at the apex and by the short, sharp charac- ter of the first sound, which also usually becomes very loud-an explanation of which is attempted by Dr. Broad- bent. The third stage is marked by the disappearance of the presystolic murmur altogether. Persons die from this disease which would not be diagnosticated if the presys- tolic murmur were looked upon as a pathognomonic sine qua non. The probable cause of the disappearance of the murmur, according to Broadbent, is the establishment of tricuspid regurgitation-the strain upon the pulmonary and tricuspid valves being very great. We must refer the reader to the article quoted, as well as to that of Dr. A. Flint in the same issue, as no more space is at our dis- posal. Mitral Diastolic Murmur.-Professor A. Flint in his article (January issue, 1886, of the Am. J. of the Med. Sciences) refers to another mitral murmur, being unable to attribute to any one the credit of having first described it as an individual murmur. As regards its clinical recog- nition, he says, a murmur which follows the second sound, and ends before the contraction of the auricle, if aortic and pulmonary regurgitation be excluded, maybe assumed to be a mitral diastolic murmur. It is easy to conceive of the mitral diastolic murmur being overlooked, if it be soft and feeble, when associated with a loud presystolic murmur, especially if the former be not sought after. It is produced by the current of blood from the auricle to the ventricle prior to the auricular contraction, and it is a mitral direct, but not a presystolic murmur. " In point of time it is diastolic, and the name mitral diastolic is an appropriate designation for it." III. It was particularly necessary to avoid prolixity in the descriptions contained in the first division of this paper, which it was desirable to present with the greatest degree of clearness and precision ; we will now add some particular suggestions pertinent to the subject, and a number of miscellaneous aphorisms which, being incon- trovertible, will be of service as references to those who are investigating endocardial murmurs. It must be observed that a murmur is not a natural, healthy heart sound ; it is a fresh, pathological sound caused by alterations of an orifice or its valves by adventi- tious growths, contractions, etc.; hence eddies are set up in the blood, and a disturbed normal relation is established between the size of the orifices and that of the cavities of the heart. Murmurs may or may not replace the normal heart sounds. Heart sounds, as stated by West,2 may be modi- fied, or even absent, without any murmur at all; and Professor Austin Flint asserts "that the quality of a murmur does not, in general, invest it with any special pathological or diagnostic symptom" (" Manual of Per- cussion," 1876, p. 213). " No positive conclusions are to be drawn from the in- tensity of murmurs, their pitch or their quality "... "as a rule, murmurs which are weak, more than those which are loud, represent grave lesions " (op. cit. sup. p. 226). Another practical fact to be noted is : that murmurs are transmitted in the direction in which the blood is passing at the time of their production. For example : systolic aortic murmurs are propagated upward, and di- astolic aortic propagated downward toward the apex. That a sound is systolic can readily be determined be- cause it coincides with the impulse of the carotid, which, being quite near the heart, can be appreciated by the touch. It also coincides with the first sound of the heart and with the apex beat,-but the latter cannot be de- 551 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pended upon, because it cannot always be heard. The radial pulse will not aid because it is not in accord with the first or systolic sound. We had stated that there was a period of rest in the heart's action. This is not strictly true ; yet varying in- tervals as to duration and rhythm do exist in the heart beats-the action of the organ being less violent and rapid during the presystolic period (when the ventricles are being filled from the auricles), i.e., when the move- ment of diastole is approaching its end. This is known as the "long pause," and the organ then enjoys a certain repose. Dr. Austin Flint, Jr., gives this concise descrip- tion of the diastolic period (" Physiol.," p. 51); (we italicize some lines) : When the second sound occurs, the ven- tricles having become suddenly relaxed, the recoil of the arterial walls, acting upon the column of blood, immedi- ately closes the semilunar valves upon the two sides. The auricles continue to dilate, and the ventricles are slowly receiving blood. Immediately following the second sound, during the first part of the interval, the auricles become fully dilated ; and in the last part of the interval, immediately preceding the first sound the auricles contract and the ventricles are fully dilated. This completes a single revolution of the heart. A reduplicated sound is often owing to a want of syn- chronism between two chambers of the heart-the valves of which ordinarily acting in concert give rise to a single sound. Irritability of the papillary muscles, and fatty degeneration give rise to tumultuous beating. All tones arise from this " That a membrane passes from a state of less tension to a state of greater." A distinct musical note is most uniformly associated with a narrowed orifice. The terms stenosis, constriction, or obstruction are more properly applied to an orifice than to a valve ; they imply that condition by which the effluent blood meets with ab- normal resistance through contraction (from whatever cause) of the outlets of the heart; or again, the walls of the orifices may be thickened and contracted-the valves being sound ; or there may be cohesion of the flaps ; or vegetations, cartilaginous hardness and calcareous depos- its may exist. Constriction and insufficiency may very naturally co-exist in any of the outlets of the heart-but more especially in the left chambers. Every diastolic murmur alone authorizes the inference of structural changes in the valves, or pericardium ; every systolic does not do so (Hoppe : On ' ' Auscultation and Percussion "). The same authority says : You may have a systolic aortic murmur from inequalities on the surface of the valves which are turned toward the ventricle. We must constantly remember the compensatory action of hypertrophy and dilatation of the ventricles and auri- cles, the slow process of these changes, and the stage which they have reached while estimating the character and signification of valvular murmurs. For example, a dilated or hypertrophied right heart, resulting from mitral stenosis, can propel so much blood into the pul- monary circuit that even the -blood in the pulmonary veins, which are at the other end of the circuit, is sub- jected to heavy pressure. In consequence of this, to say nothing of the action of the auricle, the blood pours with such force and rapidity into the left ventricle as to com- pletely neutralize the effect of the constriction of the mi- tral valve. In spite of the constriction, the ventricle re- ceives blood enough, the aortic contents are not lessened, nor is the circulation retarded. In the same way, the fulness and tension of the pulmonary vein prevent any considerable regurgitation into the ventricle, notwith- standing the insufficiency of the valve-assuming that stenosis and insufficiency, as is often the case, coexist. Where there is insufficiency of the aortic valves (sign : abnormal second sound, base), life may be prolonged for a considerable time; when, however, death ensues, it is sudden, resulting from cerebral apoplexy ; where there is stenosis of the left auricuio-ventricular valve (sign : pre- systolic murmur at apex), life is continued for but a brief period-death, however, is not sudden as in the preceding case (Hoppe). " Short breath is a symptom never missed in valvular disease of the mitral," as a consequence of hypersemia of the lung which results from it; " hypertrophy corrects this in aortic disease" (Niemeyer). Insufficiency of the aortic valve is more apt to be slowly followed by apoplexy and hyperaemia; constric- tion of the same reacts more on the lungs. Valvular disease of the aorta gives rise to embolism with a frequence next to that of endo- and myo-carditis. Strengthened apex impulse, the tortuous course of the smaller arteries, and the pulsations visible at the radial artery are signs of aortic insufficiency ; but the jerking pulse is the only pathognomonic sign. In aortic stenosis the pulse is as small and incompressible, as it is hard and full in insufficiency. In disease of the mitral the pulse is soft and irregular, and pulmonary complications are likely to arise. Strengthening of the second tone of the aorta occurs in hypertrophy of the left ventricle when this is not caused by valvular defect; owing to abnormally increased ob- struction in the peripheral part of the aortic system which opposes emptying of the left ventricle. In endocarditis (complication with rheumatism in twenty per cent.), a blowing sound at the apex is not sufficient; you must wait for intensification of the second sound of the pulmonary artery to diagnose it. This last is caused by hypertrophy or dilatation of the right ven- tricle (a result of insufficiency of the mitral-developed in the majority of cases of endocarditis), and hence over- loading of the pulmonary artery. The fuller the pulmon- ary artery becomes, so much the stronger does the shock grow which its semilunar valves must sustain during di- astole. In mitral insufficiency there is hypertrophy of all of the right heart; often dilatation of the auricles and ven- tricles-also of the pulmonary arteries and veins. In mitral insufficiency and stenosis the pressure is upon the lungs, causing oedema and short breath ; but patients often enjoy moderate health for a time. After a while the contents of the aorta diminish, the secretion of urine is lessened, the veins and capillaries become involved, the lips blue, the liver enlarged, with obstruction of the he- patic veins and bile ; so gastric catarrhs ensue ; the haem- orrhoidal, uterine and renal veins are obstructed, albumen appears and dropsy follows. Niemeyer also refers, as follows, to the difficulty of di- agnosing disease of the tricuspid: In the extremely rare cases in which the right ventricle is the seat of endocarditis, similar symptoms may be made out at the lower part of the sternum, where we listen to the sounds of the tricuspid. It would be ex- ceedingly difficult, however, to make a diagnosis here, as the right ventricle is hardly ever the sole seat of disease, and we should scarcely be able to distinguish whether the sounds were Conducted from elsewhere or actually origin- ated at the tricuspid. Affections of the tricuspid valves are very usually con- nected with dilatation of the organ ; but the dilatation or hypertrophy results from valvular disease-generally of the mitral. Digitalis is useful in mitral insufficiency and " in many cases of cyanosis, dropsy, hepatic engorgement and sup- pression of urine caused by disease of mitral valves, be- cause it diminishes or delays the necessity for the com- pensatory action of hypertrophy and dilatation." In insufficiency of the tricuspid valves, (Bennett and Tanner question whether ' ' disease of the tricuspid can be diagnosed,") blood regurgitates into the right auricle, causing turgescence and pulsation of the jugular veins, anasarca, congestion of the liver, dropsy and disease of the kidney. So these effects correspqnd with the above statement regarding the later stages of mitral stenosis and insufficiency. Tanner says tricuspid obstructive and pulmonary artery regurgitant are seldom if ever heard. Simple hypertrophy of the right heart is very rare. F. Peyre Porcher. 1 See Am. Jour, of the Med. Sciences for October. 1880. 2 How to Examine the Chest. By Samuel West, M.D., Oxon. London, 1885. 552 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. HEART, DILATATION OF. Definition and Varie- ties.-Dilatation of the heart consists in increased size of one or more of the cardiac cavities, the excess of their capacities over the thickness of their walls being promi- nently marked. It is usually described as occurring in three forms : 1. Simple dilatation, in which the cardiac cavities are enlarged, while the muscular walls retain their normal thickness. Simple dilatation-i.e., dilatation without hy- pertrophy-is impossible, provided the wall of the affect- ed cavity remains healthy. Since, however, the muscle, in many cases, is replaced by fibroid tissue, simple dila- tation is possible, if we regard the amount of muscular tissue in the affected wall, and not the mere thickness of the latter. This distinction is of some practical impor- tance, since, in the case of a dilated heart, as in that of an apparently hypertrophied heart, we should always en- deavor to determine how far its substance is composed of healthy muscular fibres. 2. Hypertrophic dilatation, or dilatation with hypertro- phy, or "active dilatation." This form is by far the most common ; indeed, accord- ing to Quain, dilatation is probably always associated with some degree of hypertrophy. 3. Atrophic dilatation, or "passive dilatation," in which the walls are distinctly thinner than in health. Even here there is reason to believe that the total bulk of muscular tissue is increased. This is less common than the preceding varieties, but occurs occasionally in the auricles, more especially in the right auricle. Hayden makes a fourth, or "mixed" form, iu which one or more portions of the walls, especially of the left ventricle, are normal or actually thickened, while at other points the wall may be reduced to the utmost tenuity. Morbid Anatomy. -One or all of the heart cavities may be the seat of dilatation. The shape of the heart is changed according to the cavity affected. If the dilata- tion is confined to the right ventricle the heart will be in- creased in breadth, and the apex may appear bifid ; while if the dilatation affects mainly, or only, the left ventricle, the heart will be elongated. Dilatation occurs most fre- quently in the auricles, and thinning of the cardiac walls is most commonly met with here ; next the right ventri- cle, and least frequently the left ventricle, is the seat of dilatation. When all the cavities are dilated the entire organ is increased in size, and assumes a globular shape. When the ventricles are excessively dilated, the trabeculae are sometimes reduced to the condition of fleshy tendinous cords. When the walls of the left ventricle are very much thinned, they collapse when the ventricle is cut into. The structural changes which take place in the muscu- lar tissue vary with the morbid process which precedes and attends the dilatation. When it results from peri- carditis or myocarditis there are serous infiltration and granular degeneration of the muscular fibres; when it is the result of fatty metamorphosis, the muscular fibres un- dergo fatty degeneration. In hypertrophic dilatation it is often impossible, even by a microscopic examination, to determine the exact changes which the muscular fibres undergo ; the abnormal state of the muscular fibres can only be determined by the evidences of feeble heart power. A heart distended with blood and relaxed by putrefaction may, on first view, be mistaken for a dilated heart. The distinctive marks of a heart softened by the putrefactive processes are its extreme softness, its satu- ration with the coloring matter of the blood, and the evi- dences of decomposition in other parts of the body. Etiology.-Two general classes may be made of the causes of cardiac dilatation. 1. Conditions which weaken the cardiac muscle, among which may be named pericarditis, endocarditis, myocarditis, and fatty and fibroid degeneration. Dilatation of the heart is also found in many constitu- tional states and acute diseases, as anaemia, chlorosis, malnutrition, pyaemia, typhus and typhoid fever, erysip- elas, etc., when often no pathological condition can be discovered in the muscular fibres. A similar form of dilatation is sometimes due to excessive use of tobacco, to onanism, and to some obscure nervous conditions. From all the above causes the dilatation is primary, and is due directly to the condition of the cardiac wall. Pri- mary dilatation may occur, however, in a healthy heart, when the cardiac cavities are over-distended during dias- tole. Under such conditions hypertrophy will accom- pany and compensate for the dilatation. But if with the over-distention there is a weakened or degenerated con- dition of the walls, the dilatation will be primary and un- accompanied by hypertrophy. The most frequent cause of systolic distention of the heart is aortic regurgitation. 2. All the causes of hypertrophy, when acting upon a weak heart, may cause dilatation. They are mostly ob- structive in their nature, and include valvular stenosis, atheroma of the aorta, arterio-capillary fibrosis, and renal disease. In most of these cases hypertrophy is the ante- cedent condition, while dilatation is secondary, and oc- curs only when degeneration of the hypertrophied mus- cle sets in, and the "vital powers" of hypertrophy gradually merge into the ' ' mechanical process " of dila- tation. Early in this series of changes there is hypertrophy alone ; later there is a condition known as hypertrophy with dilatation, which, if the nutritive supply is kept up, becomes excessive hypertrophy with moderate dilatation ; and, finally, as the dilatation predominates, passes into fully developed dilatation with hypertrophy. Simple dilatation and dilatation with thinning of the walls are usually primary. General dilatation of the heart is always of constitu- tional origin, and results from one or more of the above- mentioned causes of primary dilatation, although these causes may be secondary in operation. Thus anaemia may give rise to dilatation, which shall be primary in one case, and secondary to valvular lesion and simple hyper- trophy in another. The distinction is an important one, because the latter, or secondary, form of general dilata- tion is by far the most serious. In all cases of dilatation the other cavities of the heart, besides that primarily and directly implicated, suffer, ac- cording to their position, from the extra strain which sooner or later is put upon them. Symptoms.-The symptoms that attend the develop- ment of cardiac dilatation will depend upon the character and seat of the dilatation. In simple cardiac dilatation the heart-walls are of normal power, but the capacity of the cavities is increased, and the amount of blood to be expelled with each cardiac pulsation is greater than nor- mal ; consequently there is labored action of the heart (often so great as to be mistaken for the action of an hy- pertrophied heart); yet the force of the heart's action does not increase, and, therefore, we have a feebleness of the radial pulse. The rhythm of the heart's action will not be disturbed. In that form termed atrophic dilata- tion there is a very different state of affairs. The heart cavities are not only dilated, but the walls of the cavities are thinner than normal, the heart power is insufficient for the expulsion of the blood from its cavities, and as a result there is labored action, the rhythm is disturbed, the arteries are imperfectly filled, the veins become over- distended, and the radial pulse becomes markedly feeble and intermitting. These latter points are of especial im- portance as affecting the question of prognosis, for if the patient has all the symptoms of cardiac dilatation with- out an irregular and intermitting pulse, the prognosis is comparatively good. The same disturbance of the circu- lation occurs in that form of dilatation which is developed from the degeneration of eccentric hypertrophy. The first, and perhaps the most constant, symptom which is common to all varieties of cardiac dilatation, is cardiac palpitation. At times this palpitation is very dis- tressing. There is almost constantly a sense of painful pulsation in the region of the heart. The patient com- plains of weight, oppression, or uneasiness in the cardiac region, with a sense of fluttering, and a tendency to sigh- ing respiration. Very soon after the palpitation has manifested itself the patient will begin to suffer from dyspnoea on slight exertion; when he is perfectly quiet he suffers very little. As the irregularity of the heart's action and the palpi- 553 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tation increase, the patient's countenance assumes a pale, languid, anxious expression, with more or less lividity of the lips. The extremities are habitually cold. On ex- citement, or active physical exertion, the entire face and neck become livid; the pulse, which is usually regular, for a time becomes, irregular and intermittent. In this condition patients often live in comparative comfort; but they are conscious not only of a loss of physical, but also of mental, power, and they are troubled with dyspeptic symptoms and a sense of fulness about the epigastrium. Vomiting is not unfrequently a troublesome symptom. As the cardiac dilatation reaches a point at which there is constant cardiac insufficiency, the patient suffers constant dyspnoea, which becomes severe on slight exertion; the cardiac palpitation is always present, and often accom- panied by attacks of syncope. The countenance assumes a still more anxious expression, and the lips are always livid ; the pulse is constantly irregular and intermitting. With these symptoms there will be scantiness of urine, which will contain albumen, and perhaps blood ; the feet and ankles become oedematous, the oedema generally ex- tending upward until the patient is in a state of general anasarca. The breathing becomes very difficult-so much so that the patient is unable to lie down, but is obliged to sit with his head inclined forward and resting on some firm support; he is unable to utter more than a single word at one time. The respirations may be thirty or forty per minute, and panting and noisy in character. Cough and expectoration are not uncommon ; haemopty- sis may occur, and in some cases pulmonary infarctions form. " Petechial extravasations not infrequently occur, especially in dilatation of the right heart. The extremi- ties become cold and blue, the mind wanders, the skin assumes a yellow tinge, and the patient dies from general anasarca with pulmonary oedema, or from urinary sup- pression. During the advanced stage of this affection vio- lent paroxysms of dyspnoea sometimes occur, in some cases of which it seems as though the patient must die ; yet they are rarely immediately fatal, but the patient passes from them into a state of coma, and later dies unconscious. There is always danger from sudden syncope, which may prove immediately fatal. Although the general symptoms vary greatly in differ- ent cases, the physical signs are very distinctive. Physical Signs.-Upon inspection it will be noticed that the area of the cardiac impulse is increased, but it is so indistinct that it will be difficult to determine the ex- act point of the apex-beat. This is especially the case if the chest-walls are covered with adipose tissue, or are at all oedematous. Epigastric pulsation occurs in dilatation of the right ventricle. In persons with thin chest-walls, there will sometimes be noticed an undulating motion over the whole of the praecordial space, due to successive beats striking the chest-walls at different points. Upon palpation, dilatation can readily be distinguished from hypertrophy by the feebleness of the cardiac im- pulse. Although it can sometimes be felt as far to the left as the axillary line, yet there is an absence of the lift- ing, forcible impulse which attends cardiac hypertrophy. It is often difficult to determine the exact point of its maximum intensity, but it will be accompanied by an un- dulating motion, wanting in power. Sometimes a pur- ring thrill may be obtained. Percussion shows a greatly increased area of lateral dulness. The area will extend to the right if the right heart is dilated, and may reach the right nipple. If the left side of the heart is the seat of the dilatation, the area of the dulness will be increased to the left, and may ex- tend well into the axillary space. In general dilatation the shape of the increased praecordial space will be oval. This point is of importance in the differential diagnosis between cardiac dilatation and pericardial effusion. The superficial area of cardiac dulness is not increased in the same proportion as the deep-seated, as is the case in car- diac hypertrophy. Dilated auricles are recognized by an upward increase in the area of dulness, even to the first rib. When the jugular veins are permanently dilated and knotted, the existence of dilatation of the right auricle will be evident. Auscultation.-The sounds of a dilated heart are short, abrupt, and feeble; the second sound is often in- audible at the apex, and the two sounds are of very nearly equal duration and character, so that it is often difficult to distinguish them. Reduplication of the first sound sometimes occurs. A systolic murmur generally accompanies dilatation ; many authorities regard its pro- duction as possible without attendant valvular lesion, from tardy and incomplete contraction of the ventricle. Whenever a cardiac murmur has existed prior to the de- velopment of the dilatation, the rhythm of the murmur is lost as the dilatation develops, and it becomes simply a confused murmuring sound. This condition has been denominated asystolism. It is a condition in which it is impossible to determine whether the murmur is synchro- nous with the first or second heart-sound. Pauses or in- termissions occur at irregular intervals, which are of more frequent occurrence during exercise than when the patient is quiet. When the asystolic condition is present the prognosis is very unfavorable, independent of the general condition of the patient; under such conditions the patient is liable to die suddenly. Asystolism is gen- erally accompanied by a diffused cardiac impulse, which is peculiar, and readily appreciated by the ear as it rests over the praecordial space. The respiratory murmur is diminished in intensity over the whole of the upper por- tion of the left lung. Differential Diagnosis.-The diagnosis of dilata- tion of the heart rests mainly on the following conditions : feeble heart action, undulating impulse, indistinctness of apex-beat, lateral increase in the area of percussion dul- ness-very nearly square in its outline-short, abrupt, and feeble heart-sounds that strikingly resemble each other, and a feeble, irregular, and intermitting pulse, ac- companied by the general symptoms of systemic and pul- monary obstruction and congestion. The differential diagnosis between cardiac hypertro- phy and cardiac dilatation is never difficult. The heart- sounds are intensified in hypertrophy and feeble in dilatation. In both cases there is an increased area of apex-beat, but in hypertrophy it is distinct and forcible ; in dilatation it is feeble, diffused, and indistinct. The fact that an individual has had cardiac hypertrophy with all its attendant symptoms, but now has a tired expres- sion of countenance, livid lips, and loss of physical vigor, daily becoming more and more marked, and ac- companied, it may be, by oedema of the feet, shows that cardiac hypertrophy is giving place to cardiac dilatation. The pulse is full, strong, ami bounding in hypertrophy, and weak and feeble in dilatation. The first sound is dull, muffled, prolonged, and intensified in hypertrophy ; while it is indistinct and resembles the second sound in dilatation. The face is flushed in hypertrophy ; pale, livid, and anxious in dilatation. The presence of dis- tended, irregular, turgid jugular veins tells very posi- tively of dilatation of the right auricle ; and pulsation in the jugulars, with feeble heart action and increase in the area of cardiac dulness to the right, indicates dilatation of the right ventricle associated with tricuspid regurgi- tation. At the same time there will be hepatic, renal, and cerebral disturbances. The differential diagnosis between enlargement of the heart (whether from dilatation of the cavities or hyper- trophy of its walls) and thoracic tumors is sometimes difficult. One very reliable differential sign is the direc- tion of the increased area of percussion dulness; tho- racic aneurisms and mediastinal tumors always enlarge upward and to the right or left, while in cardiac en- largement the area of dulness is increased laterally and downward. In aneurism there is a dilating impulse, vibratory thrill, dysphagia, pain in the dorsal spine, and the peculiar aneurismal bruit. Consolidation of lung tissue in the region of the heart may give rise to some of the signs of cardiac enlarge- ment, but the other attending physical signs of pulmo- nary consolidation will distinguish between the dulness on percussion thus produced and the increased area of dulness due to cardiac enlargements. The character of the first sound of the heart, the pulse, the shape of the 554 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. area of dulness, and the presence or absence of pulmo- nary or bronchial symptoms, will aid in the diagnosis. The differential diagnosis of dilatation of the heart and pericarditis with effusion is often very difficult, but can usually be determined by attention to the outline of the cardiac dulness, the position of the apex-beat, the presence or absence of friction-sound, the presence or absence of fever, the history of the case, and the asso- ciated diseased conditions. Prognosis.-Under all circumstances cardiac dilata- tion is a serious disease, and is dangerous in proportion to the amount of structural change which the organ has undergone, as well as the degree in which the capacity of its cavities exceeds the thickness of their walls. The most important point to be determined is the exact cause of the dilatation, since, when that can be removed, a cure is frequently effected. Thus, dilatation arising from anaemia, or from excessive labor and inadequate nutri- tion, can, in many cases, be completely relieved by ap- propriate measures. The affection is often met with as a temporary result of bronchitis. Dilatation from ty- phoid softening will also disappear with the disease in which it originated. On the other hand, that form of dilatation which is secondary to hypertrophy from val- vular lesion or from renal diseases, is proportionally more serious than that of primary origin, because of the retrogressive tissue change which it implies, and the for- midable mechanical resistance which the enfeebled heart has to overcome in carrying on the circulation. After dropsy has supervened, it is scarcely possible to prolong the patient's existence more than twelve or eighteen months. Treatment.-The treatment of dilatation must be directed principally to remedying the state of cardiac debility, and preventing distention of the heart with blood. Rest, both of mind and body, is most especially to be enjoined, all debilitating measures must be sys- tematically avoided, and every means employed to im- prove the heart nutrition without exciting its irritability. To accomplish this, the diet must be most nutritious, and taken in small quantities and at short intervals. An ex- clusive milk diet will often be found most advantageous ; stimulants must only be taken in small quantities and with the food. The greatest amount of fresh air and the best hygienic surroundings should be secured. This class of patients must be placed under strict rules in regard to exercise. They should never allow them- selves to be placed in such circumstances as to render sudden and violent exertion necessary, for a single violent physical strain may jeopardize life. Flannel should be worn next the skin. A dry, bracing air generally best agrees with this class of patients. As regards the me- dicinal agents to be employed, each case must be studied by itself." All discharges that are exhausting must be ar- rested. Often, when the feet become oedematous and the patient cyanotic, iron has a wonderful effect, entirely re- moving for a time all unpleasant symptoms. In the anaemic form of dilatation, iron is especially indicated. When the disease results from excessive toil, worry, and malnutrition, digitalis and iron combined act almost as a specific-the former drug, however, is to be exhibited in small doses and with the utmost caution. In that variety of dilatation which is caused by softening, whether in- flammatory, typhoid, or fatty, quinia and strychnia, also in combination, are often of great value. Should the heart be nervously excited, the various anti- spasmodics are indicated. Ammonia and the other dif- fusible stimulants are indispensable in some cases. For the temporary relief of priecordial oppression arising from excessive cardiac distention, the application of two or three leeches over the base of the heart is sometimes highly efficacious. Dilatation resulting from the immoderate use of to- bacco is generally characterized by slight intermittence of the pulse and a tendency to syncope; likewise by a fugacious systolic murmur at the base of the heart, the action of which is usually quick, but variable, indepen- dently of physical exertion. The wisest course in cases of this kind is to gradually restrict the patient in his use of the weed, and to confine him to the mildest "smoking mixture" obtainable. In addition, cold shower-baths may be prescribed, with strychnia and iron internally. When the heart's action becomes regular, the digitalis may be given in smaller doses, but the small doses must be continued for a long time. If, after a time, the heart's ac- tion cannot be controlled by digitalis, belladonna or opium may be combined with it; the effect of the combination is to tranquillize the excited heart, but it should be re- sorted to only when the digitalis has been thoroughly tested and has failed. In the use of digitalis the same re- striction is to be observed which was described in connec- tion with the treatment of other cardiac diseases-that is, it should never be used indiscriminately. It is always desirable to postpone its use as long as possible. Should the heart become nervously excited during the adminis- tration of digitalis, as it often does, the various antispas- modic remedies may be employed. Should cough be persistent, morphine may be given. Paroxysms of dysp- noea may be temporarily relieved by lobelia, hydrocyanic acid, cannabis indica, ether, and dry cupping along the spine. During the slow progress of a chronic case of cardiac dilatation a great variety of measures may be indicated and afford temporary relief ; still, our chief reliance will always be upon digitalis and iron, combined with the most nutritious diet and absolute rest. Alfred L. Loomis. HEART, DISPLACEMENTS OF. Definitions and Varieties.-The heart, in a state of health, is subject to certain changes of position, caused, first, by the respira- tory movements, and, second, by alterations in the bodily posture. Abnormal displacements of the organ may be either congenital or acquired. The latter only-or those that occur as the result of disease-will be considered. In studying the displacements of the heart it is impor- tant to remember that the organ is held in situ directly by the great vessels, and only indirectly, through the peri- cardium, by the diaphragm. These attachments, fixing only the base of the heart, permit free play to the body of the organ, which hangs loosely in the pericar- dial sac, and very easily undergoes displacement later- ally or vertically, while its dislocation either forward or backward is exceedingly rare. This statement, how'ever, points only to a broad general classification of the dis- orders in question, since the heart is very seldom dis- placed in an absolutely horizontal, or in an absolutely vertical, plane. Morbid Anatomy.-It is noteworthy that the amount of dislocation actually found after death is usually less than the physical signs during life have led one to expect. The most obvious, though less important, change which the heart undergoes is a disturbance of its normal rela- tions to adjacent structures. Compression of the cardiac walls, which may occur to a greater or less degree in the pressure class of cases, may be the more important con- dition. The pericardium is sometimes displaced with the heart, or greatly stretched, and the great vessels at the base of the heart and at the root of the neck may be stretched and twisted, their change in position varying with the direction and extent of cardiac displacement. In some instances the circulation in the vessels is seri- ously impeded. Occasionally the pericardium and heart become adherent, and adhesions between the pericardium and pleura fix the heart in its abnormal position. The functional disturbances resulting from these altera- tions vary with the cause of the displacement. In those which are due to pressure, the heart, if healthy, suffers little or no real compression, even when the dislocation is effected rapidly ; and if displaced in front of, and in contact with a solid tumor, such as an aneurism, a solidi- fied lung, or the spinal column, its impulses may be so vigorous and diffused as to be mistaken for cardiac hyper- trophy. But if the heart is diseased, and especially if its walls are degenerated, or its cavities much dilated, sudden compression, although moderate, may cause embarrass- ment of the cardiac action, and even cause a fatal syn- cope. In those displacements which are due to retraction 555 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of either lung, the heart is displaced toward the retracted side, partly by traction, and partly by extra distention of the opposite lung, and the effects upon the functional ac- tivity of the heart are comparatively slight. In very rare cases the heart, when displaced, becomes involved in the inflammatory process of the lung or pleura, which leads to the displacement, and fibroid changes in its walls, occurring secondary to adhesions, ultimately interfere greatly with the heart powTer. Etiology.-The causes of acquired displacement of the heart are most conveniently arranged in two classes : first, conditions that exert pressure, and second, conditions that exert traction upon the heart. On the same principle all cardiac displacements have been placed under the two heads of "excentric" and "concentric." In the former of the above classes, the heart may be pressed or pushed out of position by fluid effusions into either pleural cavity. This is by far the most frequent cause of lateral displacement. Pneumothorax will also push the heart to one side, and when accompanied by perforation and inflammatory effusion, will carry the displacement to its utmost possible limit. Hydrothorax being usually double, and, therefore, pressing equally on both sides of the heart, does not displace the organ laterally, but down- ward. Intrathoracic tumors, aneurisms, and abscesses sometimes press the heart to the right or left. Hyper- trophy and emphysema, or other causes of enlargement of the lungs, occasionally operate in the same way, as also does extensive pneumonic consolidation. Pericardial effusion, when considerable, but not extensive, may push the apex into a position corresponding to the left nipple, or even above it. Cardiac displacement may also depend upon various abdominal conditions, as gaseous distention of the stomach and intestines, enlargement of the liver or spleen, the pregnant uterus, abdominal tumors or ascites. Diaphragmatic hernia or abscesses in extremely rare cases cause displacement of the heart upward. In the second class of cases the displacement is concen- tric, that is, toward the origin of the displacing force. This movement takes place during absorption of pleuritic ef- fusions, with imperfect expansion of the lung ; and in consequence of fibroid phthisical process or cirrhosis of the lung causing a gradual decrease in its volume. The heart also suffers traction in some forms of deformity of the chest from curvature of the spine. It must be ob- served, however, that in all these instances the displac- ing force is, in reality, one of pressure, resulting in dis- placement from removal of the normal counter-pressure. In certain cases, however, actual traction undoubtedly occurs, as when the pericardium becomes involved in a cirrhotic process in the lungs, or in an adhesive pleurisy, and it and the heart are displaced by the subsequent re- traction. Since displacement of the heart is a purely mechanical process, its motion will be subject to the universal law of moving bodies, that they take the direction of least re- sistance, or of the resultant of all the acting forces. The more common elements of this resultant are : 1. The restraining force of the cardiac attachments, particularly at its base. 2. The density and resistance of the surrounding tis- sues. This latter may be positive, as in case of a solid tumor, or negative, as in pneumothorax. 3. The weight of the heart is, as a rule, of slight impor- tance. In cardiac hypertrophy, however, it may be suffi- cient to produce temporarily, during decubitus on the left side, a decided displacement. 4. The direct exciting cause either of pressure or trac- tion. These elements may produce one or both of two forms of motion-either distinct displacement or rotation of the heart about one of its axes. Rotation, owing to the pecu- liar attachments of the heart, is almost invariably about the long axis, or a fixed point at the base. Passing now to a special consideration of the causes operative in the several varieties of displacement, we find that displacement toward the left, which is most com- mon, is brought about by contraction of the left lung by accumulation of fluid or air in the right pleural cavity, or by solid enlargements of the right lung or right lobe of the liver. Displacement toward the right is most fre- quently due to the presence of fluid or air in the left pleural sac, but may also result from contraction of the right lung consequent upon chronic pleurisy or fibroid phthisis ; and from the development of tumors in the left side of the chest or mediastinum. Displacement down- ward may be caused by aneurisms or solid tumors, em- physema of the lungs, etc., in the thorax, or by collapse of the stomach or intestines. Displacement upward may be due to solid, liquid, or gaseous accumulations in the abdominal cavity, ovarian tumors, enlargement of the liver, fibroid tumors of the uterus, etc. Enlargement of the left lobe of the liver usually displaces the heart up- ward and to the left, while great enlargement of the spleen may push it upward and to the right. Enlarge- ment of the liver from abscesses will also raise the organ somewhat, a fact which may become very valuable as a means of distinguishing between hepatic abscess and ab- scess in the abdominal wall over the liver. Another cause of this displacement is contraction of the upper part of either lung, the most common pathological condi- tion being phthisis. Forward displacements are usually caused by an aneurism, or a solid tumor in the posterior mediastinum. Backward displacement may be produced by tumors in the anterior mediastinum, collections of air, pus, or blood in the same situations, or a posterior exostosis of the sternum. Symptoms and Physical Signs.-Simple displace- ment of the heart, unattended by compression of its walls or torsion of the great vessels, causes no distinctive sub- jective symptoms. This is especially true when the dis- placement has been gradual. When it has been rapid, however, or is due to pressure, symptoms of embarrassed cardiac action may be developed suddenly. They com- monly consist of prsecordial oppression, more or less se- vere pain, amounting even to true angina; palpitation with its accompanying peculiar sense of lack of breath, which may extend to absolute dyspnoea; a weak, irregu- lar pulse, and a pale or cyanotic countenance. Such sud- den compression results most frequently from a rapidly developed gaseous distention of the stomach or intestines, and may quickly become dangerous, and, if not relieved, produce collapse and death. Lateral displacements are usually more readily de- tected when occurring toward the right than to the left side. In the former case the apex-beat not infrequently corresponds to the right nipple, between the fifth and seventh ribs, the apex itself being usually raised by the width of an intercostal space above the normal level. In displacement toward the left the apex-beat may be ob- served in the axillary region, with little or no perceptible movement at the normal situation of the apex. Dr. Douglas Powell has shown that in right lateral dis- placement the apex of the heart is depressed, but never so as to occupy a position external to the base; whereas, in displacements to the left the apex is relatively ele- vated, and the long axis of the heart is nearly or quite horizontal. According to Hayden, the distinctive feat- ures of lateral displacement from liquid effusion into the opposite pleura are the slow and mensurable mode of its occurrence; percussion dulness on the side whence the heart has been displaced, and clearness on the opposite side, beyond the limit of cardiac dulness; and, in the event of the removal of the displacing medium, return of the heart to its natural situation, or beyond it when the lung, previously compressed, has become incapable of expansion. Since the apex of the heart is so much more movable than its base, it is evident that, in cases of displacement, the maximum points of its sounds will not be equally removed from their normal situation. Thus, in left pleuritic effusion, when the maximum point of the first sound is carried out of place to the extent of seven or eight inches, the maximum point of the second sound is scarcely ever changed more than one and a half inch. In displacement to the right a systolic murmur has been noticed, which is ascribed to a twisting of the great ves- sels. When displacement of the heart is caused by can- cer of the lung or pleura-with or without effusion of 556 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. serum-two diagnostic symptoms of great value are es- pecially to be noted, viz., enlargement of the subcutane- ous veins of the affected side of the chest, and distinct transmission on the same side of the sounds of the heart. These signs, when accompanied by dulness on percussion, absence of respiratory sounds, and vocal fremitus, except at the root of the lung, and by excentric displacement of the heart, become pathognomonic of cancer of the lung or pleura. In downward displacement the heart not only lies lower than usual, but it generally sways a little to the right. Displacement in this direction is limited by the dia- phragm, and by the attachments at the base of the heart. It is most frequently caused by emphysema of the lungs, which constitutes, in fact, one of the most valuable signs in this form of displacement. If the apex-beat is percep- tible at all, it is situated below and to the left of its nor- mal position. There is pulmonary resonance instead of dulness in the praecordial area, and the cardiac sounds are transferred to the epigastric triangle and the lower left cartilages. Upward displacement appears to reach its maximum when resulting from ovarian dropsy. In some of these cases distinct impulse is not to be felt below the second interspace. The sounds of the heart are carried upward and weakened. In pericardial effusion the cardiac im- pulse may correspond in position to the left nipple, or even be shifted further in that direction. When the ef- fusion is very copious the apex-beat may be completely obscured. Backward displacement occurs most frequently in con- nection with other forms of dislocation. It is unaccom- panied by any physical signs due directly to the condition itself. Forward displacement is ascertained with difficulty. The physical signs are : Increase of the area and strength of pulsation and of praecordial dulness; bulging of the same sometimes is noticed in young subjects. The car- diac sounds are intensified. Diagnosis.-The diagnosis of acquired displacements of the heart is to be made by the position of the apex- beat, and of the impulse of the organ generally, by the altered locality of cardiac percussion dulness, and by the comparative intensity of the heart's sounds, more espe- cially of the first, at different parts of the chest. The chief conditions which simulate cardiac dislocation are the following: Physiological displacements, to which ref- erence was made at the outset; praecordial bulging in car- diac hypertrophy; intrathoracic tumors and aneurisms lying behind the heart and pushing it forward-thus pro- ducing the closest possible resemblance to cardiac hyper- trophy ; adhesions of the pericardium ; atrophy of the lungs. Prognosis.-Displacements of the heart being, in most instances, attended by only a slight amount of functional disturbance, and oftentimes with none at all, their prog nosis is determined by the diseases in which they origin- ate. As already mentioned, when they are accompanied by sudden and violent compression of the heart, their symptoms, if not relieved in time, may result fatally. Usually, however, the direct consequences of these dis- placements are annoying rather than serious. Treatment.-There is no direct treatment of cardiac displacements, they are only to be remedied by the re- moval of their cause ; but this, in the traction class of cases, is very rarely possible. In those, however, which result from pressure, treatment is often both urgently in- dicated and highly successful. The troublesome pulsa- tion which is sometimes experienced may frequently be relieved by the simple application of a belladonna plaster, with assurances as to the unimportance of the symptom. Alfred L. Loomis. enlarged. When, however, no other cardiac disease is present, this increase in size is inconsiderable, and is quite frequently a simple dilatation. If the degeneration has been preceded by long-continued suppuration, tuber- cular disease, etc., the heart may be atrophied. Its color is paler than normal, and varies from the hue of a faded leaf to a muddy pink or yellowish-brown. This degeneration, in some cases, is so distributed through the cardiac sub- stance as to give it a mottled appearance similar to that of a " thrush's breast." Its tissue rarely feels greasy, though readily yielding oil under pressure. In consistence it is softer than natural, varying, at different stages of the de- generation, from mere flabbiness to a condition in which its walls can be easily broken down by the finger. Walshe states that both ventricles are commonly affected. Ac- cording to other authorities the disease is most fre- quently found in the left ventricle, the right ventricle being the part next to suffer, then the right auricle, and, last of all, the left auricle. I have found the auricles equally affected. In some instances the fibrous charac- ter of the heart's structure is entirely lost, and its tissue resembles that of a fatty liver ; or, when cut, presents a granular appearance, like that of a lung in an early stage of gray hepatization. On microscopical examination the affected fibres are seen to contain very minute molecules of oil, of uniform size. These molecules, at first, are somewhat evenly dis- tributed in rows, afterward they lose all regularity of ar- rangement, and as they gradually take the place of the muscular structure the transverse stria? of the latter be- come indistinct, and finally disappear. The degenerated muscular fibres become much more brittle than in health. Generally, however, they preserve their normal outline until the destructive process has attained its extreme limit. In connection with fatty degeneration a condition called brown atrophy is frequently observed, caused by a deposit of pigment particles around the muscle nuclei, particularly at their extremities. The connective-tissue nuclei and the septa between the fibres may also be in- creased. When the disease is combined with fatty infil- tration, fat cells are seen between the muscular fibres. The heart's functional activity is more or less seriously impaired, corresponding to the extent of the degenera- tion. In the advanced stage of the disease the muscles lose completely their contractility, and, as the cardiac power becomes greatly diminished, the general arterial system is under-distended, and the general venous sys- tem over-distended ; this is most marked when, in con- nection with chlorosis and pernicious anaemia, the fatty change has reached an advanced stage, and is widely dis- tributed thoughout the heart. In other cases of fatty de- generation arterial anaemia alone is produced, cardiac dilatation and venous engorgement, with all their conse- quences, being entirely absent. The different results in these two classes of cases can best be explained by tak- ing into account the extent, and more particularly the distribution, of fatty change, the amount of work which the heart is called upon to perform, the state of the mi- tral orifice, and the condition of the cardiac and vaso- motor nerve mechanisms. Etiology.-The conditions which may lead to fatty degeneration of the heart are both general and local. The former class includes chlorosis, progressive pernicious anaemia, tubercular disease, and, in fact, all affections and states of the system in which the general nutrition is greatly impaired. Fatty degeneration is met with in a very intense form in phosphorus-poisoning; it results from poisoning by arsenic-"a curious fact," remarks Bramwell, "when it is remembered that arsenic is the best remedy for fatty heart." In acute specific fevers the cardiac tissue becomes softened, and presents under the microscope a granular appearance, which is believed by some pathologists to be an incipient stage of fatty de- generation. This degeneration is also occasionally found to originate in pregnancy. Local or limited fatty degen- eration is generally due to degenerative changes in the coronary arteries, but also occurs when the removal of waste products from the cardiac walls is interfered with, as in the later stage of mitral lesions. It is often con- HEART, FATTY DEGENERATION OF. Definition. -A disorganization of the muscular fibres of the heart, in which their albuminous and fatty constituents are sepa- rated, the latter, in form of oil-dots, taking the place of the wasted cellular elements. Morbid Anatomy.-The heart is generally somewhat 557 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nected with fatty infiltration, and is not uncommon as the result of acute pericarditis or myocarditis. The. an- lemic form is more common in women than in men, and in young than in old people. The idiopathic form, on the other hand (or that which is so often associated with disease of the coronary arteries), is more frequent in males in the proportion of two to one, and is essen- tially a disease of advanced life. As respects modes of living, occupation, and social po- sition, it has been found that, contrary to what obtains in the case of fatty growth on the heart, fatty degenera- tion is considerably more prevalent among the poor and ill-fed than among the wealthy and luxurious. Symptoms and Physical Signs.-In many cases, es- pecially of exhausting disease in which the heart partici- pates, the condition is fatally developed without giving rise to any suspicion of its existence during life. In others, arising from some local cause, as disease of the coronary arteries, the clinical evidences of the affection are more or less precise and pointed. The rational symp- toms are referable to disturbances' of the circulation, principally in the brain and lungs. Those which are connected with partial failure of the circulation are pal- lor of the surface, with anxious expression of counte- nance, general debility, weak, irregular, intermittent, or very slow action of the heart and radial pulse (though in some cases the pulse may be more frequent than normal), palpitation or prsecordial oppression, with shortness of breath, dizziness, and a tendency to syncope after exer- tion, often accompanied by a dry, irritable cough. Arcus senilis is regarded by some as diagnostic of fatty heart. In advanced cases dyspnoea may become constant, and "Cheyne-Stokes' respiration"' frequently precedes the final issue. The memory is, in many cases, impaired, the patient may become wayward, irritable, irresolute, and incapable of concentrated mental effort. Attacks of ver- tigo, or even of syncope, from a mere change of position are not uncommon, and occasionally true angina pectoris is fully developed. While all these symptoms are usually quite gradual in their development, cases are by no means rare in which busy and useful lives are cut short at a day's notice by rupture of the heart, due to arrested blood-supply and acute localized softening. Death, in a large proportion of cases, occurs suddenly. The physical signs are few, and are those of a weak heart. The cardiac impulse is more diffused than in health, and is weak, or sometimes altogether imper- ceptible. The praecordial dulness is increased in propor- tion to the degree of cardiac enlargement. The first sound is usually feeble or muffled, sometimes scarcely audible, and its duration is considerably shorter than in health. The second sound is often comparatively dis- tinct. Murmurs may be present, especially in anaemic cases. Diagnosis.-In order to establish the diagnosis we must satisfy ourselves, first, that the action of the organ is per- manently weak, and that there is no other cause for this weakness. Before deciding upon the first point it is very important that we should examine the patient more than once, and under various conditions of cardiac action. When this rule is observed, a consideration of the symp- toms and physical signs above described will enable us to take the first step in the diagnosis. For the second step, the conditions to be excluded are valvular lesions, cardiac dilatation, myocarditis, fibroid degeneration, and adherent pericardium, in all of which the same indications of car- diac weakness may be presented. Any of these lesions, of course, may be combined with fatty degeneration, and in such case the existence of the latter can only be sus- pected, not positively affirmed. The physical signs already noticed, together with the comparative absence of dropsy and other systemic effects of dilatation, seem to furnish the most reliable guides to direct diagnosis in pure cases of fatty heart. It is almost always impossible to distinguish fatty de- generation of the heart and chronic myocarditis. In chlorosis and other conditions of advanced anaemia the diagnosis of fatty heart can be positively made, patho- logical experience having demonstrated that the cardiac muscle is in a condition of fatty degeneration in these cases. Prognosis.-The prognosis of fatty degeneration of the heart depends upon the cause. When this can be re- moved, as in cases originating in phosphorus-poisoning, anaemic conditions, or long-continued pyrexia, the patient will almost certainly recover. On the other hand, if the degeneration is the result of old age, or disease of the coronary arteries, or if it attacks hearts affected with chronic valvular disease or other permanent structural lesion, the prognosis is in the highest degree unfavor- able. In this connection it is important to remember that death from fatty disease of the heart is very likely to be sudden; the fatal result may be due to syncope, coma, angina pectoris, or cardiac rupture, the first and last of these causes contributing to it most frequently. As Sir James Paget remarks, " They who labor under fatty de- generation of the heart may be fit for all the ordinary events of a calm and quiet life, but they are unable to resist the storm of a sickness, or an accident, or an opera- tion." They are also mentioned as peculiarly unsafe subjects for chloroform anaesthesia. Treatment.-This consists chiefly in promoting the general health by suitable diet and regimen, and in the avoidance, so far as possible, of everything tending to the slightest overtaxing of the damaged organ. Moderation in eating should be especially enjoined, and a heavy meal should on no account be taken just before going to bed, as such an indulgence has often resulted in sud- den death before morning. Out-door exercise is bene- ficial when not carried so far as to induce fatigue or dyspnoea. The medicines administered should be mainly tonics. Among these may be mentioned quinine, dialized iron, and phosphorus in small doses. For attacks of dyspnoea, cardiac pain, angina pectoris, etc., arsenic, strychnine, and nitrite of amyl are some of the most useful drugs. Congestion of the kidneys and liver must be carefully guarded against. As a cardiac tonic, the first place is as- signed by Dr. Hayden to digitalis. Bramwell regards this remedy as eminently serviceable in some cases, especially where there is associated mitro-valvular disease, or car- diac dilatation; in others it seems to him useless, or even prejudicial. I have learned to use digitalis with great care in all forms of degeneration of the heart-walls. Galvanism, applied from the back of the neck to the praecordium, by an interrupted current, has been found useful in a few cases of syncope. Alfred L. Loomis. HEART, FATTY INFILTRATION OF. Definition. -An excessive development of fat on the surface, or in the substance, of the heart, the oil-cells being deposited be- tween the muscular fibres instead of within them, as in fatty degeneration. The function of the cardiac muscle is not abolished, but mechanically impeded. Morbid Anatomy.-A certain amount of adipose tis- sue, formed by a cellular absorption of free fat from the blood, is found on the exterior of the heart in every well- nourished individual. In very fat persons the accumula- tion may be quite considerable without interfering to any appreciable extent with the functions of the organ. In fatty infiltration an abnormal quantity of fat is found along the course of the primary and secondary branches of the coronary artery, the grooves and furrows of the heart are filled with masses of fat, a thick layer of fat is spread over its surface, and, in advanced cases, the whole heart may be encased in an adipose covering. The presence of such a superabundant deposit, even if confined to the surface, will, of itself, be sufficient to embarrass the ac- tion of the heart; but, as the process advances, fat will generally be found between the fibres of the myocardium, and even the papillary muscles are sometimes encroached upon. In this way absorption, atrophy, and degenera- tion of the muscular structure may be produced. But, apart from such an occurrence, it is only exceptionally that the portion of muscular fibre as yet unaffected by fatty infiltration will be found in a normal condition. In old people especially, an excess of fat around the heart is very apt to be conjoined with fatty metamorphosis of the 558 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. organ, the cardiac and arterial changes being in their case the common result of a general structural decay. When microscopically examined the portion of the heart affected with fatty growth is found to contain very few muscular fibres toward its external surface, the places of the others being occupied by fat-cells. The latter diminish in number as they proceed inward, until, just beneath the endocardium, only a few of them are present. The muscular fibres, even when completely covered up, may still retain their normal anatomical ele- ments, and thus the action of the heart may not be markedly interfered with, although its parenchyma is apparently replaced by fat. Small fatty tumors, vary- ing in size from that of a pin's head to that of a pea, have also been observed beneath the endocardium. Etiology.-Fatty infiltration of the heart is almost always traceable to the same causes which give rise to general obesity, and hence is very seldom met with in "thin" persons. Sedentary habits, over-indulgence in fatty, saccharine, and amylaceous articles of diet, and in such spirituous beverages as sweet wines, ales, and porter, are the most frequent causes of the condition, when it is not due to heredity. It rarely occurs to any extent before the age of thirty years, and is most frequent after that of fifty. Males appear to be four times more liable to fatty infiltration of the heart than females. Symptoms.-In slight fatty infiltration there are no symptoms or physical signs by which its presence can be recognized, but an extensive accumulation of fat on the surface and in the substance of the heart gives rise to symptoms indicative of interference with its function. The general circulation becomes feeble, there is a sense of weight or oppression in the chest, difficult breathing, drowsiness, and attacks of syncope ; the pulse is small, the first sound of the heart indistinct, and the cardiac im- pulse weak ; the area of percussion is increased. These phenomena in a fat person are sure indications of fatty infiltration. Diagnosis.-A diagnosis is often impossible. In fat persons we may frequently suspect its presence or pre- dict its occurrence, since we know that it is generally, if not invariably, an attendant on general obesity. When the latter condition is found to coexist with cardiac weak- ness, for which no other cause can be assigned, fatty in- filtration may be positively diagnosticated. In very fat persons it is exceedingly difficult to make a physical ex- amination of the prtecordial region, and according to Bramwell, our best guide, under such circumstances, is the condition of the radial pulse. All the signs of fatty infiltration of the heart are present in fatty degeneration of its walls, and when, as is often the case, the two condi- tions occur together a positive diagnosis is impossible. Prognosis.-From what has been said it will be readily inferred that a slight excess of fatty deposit upon the heart is of no consequence. A larger accumulation may embarrass the action of the heart, but, provided there is no wasting or degeneration of its muscular fibres, it will not give rise to cardiac weakness, and hence is not necessar- ily a serious condition. When fatty infiltration, how- ever, is associated with myocardial changes, or with dis- ease of the coronary arteries, the prognosis is much more unfavorable. As in fatty degeneration, sudden death may occur from syncope or rupture of the heart. Treatment.-This, in the early stages, should be directed against the general tendency to obesity. The diet must be strictly regulated, all those articles of food and drink which are known to contribute to the forma- tion of fat being interdicted, so far as is consistent with the maintenance of good health. Active out-door exer- cise, good air, and cheerful surroundings are highly bene- ficial ; but anything which throws a sudden strain upon the heart is to be strictly forbidden. Attention should be paid to the excretory organs, the bowels, in particular, being kept regular and free to prevent straining at stool. Liquor potass® (ten drops, three times a day) may be ad- ministered for the reduction of obesity. When cardiac weakness is detected, the treatment for fatty degeneration will be applicable. Alfred L. Loomis. HEART, FIBROID DISEASE OF THE (Gowers); con- nective-tissue hypertrophy (Quain); cirrhosis of the heart, myocardite sclereuse (Lancereaux) ; chronic myocarditis (Ziegler); myocardite, sc 16 reuse hypertrophique (Rigal); chronic myocarditis (Schroetter, Osler). For many years the white, fibrous streaks and patches which constitute the characteristic lesions of this disease have been ascribed to proliferation of the intermuscular connective tissue. But while the majority of observers have attributed this proliferation to inflammation (Bouil- laud,1 Hope, Rokitansky,2 Fagge,3 Lancereaux,4 Green,5 Ziegler,6 Schroetter,7 Legg,8 Pelvet,9 Birsch-Hirschfeld,10 Rigal,11 Parrot,12 Neumann13), a few have interpreted it as the result of some non-inflammatory nutritive pro- cess. Thus Cruveilhier, who described several typical cases, and noted the development of partial aneurism from the fibroid lesion, ascribed this to an " irritative transformation" of the muscular fibre of the heart.14 Quite recently Gowers has also averred that ' ' the con- dition may certainly arise by a slow chronic process, in which no characteristic of inflammation can be traced." 15 Osler also defines the process as " an interstitial growth."16 Yet this chronic process differs in no essential particular from the cirrhoses of other organs ; and these, excluding the attempt which has been made to class uterine sclero- sis as a lesion apart,17 are now always regarded as chronic inflammations. Localized fibroid induration of the heart occupies a middle place between diffused, often micro- scopic, connective-tissue lesions on the one hand, and aneurism, with its usual concomitant of thrombosis, on the other. For it is in a form of the first that the fibroid lesion originates ; and this lesion is by far the most fre- quent cause of the latter. In the most advanced stage the fibroid patches may seem destitute of the slightest re- lations with the connective tissue. Hilton Fagge notes an entire absence of cells from the specimens he analyzed, and Wickham Legg describes a certain form of myocar- ditis (one of two kinds that he has observed) in which the tissue resembles perfectly ordinary fibrous tissue, and is destitute of either cells, nuclei, or translucent matrix. The earlier stages of the connective-tissue alteration may, however, be discovered in the cases of diffuse interstitial myocarditis which are observed in the course of infectious diseases; in the chronic vascular irritations associated with nephritis ; as an apparent extension from chronic inflammations of the pericardium or endocardium ; as a sequel to cardiac malacia (Ziegler); finally, in certain cases of syphilis or of rheumatism, in which no other cause for the lesion is discoverable except one of these constitu- tional diseases. The grouping together of lesions developed under so many different circumstances is justified by the similarity of their essential characters. In all there is proliferation of connective-tissue elements ; in all, the perimysium, and even the muscular fibre, is more or less affected ; the es- sential difference lies in the nature of the irritants which may have modified the nutritive processes of the tissues. In 1806 Qorvisart remarked that "in inflammation of the heart there is reason to believe that the cellular tissue suffers more than the muscular, which is, indeed, always compromised, but much less than the other." 18 The ear- liest stage of connective-tissue lesion is seen in infectious diseases, when the lesion of the muscular fibre accom- panying it is analogous to the myositis observed in the same diseases.19 The lesion has been studied in typhoid fever,20 in diphtheria,21 and also in variola, cerebro-spinal meningitis, and relapsing fever.22 Stevenel relates the case of a man, aged thirty-four, who succumbed with symptoms of cardiac paralysis during the course of a typhoid fever. To the naked eye the heart showed no change, except a grayish dead-leaf alteration. Examined microscopically, the connective tissue around the blood- vessels was found infiltrated with a notable quantity of young cells. Many of the blood-vessels were obstructed by thickening of the tunica intima, or even obliterated by coagulations (endarteritis). The nuclei of the muscu- lar fibres had increased in number, the fibres themselves were slightly atrophied, and their striations were replaced by granules. 559 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In three cases of typhoid fever, in which death oc- curred suddenly, the process had advanced a step further. The primitive muscular bundles formed groups separated from each other by tracts of connective tissue much broader than normal, and infiltrated with new elements ; the latter most abundant around the blood-vessels. The nuclei of the muscular fibres were tumefied and granular, some even vesicular, and greatly increased in number. The nuclei of the perimysium were similarly multiplied, and contributed to the infiltration of the tissue with new elements. With these lesions was associated a diffuse endarteritis of the small blood-vessels of the heart-walls, characterized by abundant multiplication of the elements of the intima, tumefaction of this entire membrane, and obliteration of the lumen at many points by clots. From this diffused vascular lesion could not but result a more or less complete anaemia of the heart-wall, which became probably the immediate cause of death. One of Leyden's cases of diphtheritic myocarditis is thus quoted in Stevenel's thesis : A man, thirty-two years of age, was seized, during convalescence from a severe diph- theritic angina, with paralysis of the soft palate, followed by diminution of vision and of accommodation. The pulse w'as accelerated to 116 to 120, small, and intermit- tent, and all the symptoms were accompanied by great general prostration. Death occurred in a paroxysm of extreme dyspnoea. The heart was found dilated, but contained no clots and presented no evidences of endocarditis. The myo- cardium was brown, softened, and dotted here and there with little points of haemorrhage. The muscles of the soft palate were atrophied, both to the naked eye and on histological examination. The interfascicular connective tissue was thickened and infiltrated with nuclei. The lesions of the myocardium were analogous to those of the paralyzed muscles. Around the vessels, and between them and the muscular fibres, was an intense prolifera- tion of nuclei, and, disseminated in the myocardium, were foci of atrophy, where the myolemma had disap- peared and was replaced by a connective tissue rich in nuclei. In addition to the foci were other points consist- ing of collections of pigment granules. The slightest de- gree only of fatty degeneration was detected. This acute infectious myocarditis has probably no ten- dency to pass into chronic sclerosis, for the embryonic connective-tissue cells have no tendency toward organi- zation. If the patient do not succumb during the as- cending march of the process, nor soon after its arrest from the effects of the cardiac anaemia thus induced, the lesion regresses from the cardiac, as it does from other infected muscles, and leaves no trace. In this particular class of cases there seems to be as little tendency to suppuration as to induration. The acute myocarditis which results in abscess seems hardly to oc- cur except with pyaemia. There is a constant tendency to induration in the chronic forms of myocarditis. This process, even in its earliest stages, is far more conspicu- ous to the naked eye than are those just described. As, however, the lesions, instead of being diffused, are iso- lated in patches of varying extent, they cause less imme- diate danger than do the microscopic alterations of the acute disease. These patches are at first brownish-red, the myocar- dium being injected and tumefied. Later, the red color becomes interspersed with yellowish and grayish spots, which give a marbled aspect to the whole. This gradu- ally yields to a whitish hue, which becomes more and more uniform and intense, until it reaches the ultimate dense whiteness, or mother-of-pearl hue, of complete in- duration. The histological structure of the patch varies in each of these three stages. In the first the myocardium is in- filtrated with extravasated blood-corpuscles, and also with round or embryonic cells, which elongate, become first star-shaped, then fusiform, and finally separated by a fibrillated fundamental substance, having the character- istics and reactions of ordinary connective tissue. As this fundamental substance appears, the fusiform cells become more and more consolidated into a firm dense tissue, and lose their original stellate appearance. This change of shape is thought to result from the press- ure to which they are subjected (Pelvet, Ranvier). Coincidently with these changes in the connective tis- sue, the nuclei of the muscular sarcolemma multiply, the protoplasma within wastes, " like a glass tube drawn out at each end " (Pelvet). The striations grow faint, and, according to Lancereaux, are replaced by fatty granula- tions. But Pelvet asserts that the wasting fibre retains its normal structure up to the moment of its complete disappearance before the encroachments of the connec- tive tissue. If this be so, it offers a marked contrast to infectious myocarditis, in which the alterations of the muscular fibre dominate the striations. The histological analysis explains the variations in the color and appearance of the patches. These are reddish- brown at the earliest stage, when the tissue is highly vas- cularized, and extravasated blood-corpuscles mingle with emigrated leucocytes and embryonic connective-tissue cells (Lancereaux and Ziegler). The yellowish patches when present indicate the fatty degeneration of muscular fibres, which by no means always exists. The pearl-gray and white hues charac- terize the complete formation of fibrous tissue. But this is not always the last stage of the process. A calcare- ous degeneration not infrequently takes place in the fibrous tissue, and the patch is roughened by chalky and ossiform plates and fragments. Corvisart described this osseous degeneration as a lesion distinct from another form of induration, which is evidently identical with the mod- ern hypertrophic sclerous myocarditis. Of this latter he relates a remarkable case, in which the entire left ventricle was found distended, its walls arched and double the ordinary size, hard, but very elastic and resonant on per- cussion, like a piece of horn. The color is said to have been natural, but it is probable that more minute investi- gation would have shown the red to be obscurely varie- gated with whitish or grayish streaks. An admirable description of the lesion, observed at the stage just preceding the complete evolution of the patch, is given by Rigal.23 Smooth, milky patches, one- fourth of a millimetre in thickness, were found dissemi- nated over the endocardium of the columnse carne® and of the interventricular septum. One of the latter occu- pied nearly the entire extent of the septum, and a section passing through the cardiac wall, at its level, showed the myocardium very firm and resisting, creaking under the knife. In certaip points wrere seen whitish nodules, or tracts which indicated an altogether abnormal develop- ment of connective tissue. A similar appearance was very marked on one of the papillae of the mitral valve. On microscopic examination of a section of this papilla was discovered, with a low power, a series of irregular islands of whitish hue, constituting an insular cirrhosis, entirely analogous to that described by Charcot in the liver. The centre of the island was formed by a small artery, surrounded by connective tissue, which seemed to radiate diffusely toward the periphery, dissociating the muscular bundles in its progress, until they seemed to be lost in its midst. The muscular bundles atrophied gradu- ally, appearing deformed at the periphery of the patch, then wasting more and more, until at the centre they had entirely disappeared. The connective tissue replacing the muscle was at first embryonic and then fibrillary. The arteries were the seat of multiple lesions. The ex- ternal tunic was doubled in thickness ; the internal tunic was the seat of small vegetations beneath the elastic lamina, obliterating the lumen of the vessel. These lesions predominated in the left ventricle, but ex- tended also to the right. Parrot (loc. cit.) relates a case in which he was led to discover the lesion, at first unnoticed, by observing the diminished size of the antero-external papilla of the mitral valve. The free extremity of the papilla was covered by a fibrous cap, which sent to its surface and throughout its mass prolongations in the shape of mother-of-pearl bands. ' The posterior pillar was still more sclerosed, being reduced to the state of a tendon, and not more than three millimetres thick. This fibrous transformation 560 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. had invaded all the parietal region upon which the papil- lae were implanted, and the thickness of the wall at this point was notably diminished. This diminution of bulk is in marked contrast with the hypertrophic form of cirrhosis described by others. But, in proportion as the fibroid patches become distinctly formed and visible to the naked eye, the tissues always become thinned and atrophic. It is the third stage of the lesion. It is in this that whitish streaks or patches appear, varying in size from little islands, one or two centimetres in diameter, to broad bands encircling a large part of the circumference of the heart. The patches and bands are principally seen in the left ventricle, especially at the apex, which may come to consist exclusively of such tissue. But no part of the heart is exempt, although the lesion is extremely rare in the walls of the right auricle. When a fibrous band surrounds the infundibulum of the pulmonary ar- tery this becomes constricted as the fibrous tissue retracts, and a stenosis pulmonalis is produced. Elsewhere the fibrous disease determines local or general dilatation, as the cardiac walls, deprived of their normal contractility, yield to the pressure of the blood (Cruveilhier). When the fibrous patches are white, they are also glistening and resistant, resembling a good deal the fibrous inter- sections of certain muscles. Their position, embedded in the fleshy substance of the heart, renders the comparison still more appropriate. In Hilton Fagge's remarkable series of seven cases24 we find that in the first the fibroid disease involved the whole wall of the left ventricle, the columnae carneae of the right ventricle, and the mitral valve. In the second case there was advanced fibroid growth at the apex of the left ventricle, and at the an- terior part of the septum. In the third the walls of all the cavities of the heart were hypertrophied, the substance tough, the cut surface pale and mottled with gray dots. In the fourth case the wall of the left ventricle at the apex was entirely formed of dense, fibrous, white tissue. In the fifth case the fibroid disease was diffused through the left ventricle ; in the sixth, was limited to a small patch at the apex, and in the seventh similar patches were' scattered through the wall. In a case described by Neumann,25 the entire wall of the left ventricle was thin, containing very little contractile substance, and seemed composed of a gray cicatricial tissue. Only in very rare instances does the fibroid process result in the formation of an encapsulated tumor. Luschka observed such a neoplasm in a boy, six years of age, who died of croup. It was four centimetres long, three and a.half centimetres broad, and was embedded in the substance of the wall of the upper half of the left ventricle. It had both the ap- pearance and the consistency of a uterine fibroid. It was surrounded by a capsule at a point where it reached the pericardium, and apparently had originated in the visceral pericardium. It was composed of compressed connective- tissue bundles, mixed with cells and elastic fibres. Zander26 describes a case of cardiac fibroma in a wo- man, aged thirty-six, who entered the hospital complain- ing of nothing but an abscess in the ear. After fourteen days dropsy suddenly occurred; the heart was then ex- amined, and a systolic murmur discovered, with its max- imum over the pulmonary artery. Death occurred after dropsy had become general. A tumor the size of a large apple was found in the right ventricle, which it nearly occluded. It was formed of true fibrous tissue. A very remarkable case of such tumor is described by Douglas.27 The patient was a robust and athletic man, aged thirty- five. His health failed gradually for a few months, then there was a sudden attack of haemoptysis, followed by severe dyspnoea, which lasted from December 28th to January 28th, the day of death. The dyspnoea was ac- companied by excessive insomnia, profound prostration, nausea, occasional paroxysms of acute substernal pain, harassing cough, and anasarca beginning the fifth day before death and rapidly increasing. The cardiac impulse was indistinct, without force or heaving impulse, but ap- parently diffused ; its situation was at the apex, but ill defined ; there was no increased area of dulness ; the first sound had lost its fulness, and resembled the second sound ; there was no abnormal murmur ; the pulse was from 120 to 150. The liver was engorged. At the autopsy a fibrous tumor was found growing from the 'wall of the left auricle, nearly filling its cavity, and projecting through the mitral orifice. It is said to have been composed of fibro-cellular tissue ; but the rapidity of development sug- gests rather a spindle-shaped sarcoma. The symptoms, however, except for the rapidity of their evolution, are such as would be caused by any tumor in the cardiac cavities, and are therefore quoted here. The most frequent form of fibroid induration consists in the slowly developed white patches. Wickham Legg describes two forms of these white patches. In the first they are firm, white, almost cartilaginous, scattered dif- fusely in islets around one large mass, or in several large masses at a distance from each other, irregular in shape, and sharply separated from the surrounding tissue. Un- der the microscope there is seen a transparent or slightly fibrillar matrix, in which appear nuclei rounded in shape and varying in size from that of a red to that of a white blood-corpuscle. Around the nuclei may be traced cells about double their size, round, oval, or even spindle- shaped. At the borders of the new growth the matrix is prominent, passing between and separating the muscular fibres ; toward the centre of the growth the nuclei be- come much more abundant, while in the centre there is a confused granular mass -without definite structure. The other form of fibrous growth described by Legg is dis- tinctly fibrous in appearance, and creaks under the knife. Under the microscope it is seen to be composed partly of fine, delicate, wavy fibres, and partly of ill-formed coarse fibres, running in no definite directions. There are neither nuclei, cells, nor matrix ; the whole mass is made up of fibres. The author considers these two forms to repre- sent distinct varieties of myocarditis. It seems to us far more probable that they represent different stages in the evolution of an identical process. When an aneurism has developed in the fibroid patch, the connective tissue becomes gradually replaced by elas- tic tissue. This forms a loose network in the middle layers, but at the internal surface it is condensed into elastic laminae (Pelvet). Most authors (Cholmeley, Bris- towe, Skrzeczka, Farget) affirm that muscular fibre to- tally disappears from the fibroid patch; and this seems to be the case when the examination is made only by teazing and raclage. But in sections it is easy to as- sure one'sself (says Pelvet), that some muscular fibre al- ways persists, though diminishing gradually toward the centre of the patch, that is, the bottom of the aneurism. Virchow was the first (?) to suggest that the insular fibroid disease of the heart depended upon syphilis. Through his authority the presence of this cardiac lesion was at one time considered of itself sufficient to establish the anatomical diagnosis of syphilis.28 Even as late as 1876, Schroetter (loc. cit.) says there can be no doubt that fibroid induration may result from syphilis. In 1866 Kantznow and Virchow described, under the name "myoma of the heart," a tumor lying over the conus pulmoualis, in a child prematurely born at eight months, whose mother had been previously infected with syphilis. Under this influence she had had four miscar- riages, but for five years had seen no trace of the disease, and seemed to be in excellent health. The tumor was half an inch long, and was accompanied by whitish spots disseminated under the pericardium, exactly re- sembling miliary gummata. But the tumor was com- posed of muscle cells three or four times as broad as the normal fasciculi. The authors interpreted this as the result of an irrita- tive myocarditis, analogous to the bony growths which may be developed around periosteal gummata.29 Recently numerous cases have been reported where the absence of all other sign of syphilis has led observers to re- nounce the earlier opinion, and to ascribe the heart lesion to other causes (Legg, Bradshawe, "Lecture on Cardiac Aneurisms," 1884).* Lancereaux describes syphilitic myo- carditis apart, as a lesion characterized by the presence within the myocardium of an inflammatory tissue which becomes necrosed and forms peculiar nodules. These nodules are white or yellowish, firm, inelastic, rounded 561 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or semicircular, varying from the size of a pea or a bean to that of an almond, and project from one of the sur- faces of the heart. When a section is made through the cardiac wall containing one of these nodules, the latter is seen to be separated from the surrounding muscle by a grayish, resisting, fibroid tissue, which passes in- sensibly into normal tissue. The nodules are always multiple, here and there agglomerated, and the heart be- comes deformed by their presence, being dilated at the points where the muscular fibre is atrophied and trans- formed, and hypertrophied where the myocardium per- sists. The minute structure of these nodules differs essen- tially from that of the fibroid indurations, and perfectly resembles that of gummy tumors in other parts of the body. It consists of a peri-vascular accumulation of round embryonic cells, united by an intermediate sub- stance which, from lack of vascularization, undergoes a granular fatty degeneration. This mass is surrounded by sclerosed connective tissue, which, being provided with blood-vessels, arrives at a complete development. The muscular fibres comprised in the mass undergo fatty degeneration. The whole nodule is destined to soften, and, if the life of the patient be sufficiently prolonged, to be reabsorbed. The lesion is manifestly different from the fibroid in- duration proper. (There is an excellent picture of this form in Lancereaux, and also a case in the " Atlas," p. 236.) But although the typical syphilitic myocarditis is so different from the ordinary sclerosis or fibroid indura- tion, the myocardium may be infiltrated under the in- fluence of syphilis in a manner indistinguishable from the early stage of other cardiac scleroses. Copland re- lates a case of extensive visceral syphilis in an infant aged three months, in which the myocardium was found to be very firm and resisting, and of a uniform, pale, pinkish-yellow tinge; the walls of both ventricles and septum were very thick, and emitted a creaking sound on section. Microscopically, the tissue was found to be every- where infiltrated with small round cells embedded in a structureless matrix, between groups and bundles of mus- cular fibres. The infiltration was most abundant around the small arteries. The striation of the muscle fibre was preserved.30 Far better demonstrated than the influence of syphilis is the association of cardiac fibrosis with chronic nephritis. Of this association Lancereaux (" Atlas," p. 233) relates a typical case. A woman, sixty-nine years of age, entered the hospital with all the signs of cardiac asystoly, and died. The heart was found voluminous, with all its cavities di- lated ; the wall of the left ventricle was injected, diversely colored in yellow, gray, and brown, and indurated at several points. At the apex was a patch of densely white mother-of-pearl tissue. These patches were composed of elongated and fusiform cells, separated by a fibrillary tis- sue, and by atrophic muscular fibres. The correspond- ing endocardium was thickened and covered with fibrin- ous concretions. The brownish patches consisted of little sanguinolent extravasations. The kidneys were indu- rated, covered with stellate depressions, resulting from the extensive atrophy of the cortex. In an interesting case related by Stevenel, a myocar- ditis, characterized by an abundant intermuscular pro- liferation of connective tissue without any lesion of the endocardium or valves, coincided with a " marked tume- faction of the cortical substance of the kidney." This latter lesion is not more minutely described by the writer, who lays much stress on the difficulty of explaining the myocarditis. The memoir of Debove and Letulle31 was written ex- pressly to point out the coincidence of cardiac with renal cirrhosis. The memoir of Rigal32 is intended to show that the sclerous hypertrophic myocarditis is not exclu- sively limited to cases of chronic nephritis, but occurs in- dependently of it. Of the two cases described, however, the kidneys were affected in one. The discovery of myocarditis in this connection is ex- tremely important; for it explains, far better than can the mechanical theories of either Traube or Gull and Sutton, the hypertrophy of the left ventricle, so frequent in renal cirrhosis. The blood-vessels of the heart-walls are al- ways affected with an arteritis, which seems to be the localized expression of the " arterio-capillary fibrosis," diffused throughout the body, and to constitute, indeed, the starting-point of the fibrous disease of the myocar- dium. Fibrous patches in the heart sometimes result from an entirely different morbid process from those which have been described ; they are merely scars of ci- catricial tissue replacing spots of myomalacia or soften- ing. This localized softening depends upon localized ischaemia from atheroma or embolism of branches of the coronary arteries (Ziegler).33 The possibility of this asso- ciation of morbid phenomena is perhaps the basis for the theory advanced by Cohnheim34 and Huber,35 that fibrous myocarditis is due to plugging of the cardiac arteries-in other words, is a necrobiotic process like that of infarc- tion. Huber alleges eighteen cases of fibrosis, in all of which was also present highly marked atheroma of the coronary arteries. But fourteen of these cases were over sixty-two years of age. Legg describes six cases of fibroid disease with aneurism, all but one occurring in persons younger than forty, and in none of these were the arteries affected. In the case over forty they were atheromatous. This parallelism between coronary atheroma and a cer- tain advancement of age in the subject holds, according to Legg, in all the published cases. Associate Lesions.-Among lesions of blood-vessels atheroma has thus no evident connection with cardiac fibrosis, except through the intermediate stage of localized softening; diffused endo- and peri-arteritis have been shown, on the contrary, to invariably accompany at least the hypertrophic and diffuse form of the disease. It is sometimes difficult to decide whether the myocar- ditis has not been produced by extension from the peri- or endo-carditis, and undoubtedly in some cases the lesion has developed in this way. Valvular lesions may be en- tirely absent-a fact which often renders the clinical diag- nosis of heart disease extremely obscure, or may lead to its being entirely overlooked. On the other hand, if an endocarditis exists at any portion of the ventricle, it gen- erally extends to the valves; or, without endocarditis, coincident atheroma of the aorta is liable to be associated with lesion of the aortic valves. In a specimen of myo- carditis at the New York Hospital Museum, where the aortic anterior wall of the left ventricle was intersected with streaks of white fibrous tissue, two of the aortic cusps were fused together to the extent of one inch. There was extensive atheroma of the aorta. (Sp. 2,031.) Insufficiency of the mitral valve may be caused by shortening and ri- gidity of the papillary muscles from fibroid disease, even when the valves themselves are quite healthy. Sometimes fibroid disease exists in no other part of the heart. Partial aneurism and cardiac thrombosis are peculiarly interest- ing consequences of fibroid disease. Long ago Cruveil- hier pointed out that when a portion of the heart-wall had lost its contractility it is liable to yield to the pressure of the blood at the centre of the patch, and to be com- pressed by the contraction of muscular tissue at its periphery, the result being the formation of a partial aneurism. This is not so liable to occur if the fibroid degeneration is widely diffused in streaks, mingling evenly with the muscular tissue, instead of being concen- trated into a definite patch. On the other hand, a very small area of degeneration may result in an aneurism when it is situated at the apex of the heart, or at the upper portion of the interventricular septum. When an aneurism has been formed, blood stagnates and coagulates in it as in arterial aneurisms; layers of fibrine are formed, which may simply line the dilatation or may occlude it. In either case there is always danger that a fragment of fibrine may be detached and carried into the arterial circulation as an embolus. Even in the absence of an aneurism, fibrine is apt to be deposited on the patches of nou-contractile tissue, which remain mo- tionless amid the incessant waves of motion animating the muscular tissue around them. 562 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. Symptoms of Fibkoid Disease.-These are necessarily extremely obscure. Small areas of the lesion may occa- sion no symptoms whatever, unless by their situation they interfere with the functions of the mitral valve. Larger patches, as well as the diffused form, the generalized interstitial myocarditis, interfere with the effective con- traction of the heart, and occasion the symptoms of car- diac asystoly to a degree proportioned to their extent.* Thus, feebleness of the heart's action is the first indica- tion of fibroid disease, which is manifested locally by feebleness of the cardiac impulse and of the first or ven- tricular sound ; and generally by the usual evidences of failing and obstructed circulation, symptoms which do not appear till late in the disease. Coincidently, the area of cardiac dulness is enlarged, the heart indeed being often markedly hypertrophied. In the case already quoted from Corvisart, the heart's im- pulse was noted as " heaving," and extended over a large area, while the pulse was very small and frequently inter- mitted. In Rigal's case, in which the myocarditis was diffused and rather acute, the enlargement proceeded- quite rapidly in the course of a few weeks. A case described by Sanders36 is quite typical of the localized form of fibroid disease. This began apparently in the endocarditis which accompanied an attack of pleurisy, the patient being then fifty-one years old. Re- covery from the acute disease took place in two months. There was a recurrence of severe dyspnoea after two years. The face was then slightly livid and congested, becoming much more so or. the least exertion. This caused great exhaustion, and threatening of syncope, with some oedema of lower limbs, gradually increasing to an anarsarca that extended to the middle of the trunk. The heart was enlarged transversely, so as to measure four and a half inches. The cardiac impulse was strong but diffused, the apex-beat indistinct, the radial pulse very small and weak, occasionally intermittent. The first sound of the heart was full over the right ventricle, but deficient over the left; there was occasional redupli- cation. No abnormal murmur. The jugular veins were sw'ollen and prominent. In Neumann's case,31 that- of a woman of forty-one, who had suffered from angina pectoris, symptoms of embolism in the arteries of the legs occurred fourteen days before death; at that time there was nothing dis- tinguishable about the heart but a galloping rhythm to its beat. In this case the left ventricle consisted almost entirely of fibrous tissue, and numerous thrombi nestled among the degenerated trabeculae. Rigal sums up the symptoms of hypertrophic sclerous myocarditis as follows : Enfeeblement of the cardiac con- traction, weak pulse, obscure apex-beat, acceleration of pulse while this remains regular; absence of modifica- tion sounds, except occasionally a reduplication, or bruit de galop; enlargement, sometimes rapid, of the area of cardiac dulness, this contrasting with the feebleness of the apex-beat ; dyspnoea, often scarcely perceptible in repose, but greatly aggravated by exertion. In addition are intermitting attacks of praecordial pain, of pulmonary congestion, of generalized oedema, finally, even of valvu- lar murmur at the mitral and tricuspid orifices. The morbid condition may be further complicated by the symptoms of embolism consequent on thrombosis, or of hepatic or renal cirrhosis coinciding with the heart dis- ease. In the interesting article upon chronic diffused myo- carditis by Ruble,38 the pulse is described differently, as being remarkably irregular and unequal in force. This irregularity may reach such a pitch as to constitute a ' ' de- lirium cordis," and is, according to this observer, the most characteristic symptom of the disease. The sphygmo- graphic tracings strikingly exhibit the peculiar combina- tion of irregularity and inequality. It cannot be asserted, however, that such tracings would never be obtained in pericarditis, endocarditis, fatty degeneration, or valvular disease, until a larger number of cases of isolated fibroid disease have been observed. Clinically, this is so fre- quently combined with other cardiac lesions that the precise interpretation of many symptoms is most difficult. The myocarditis of acute infectious diseases usually ap- pears at the moment that the patient is apparently enter- ing upon convalescence. It is marked by signs of rap- idly increasing heart failure, and the patient usually dies painlessly in a few days. In the cases described by Meigs39 and Beverley Robinson40 as heart-clot in diphthe- ria, the symptoms were probably due to such a myocar- ditis, the clots found in the heart cavities being secon- dary to the disease of its walls. It is conceivable that the acute process should subside here as elsewhere, and Meigs relates a case of recovery after symptoms almost as alarming as those exhibited by the fatal cases. Diagnosis.-When there is no valvular trouble, and therefoe nor abnormal cardiac murmurs, it is easy to overlook cardiac disease, and to ascribe to general debil- ity the symptoms which indicate failing heart-power. On the other hand, as has been shown, mitral insufficiency may be caused by fibroid disease, or a myocarditis of varying extent may complicate valvular lesions. The difficulty, then, is to distinguish the symptoms indicating disease of the valves from those which point to disease of the myocardium. This is all the more important, be- cause it is by invasion of the myocardium that any form of heart lesion finally leads to asystoly.* It is desirable to distinguish, among diseases of the myocardium, between a fatty degeneration, a fibroid de- generation, and the aneurisms that scarcely exist, except as a consequence of the latter. The successive steps in the diagnosis are, therefore, the establishment of failing heart-power from organic disease ; the location of this in the myocardium, with or without valvular lesion ; and the decision that the pre- cise form of the myocarditis is fibroid. 1. In chloro-anaemia, or in neurasthenia, there may be dyspnoea, palpitations, praecordial distress, even oedema at the malleoli, rapid, weak, and irregular pulse, and pro- found general debility. The symptoms are, indeed, due to the diminished force of the ventricular systole, and are, therefore, to a considerable extent, identical with those of myocarditis. But, when the latter is at all exten- sive, the apex-beat of the heart is displaced to the left, and the area of cardiac dulness increased by dilatation or by hypertrophy of the ventricle. In functional disease, espe- cially chloro-anaemia, the heart is liable to be diminished in size, but not enlarged. In myocarditis the cardiac impulse is diffused, heaving, feeble, like that of pure dila- tation, and contrasts markedly with that characteristic of a similar amount of enlargement without myocarditis. In functional disease, the apex-beat may be feeble, but lacks the other characteristics ; it may also be sharp and jerk- ing. The pulse is feeble in myocarditis, resembling that of mitral insufficiency, and is rapid, but regular. In chloro-amemia the pulse is sometimes ample ; in adult neurasthenia and anaemia there is no distinguishing characteristic of the pulse. If there are heart-murmurs in anaemia, they are situated at the base of the heart, and coincide with murmurs in the jugular and carotid. There is no murmur in myocarditis, except from mitral insufficiency, or from organic lesion of the valves, and it then has its usual peculiarities. The first sound is not infrequently reduplicated from unequal action of the ventricles. If mitral stenosis can be excluded, such re- duplication, long persistent, is an important indication of myocardiac disease. The dyspnoea and palpitations of functional disorder are disproportioned to the amount of exertion, but those of myocarditis are very closely proportioned to it. At- tacks of angina pectoris are not infrequent in the course of fibroid disease, and then the coronary arteries are usu- ally involved. Praecordial distress, thumping of the heart, and its violent or irregular action, are observed in * The hardening of the heart is accompanied by a loss of muscular contractility. Corvisart, loc, cit. * Juhel-Renoy (Archives Gen., 1883, vii., 2) observes justly that the brilliant achievements in diagnosis of valvular disease, effected by means of auscultation, have led to some injurious neglect of the non-valvular diseases of the heart, 563 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. either organic or functional disease, and can only be in- terpreted together with other symptoms. When nephritis exists, cardiac symptoms that might otherwise be interpreted as functional, should at once awaken a suspicion of diffused myocarditis. 2. When valvular disease exists, and is betrayed by the usual auscultatory and sphygmographic signs, it is impossible to distinguish positively disease of the heart muscle. Yet some form of muscular degeneration is al- ways imminent in long-standing valvular disease, and to it symptoms of asystoly are immediately due. Proba- bly, an interstitial myocarditis would be much more fre- quently found than is at present supposed, if the heart- tissue were examined microscopically in all cases of valvular lesions. A rapid enlargement of the heart, with feeble action, dyspnoea, and angina pectoris, all point toward fibroid disease. 3. It is wholly impossible to clinically distinguish fibroid patches from the aneurisms which so often result from them. Fatty degeneration resembles fibroid dis- ease in the signs of weakened ventricular systole, the muffling of the first sound of the heart, without valvular murmurs. But the heart is not enlarged. Fatty degen- eration, moreover, occurs under circumstances of anae- mia ; fibroid degeneration is associated with chronic ne- phritis, with other scleroses, or with syphilis. It is evident that small patches of fibroid disease must remain entirely latent. Duration.-This is very indefinite, since the begin- ning of the morbid process can only be fixed in those cases in which it begins in an acute attack of peri- or endo-carditis. Several years of good health often inter- vene before the patient is again troubled; but then, to judge from several recorded cases, when the symptoms be- gin to show themselves, the progress is often uninterrupted toward a fatal issue within a few months. The fibrous myocarditis which is developed during a chronic nephritis may be relatively rapid in its course. The interstitial myocarditis of infectious diseases, and which is only an- atomically related to the fibroid degeneration, is extremely rapid. It probably exists for some time, i.e., two or three weeks, before becoming perceptible; but death super- venes within a few days after the first symptoms have appeared. Treatment.-There is no treatment known for fibroid disease of the heart, apart from that of the conditions under which it arises. Thus syphilis and rheumatism demand the treatment respectively appropriate to each ; pericarditis requires the local ice treatment, not only on account of the dangers peculiar to itself, but by reason of the liability to myocarditis. When the tendency to fibrous degeneration seems to be general in the kidneys, liver, and arteries, as well as in the heart, the prolonged use of the bichloride of mercury sometimes appears to arrest the mor- bid process. The attacks of angina pectoris that not in- frequently complicate cardiac fibrosis, are best combated by nitrite of amyl, or possibly may be averted by the per- manent use of glonoin. The dyspnoea and palpitations which are so liable to be induced by exertion demand the maintenance of as nearly complete repose as possible. Digitalis is often useful in palliating these symptoms, as the prolongation of the diastole which it causes seems to favor the nutrition of the heart muscle. When digitalis is found advantageous in hypertrophy of the heart, it is always probable that this is the pseudo-hypertrophy of interstitial growth, and not the true hypertrophy of mus- cular tissue. There seems to be no danger that digitalis will cause rupture of the heart, or that this, imminent in fatty de- generation, will occur spontaneously. Hayem : Myosites, Arch, de Phys., 1870. Fagge: Tr. Path. Soc., vol. m. (14 cases). Neumann: Charite Annalen, 1881. Luschka: Arch. Virch., 1866. Sanders : Edin. Jour., 1869. West: Lancet, 1884. Skrzeczka : Virch. Arch., t. xi., 1857. Rigal: Myocardites, Arch. Gen., 1881. Cohnheim : Arch. Virch., 1881, Bd. 85, Disease and Closure of Coronary Arteries. Huber: Ibid., 1882. Habershon: Path. Trans., London, 1876. Gowers: Ibid., 1876. Mary Putnam-Jacobi. 1 Traite des Maladies du Coeur. 2 Rokitansky : Lehrb. d. Anat. Path. 3 Trans. Path. Soc. Lond., vol. xxv., 1874. 4 Traite Anat. Path., 1881. 6 Pathological Anatomy. 8 Ibid. 7 Ziemssen's Handbuch, Bd. vi. 8 Cardiac Aneurisms, Bradshawe Lecture, 1884. 8 AnSvrismes du Coeur. Paris, 1867. 10 Pathol. Anat. 11 Archives Gen., 1881, 7, ii. 12 Diction. Encyclop., art. Cardite. 13 Charit6 Annalen, 1881. 14 Anat. Pathol., livraison xxi., 1835. 15 Reynolds's Syst. Medicine, vol. iv., art. on Fibroid Disease of Heart. 16 System of Medicine, Pepper, vol. iii., p. 607, 1885. 17 Areolar Hyperplasia of Thomas. 18 Essais sur les maladies organiques du coeur, p. 55, 1806 18 Hayem: Recherches sur les Myosites symptomat., Archives de Phys., 1870. Zenker : Ueber die Verand. der willkur. Muskeln in Typh., abd. Leipzig, 1864. 20 Hayem: Sur la mort subite dans la fievre typhoide, Arch, de Phys., 1869. Stevenel : These de Paris, 1882. 21 Leyden : Zeitschrift fur klin. Med., t. iv., 1882. 22 Ibid. See also Ziegler: Special Path. Anat., p. 56. 23 Loc. cit. 24 Tr. Path. Soc., vol. xxv.. 1874. 25 Charite Annalen, 1881. 28 Virch. Arch., Bd. Ixxx., 1880. 27 Edin. Med. Jour., 1868. 28 Virchow : Dessen Archiv, 1859, Bd. xv. 29 Virchow's Archiv, 1866. 30 Path. Trans., London, 1876. 31 Archives Gen., 1880. 32 Ibid., 1881. 33 Loc. cit., pp. 45 and 46. 34 Virch. Arch., 1881, Bd. 85. 35 Huber; Ibid., 1882, Bd. 89. See discussion of this in Legg., loc. cit., p. 17. 38 Edin. Med. Jour., 1869. 37 Charitd Annalen, 1881. 38 Deutsch. Archiv fiir klin. Med., Bd. xx., 1878. 39 Am. Jour, of the Med. Sciences, 1864. 40 These de Paris, 1871. HEART. FUNCTIONAL DISORDERS OF THE. Functional disorders of the heart include those varieties characterized by disturbance of its force, frequency, rhythm, or sounds, and unaccompanied by structural le- sion. The muscle, the connective-tissue structure, peri- cardium, endocardium, valves, the nutritive blood-ves- sels, must all be free from disease. As yet the pathology of the cardiac nerves is not suffi- ciently explored to enable us to draw the line between disordered heart-action from functional derangement of the cardiac nerves, and disorder from organic nerve lesion. This latter uncertainty bids us include under functional diseases, disorders such as angina pectoris and exophthal- mic goitre, which the writer feels will, before many years, be demonstrated to result from either true nerve lesion or lesion in a distinct organ. It is not denied that functional disorders of the heart may coexist with true valvular disease, the latter, in the particular instance, seeming not to disturb the heart's ac- tion, and the cause of the disturbance coming from an- other viscus. Such hearts are naturally predisposed to disturbance, and we shall refer the reader to the appro- priate headings for the discussion of this form of func- tional disorder. Etiology.-It will be convenient to divide the causes of functional disorders of the heart into two sets, of which one may be classed as extrinsic, and the other as intrin- sic. Under the extrinsic we have all causes which em- barrass the free action of the heart. These are : (a) Pressure upon the heart or its large vessels ; (b) Displacement of the heart; (c) Pericardial adhesions. Under the intrinsic we have, in addition to anomalies of anatomical structure, such as abnormal valve structure or its tendinous fibres, others which depend upon (a) Changed blood states ; (b) Faulty innervation; (c) Causes producing temporary muscular relaxation of the heart-walls; (d) Heredity. Pressure upon the heart or its vessels, and displace- ment, may be temporary or permanent. Temporary causes arise from fluid or gaseous accumulations within the pericardium or in any neighboring viscus or cavity, Bibliography. Art. Fibroid, Reynolds's System of Medicine. Brehme : Myocarditis. 1882. Corvisart: Essais sur les Maladies du Coeur. 1806. Zander : Arch. Virch., 1880. Stevenel: Des Myocardites, These de Paris, 1882. Lancereaux : Anat. Pathol. Paris, 1875. Parrot: Cardite, Dictionnaire Encyclopedique. Debove et Letulle ; Myocardite ScUreuse, Arch. Gen., 1880. 564 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. pushing the heart before it in any direction. Permanent displacement may result from deformity of the thorax, or may be of congenital origin, as when the organ is found in the right thorax, or is dislocated downward as a re- sult of a too long or too lax aortic arch. It may further be the result of traction, in any direction, exerted by a re- tracting and contracting lesion in the pleura or lung, or by a tumor within or without the pericardium. Pericar- dial adhesions may act either to displace, or simply to in- terfere with free action of the heart. Change of blood state furnishes a long category of dis- eases which are fruitful causes of the production of functional disorder. Rheumatism, anaemia, the puerpe- ral state, stand out pre-eminently in this category. In a recent publication,1 Dr. J. Kingston Fowler refers to the experiences of Dr. Money, who met with cardiac murmurs in 84 out of 111 puerperal women. Among the many causes acting through the nervous system we have hysteria, chorea, shock and fright, ex- cessive use of tobacco, of alcohol, of tea and coffee, ex- cessive venery, hypochondriasis, etc. Overexercise in work, gymnastics, or marching, may be an additional factor. Still further, we may mention any disease of any organ in the body, which exercises a depressing influence upon the nervous system, such as disorders of digestion, in- cluding hepatic troubles and uterine disease. Temporary muscular relaxation is not uncommon after severe acute febrile disorder. The condition is one that need not imply muscular degeneration, since the functional derangement caused thereby often promptly disappears after a short tonic course. Heredity is often evidenced in abnormally slow action of the heart, less often in unusual frequency, or irregu- larity, of cardiac action. Concerning the actual mode in which all these causes produce their varying types of functional disorder, neither physiology nor pathology can as yet speak positively. Recent investigations upon the lower animals tend to prove that the innervation of the auricles and ventricles can be separately influenced. Inference in the case of the human subject is as yet the only stage which this study has reached ; conclusions are still distant. The relative influence of the sympathetic and the pneumo- gastric nerves is still far from complete solution. The varieties of functional disorders are briefly sum- marized as follows : First, those affecting the ' ' force " of the cardiac action-(a) overaction, which frequently sim- ulates hypertrophic heart-action; (b) feeble action, giving rise to the suspicion of fatty, rarely of dilated, heart. Second, those disorders which relate to " frequency " of cardiac action-(a) infrequency or slow heart; (b) un- usually frequent action (tacchycardia). Third, concerning the " rhythm," we have (a) irregular action of the heart; (J) intermittent action. Fourth, as relates to the " sounds," there are varieties of (a) absent or feeble sound (first or second sound); (b) accentuation of sound (first or second sound) ; (c) reduplication of sound (first or second sound, or of both sounds coincidently) ; (d) murmurs (presystolic, systolic, or diastolic) heard over the base, apex, or prae- cordium generally. Concerning these four groups, in which we find distinct types of disorder, a number of the characteristics of several are frequently combined in indi- vidual cases, which latter are themselves types of disease. Fifth, we have angina pectoris, and exophthalmic goitre. Diagnosis.-Since the clinical history of many of the functional diseases is obscure, we shall under this head- ing refer to such peculiarities of individual disorders as are deemed of importance. A common characteristic of most of these ailments is that the patient is sometimes un- aware of any trouble affecting the heart, while, on the other hand, the subjective symptoms may present to us one of the most active histories of an apparently serious lesion. Examination for life insurance, or physical exploration in the course of treatment for some apparently foreign ailment, often reveals for the first time any cardiac irreg- ularity. The objective phenomena do not in any manner coin- cide with the subjective, the two being often, indeed, dis- proportionately severe. In every effort to solve the nature of a cardiac affection a careful clinical history which shall include the ancestral record and the habits of the patient is of the utmost importance. In the physical ex- ploration the carotid and radial pulses, the situation of the apex-beat, and the accurate determination of the size of the heart, should all alike receive careful attention. Palpitation is a very common phenomenon, often asso- ciated with the gouty or rheumatic diathesis, or with di- gestive and nervous disorders, and quite commonly with hysteria. At times it is simply accelerated action ; again, it is increased force of action, or it is a combination of both. Sometimes it coexists with irregular heart-action or with the presence of murmurs. Palpitation is the common cardiac phenomenon of exophthalmic goitre. Associated with palpitation is a form of tumultuous lieart, characterized by moments of frequent beat and overaction, and then again by intermission of cardiac systole, or feeble beat. In aggravated cases of chorea we have such a tumultu- ous heart, to which the name of choreic heart has been given by Sturges.2 In these cases the heart overacts, is irregular, and frequently presents systolic apex murmur. Such hearts are quite commonly supposed to be hyper- trophied, simply by reason of the strong impulse. The " irritable" heart, sometimes a tobacco heart, some- times sympathetic of disease elsewhere, is a form of pal- pitation associated with prtecordial pain, and has been well described by Da Costa.3 Tacchycardia, or abnormal frequency of beat, is met with as an inherited disorder (the writer has seen one such case), is more common in females than in males, and is not infrequently associated with hysteria. The cardiac pulsations may be succeed- ing each other at the normal rate, when suddenly the vio- lence and frequency of the heart's action alarm the patient exceedingly, but after frequent repetition and subsidence of such attacks he becomes forewarned as to their nature. The heart systoles may increase to two hundred and upward per minute in some cases, and this without interfering with the patient's ability to attend to ordinary duties. The radial pulse-beats usually fall short of the number of cardiac systoles, for some of the latter are not strong enough, and are overtaken by the succeed- ing systole in the interval of maximum distention of the radial artery. Thus it is not safe to assume the number of cardiac contractions from the radial pulse. In all of these preceding conditions the differential diagnosis from cardiac hypertrophy is first to be made. Percussion and auscultatory percussion will determine the exact size of the heart. Again, the absence of the pulse of hypertrophy and of pulsation of the carotids, so commonly associated with cardiac enlargement, would exclude the latter condition. The administration of bromides, rest, the use of diges- tive remedies, and the allaying of excitement, may so reduce the cardiac overaction within a few days that even physical exploration no longer becomes necessary. Tacchycardia furnishes intervals of normal action of the heart, from which the diagnosis is readily deduced. The "irritable" heart is more particularly recognized by the following peculiarities described by Da Costa : "The first sound is short, sometimes sharp, resembling the second sound ; at other times it is extremely defi- cient and hardly recognizable; the distinctness of the second sound is heightened. Only at times murmurs are heard in the neck or heart. The pulse is easily com- pressible, it may or may not share the character of the impulse." The action of the heart is very rapid, often irregular. The impulse is extended, but not forcible. The diagnosis from hypertrophy is made by the absence of increased area of dulness, by absence of forcible im- pulse, by a feeble, instead of a strong, first sound, and by absence of the full, non-compressible pulse of hyper- trophy. The kinds of slow cardiac action and intermittent car- diac action are both congenital and acquired. Congeni- tal slowness or infrequency of pulse is quite commonly met with in adults, in whom the pulse ranges from 60 to 65 beats per minute.4 565 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Napoleon I. had a pulse-beat of 40, and the writer has met one case of pulse-beat of 45, which appeared to have been congenital. It is not uncommon to find infre- quency of the pulse an inherited condition, and in some instances several members of the same family present the. same peculiarity. Flint has called our attention to the acquired variety of infrequency. He has noted cases in which the pulse was reduced to 40, and even to 26. He believed this to result as an acute condition after serious illness in some cases, and one from which some patients recovered, while it remained permanently in others. In some of these cases the infrequency is associated with syncope, or with sudden pallor which comes and goes. These symptoms are more common in the inter- mittent form of functional disorder, which is sometimes associated with infrequency, and even with palpitation. Dr. Alonzo Clark has described a case in which the pa- tient lost consciousness for the moment, and subse- quently was again able to continue the thread of his discourse. Infrequency is met with commonly in per- sons of phlegmatic temperament and with habitually but little color. It is none the less found in others with ruddy complexions and active disposition. It naturally arouses suspicion as to the co-existence of cerebral lesion, while it is not uncommonly a cognate phenomenon of a disordered liver, of malarial poisoning, and the like. It is apt to be mistaken for fatty heart, possibly even for dilated heart, in older persons. Whenever slow pulse is met with, the question of its being congenital or acquired should at once be determined. Next, the exclusion of fatty or dilated heart can be made by the presence of the normal heart-sounds and the normal cardiac impulse, and a normal area of praecordial dulness. If no murmur exist, and the number of cardiac impulses and radial pulse-beats coincide, the condition is probably one of functional disorder. Cerebral lesion and other disorders should be carefully inquired into, and error can in this manner be avoided. Reduplication of the heart-sounds may involve not only the first, but the second sound as well. The unequal ac- tion of the auricles or ventricles is as yet the best explana- tion we have to present, and the experiments upon the cardiac, sympathetic, and pneumogastric nerves in the lower animals tend to confirm the probability of such ir- regular action under certain conditions. The diagnosis presents no difficulties if the examiner will not mistake a reduplicated sound for a sound and murmur, or simple accentuation of sound for a reduplicated sound. This form of functional disorder is, however, more commonly associated with organic disease of the heart. Functional heart murmurs present a field which has engaged the time and attention of numerous observers. No portion of this subject requires nicer balance in judg- ment and greater care in exploration than the accurate diagnosis at times of the functional from the true organic murmur. In all conditions of anaemia the relaxed heart- muscle would naturally increase that amount of normal insufficiency which all physiologists admit takes place at the tricuspid orifice. Unequal tonicity of cardiac muscle, relaxed condition of the walls of the blood-vessels, giving rise to vibration and allowing undue pressure upon them from neighboring viscera, the changed condition of the blood itself as occurs in so many diseases already enum- erated, together with occasional anomaly of internal struct- ure of the heart, as in the valve or its tendinous attach- ments-all these5 constitute numerous causes for the production of every variety of functional murmur. The systolic murmur heard over the base of the heart and over the aortic and pulmonary orifices is the most common. Pnesystolic murmur has been held for many years by Flint to be in many cases only a functional murmur. Systolic murmurs at the apex, and diastolic murmurs, are of frequent occurrence as functional murmurs. In making the differential diagnosis between organic and inorganic murmurs the previous existence of a disease leaving cardiac lesion as one of its sequelae is a factor for consideration. Likewise, any general blood disorder pre- disposing to anaemia, or the co-existence of disease in some organ, such as chronic kidney lesion, all are elements of serious importance in the general history of the case. The physical exploration and the determination of the size of the heart would militate for or against functional disorder. As corroborative only, the presence of thrill most commonly associated with organic disease can be used in drawing a conclusion. The sphygmograph may also be used in noting any change in the character of the carotid or radial pulses, aside from simple increased strength or feebleness. Finally, the character of the murmur and its mode of conduction are of great moment. Functional murmurs have none of the harshness or roughness of or- ganic murmurs, being usually soft or blowing in charac- ter. The functional murmur rarely replaces the heart- sound ; the heart-sound remains and the murmur is pres- ent in addition. The position of the patient's head to the left favors increased loudness of anaemic murmurs in some cases. The act of inspiration or expiration does not usually affect the intensity of the functional murmur. Sahli6 found that in four cases of chlorosis the diastolic murmur increased as the ear was carried up toward the neck, and was lost as it descended toward the apex and ensiform cartilage. In these cases two sounds and a sys- tolic murmur were heard at the apex, and two sounds and a diastolic murmur were heard at the base. The autopsy confirmed the fact that it was simply the downward trans- mission of the bruit within the blood-vessels, no cardiac lesion being found. While such a careful consideration will usually assist the diagnosis, all authors agree that there are cases in which nothing but a second examina- tion of the' patient, a careful dietetic and medicinal regi- men, and observation for some time, can positively deter- mine the differential diagnosis of organic and functional heart disease. Prognosis.-Persistent cardiac palpitation may termi- nate in hypertrophy, the continued cardiac overaction resulting in increase of muscle structure. While the prognosis of functional cardiac disorder is good, long- continued irregular action may unquestionably, in the lapse of years, so impair the heart structure as to lead to organic lesion. I need only refer here to the well-founded remark of Loomis, that the prognosis of heart lesion de- pends not upon the greatness of the murmur, but upon the ability of the heart-muscle to do its work. Only the nat- ure of the individual case under consideration would warrant an unfavorable prognosis. In angina pectoris, unassociated with true cardiac lesion, the prognosis is better than in such accompanying organic disease. In the latter case a first or a second attack may prove fatal, in the former, attacks recur over periods of years. Treatment.-The most important indication for treat- ment in functional disorder of the heart is to give assur- ance to the patient that the palpitation or prsecordial pain or discomfort does not portend serious result, and to fully explain to the patient the importance of not ag- gravating the trouble by adding mental distress over the condition to the existing disease. To establish such a confidence in your statement will prove a strong adjuvant to medicinal treatment. The general indications are: first, prophylactic meas- ures ; second, those directed against existing causes ; and third, symptomatic treatment of the cardiac condition. Prophylaxis becomes a decided factor in the hope of permanently restoring the patient's health, but is usually a subsequent consideration to the other indications, for our first opportunity is with reference to existing func- tional disorder. The treatment for anaemia must be per- severed in, and habits of in-door life, or of mental and physical overwork, which tend to promote or increase this condition, must be combated. A course at the Hot Springs of Virginia, or at Vichy, in France, may be taken. Or, in case of the gouty and rheumatic diathesis, a visit to Carlsbad every second year may be made with advan- tage. A four weeks' stay at the Hot Springs, or a summer at Carlsbad, has, under my observation, been of inestimable service in these cases. Abstinence from tobacco is often better than moderate indulgence in these cases, since the 566 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart- Heart. latter, while not sufficiently potent to act as a cause, will often predispose to functional disorder, which a slight digestive trouble will at once excite. The mode of life of the patient must be so regulated in his mental habits, his diet, his physical exercise, as to conduce to the harmonious workings of all organs. Some- times travel abroad, with complete freedom from all ex- citing or unpleasant associations will alone avail in this direction. Among the common exciting causes which we have to combat at once, in most cases, are the digestive disturbances. In men the use of the mist, rhei et sodae, alone or in combination with bitters, and aided by cathar- tics, will speedily give relief. The author has seen a patient rejected for suspected cardiac disease by a com- petent physician-a life insurance examiner-and, after three weeks of care in diet and treatment as above, the heart resumed its normal rhythm, and was so recognized by the physician in question. The use of a mixture containing bromide of sodium, pepsin, and powdered charcoal, a combination not origi- nal with the writer, acts wonderfully in many cases of nervous dyspepsia, so commonly associated with func- tional heart disease. Abstinence from tea or coffee must be insisted upon. In some persons both must be refrained from, in others, one or the other may be used moderately. Tea and coffee affect individuals differently, the one producing excite- ment, and the other calming, and vice versa. Our views upon tobacco are already fully stated. In chorea the heart symptoms usually subside with the chronic manifestations under the specific treatment for the affection, temporary relief being afforded by symp- tomatic remedies, but not to the same extent as in other affections. It is, of course, impossible to combat all of the causes, and in these instances our only recourse must be had to the allaying of symptoms and to the avoidance of aggravating conditions of the viscera that would act as accessory or exciting causes of functional disorders. The symptomatic treatment embraces a large range of reme- dies, cardiac stimulants and sedatives both having their indications in appropriate cases. In some severe cases of cardiac palpitation the application of the ice-bag over the praecordium is serviceable; in others, of weakened heart- action and oppression, synapisms answer the purpose. A blister over the praecordium, brandy, whiskey, and wines frequently relieve. Similarly, the ethereal preparations, the compound spirits of ether, chloric ether, and the like, are of service. The French are much given to the use of lavender. Valerian and opium are of use. In cases com- plicated with dyspnoea, fluid extract of quebracho, alone or combined with ammonia or ethereal preparations, in some cases with tr. opii camph., exerts a most excellent effect. Aconite and its preparations, and occasionally veratrum viride, are useful. The use of nitro-glycerin and digitalis often answers indications, according as we seek to strengthen or to de- press, or simply to regulate, cardiac action. Henry N. Heineman. 1 London Lancet, January 17, 1885, et seq. 2 Sturges on Chorea. 3 Da Costa : Medical Diagnosis. 4 Flint: Practice of Medicine, Functional Disorders of Heart. 5 A. B. Ball: Causes of Anannic Murmurs, N. Y. Medical Record, 1884, No. 12. 8 Centralblatt f. klin. Medicin, No. 43, 1885. HEART, HYDATIDS OF. Hydatids have been fre- quently found in the human heart, occurring there (ac- cording to Cobbold and Davaine) in about 3.50 per cent, of all cases of the disease in man. They are generally multiple, and when not embedded in the substance of the myocardium, may be placed beneath the pericardium or endocardium, in the form of a prominent tumor. In some cases the sac, attached by a narrow pedicle to the endocardium, swings freely in the interior of the organ, usually in the right auricle or ventricle. In others it be- comes impacted in the cardiac cavities or orifices ; or it may rupture, and the contents be carried as emboli to the lungs. Rupture of a cyst into the pericardial sac causes pericarditis ; and rupture both internally and externally has given rise to haemopericardium. Symptoms.-The symptoms of this disease are exceed- ingly indefinite ; several of the subjects who were not sup- posed to be laboring under any cardiac affection have died suddenly ; in other cases the ordinary phenomena of chronic heart-disease had been noticed, which were not traceable to the presence of the parasite. In the event of internal rupture and embolism, or of haemopericardium, as described above, a suddenly fatal termination is inevi- table. Diagnosis.-Hydatid disease of the heart appears never to have afforded any indication of its presence dur- ing life. Where it is known to affect other viscera, the coexistence of cardiac symptoms might suggest that the heart also was implicated. Treatment.-There is no special treatment for this affection. Alfred L. Loomis. HEART, HYPERTROPHY OF. Definition and Va- rieties.-Cardiac hypertrophy, as here considered, con- sists in an increase of the walls of the heart, resulting simply from an excessive development of its muscular tissue. Three varieties are usually recognized : 1. Simple hypertrophy, in which the walls are thick- ened, while the cavities are of normal size. 2. Eccentric hypertrophy, or hypertrophy with dilata- tion, in which the walls of the heart are thickened, and the cavities are at the same time enlarged. 3. Concentric Hypertrophy.-This variety, in which the muscular wall is supposed to be thickened by the addi- tion of new material, in such a manner as to cause con- traction of the cavities, is of questionable occurrence, and is probably a post-mortem phenomenon. Hypertrophy of the heart is commonly confined to one or two cavities, although it may involve the whole organ. The ventricles are much more frequently affected than the auricles, and the cavities on the left side more fre- quently than those on the right. Morbid Anatomy.-In an hypertrophied heart the individual muscular fibres do not deviate in any of their characters from a healthy standard, and there is no for- mation of new tissue. As the primitive fasciculi do not increase in thickness, obviously new ones are formed ; these have precisely the same structure as the original, and even when closely packed exhibit no greater degree of hardness or tenacity. Dr. Quain has described an in- crease of connective tissue, which he designates as false hypertrophy. In eccentric hypertrophy there will always be an in- crease in size of the papillary muscles, and the septum will be thickened, which does not necessarily occur in connection with simple hypertrophy. The ventricular septum is far less liable to hypertrophy than the rest of the ventricular parietes It is often difficult, even after death, to determine the existence of a moderate degree of cardiac hypertrophy, while extensive hypertrophy is very readily recognized. When cardiac hypertrophy exists, the first thing no- ticed is the change in shape of the organ, which will correspond to the seat of the hypertrophy. If this is con- fined to the left ventricle, either simple or eccentric, the heart will assume a more than usual pyriform shape, and will become elongated-the right ventricle appears as a mere appendage to the left. On the other hand, hyper- HEART, H/EMORRHAGE INTO THE WALLS OF, is an extravasation of blood into the substance of the heart. Morbid Anatomy.-The circumstances in which blood may be extravasated into the heart-walls are, 1. Rupture of the heart. In such cases the blood is driven from the cavity of the ventricles and forced between the muscular fibres with each cardiac contraction. 2. Rupture of a branch of the coronary artery may cause extravasation in the cardiac walls, and embolism or thrombosis of the coronary vessels may produce a haemorrhagic infarction. Ecchymosis may occur from blood-changes in connection with the acute infectious diseases, or in scurvy. Such haemorrhages are not immediately fatal; the blood under- goes the changes usual in extravasation, and its site will be marked by pigmented spots. Alfred L. Loomis. 567 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trophy of the right ventricle increases the horizontal measurements of the organ and gives it a more oval shape, the apex not being as pointed as in health, since the ex- tremities of the ventricles are approximated. In general eccentric hypertrophy the whole heart will be increased in size, but the change will be most marked transversely, and the organ will assume a globular shape. Sometimes the shape of the organ is not notably changed in general hypertrophy. In all varieties of hypertrophy the car- diac walls are stiff, so that when the cavities are opened and the blood has been removed they do not collapse. The substance of an hypertrophied left ventricle can gen- erally be torn with ease, while an hypertrophied right ventricle is tough and leathery. The color of the mus- cular tissue is redder than normal. There is almost no limit to cardiac hypertrophy. The heart may reach such a degree of enlargement as to weigh forty or more ounces (cor bovinum). After the hyper- trophy reaches a certain point there is dilatation, pre- ceded and accompanied by fatty degeneration of the more recently formed muscular fibres. The walls of an hyper- trophied heart vary in thickness, according to the cause of the hypertrophy. Those of the left ventricle may be- come an inch and a half, or even two inches thick, while those of the right ventricle rarely reach an inch in thick- ness. The auricles are seldom more than double their normal thickness. The columnse carneae of the right ventricle are more liable to hypertrophy than the walls. Sometimes the walls of a cavity are thinned at one point, while they are hypertrophied at another. The heavier a heart becomes, the deeper does it lie in the thoracic cav- ity ; the diaphragm is pushed down, and the heart in- clines more to the left of the thorax. But it sometimes be- comes fixed at the normal level by pleuro-pericardial adhesions. The coronary arteries become enlarged. The walls of the aorta are thickened, and its calibre is in- creased. The auricles are almost always dilated consid- erably. In extensive dilatation with hypertrophy, the columnae carnet become stretched and attenuated. Etiology.-True hypertrophy of the heart, it should be remembered, can only arise when the cardiac muscle is healthy and properly nourished. When the muscular fibres are degenerated, or the supply of arterial blood to the cardiac walls is insufficient, hypertrophy cannot be- come extensive, but must soon give place to dilatation, resulting from fibroid or fatty changes in the affected structures. In general terms, cardiac hypertrophy is the result of overwork. The causes of hypertrophy may be classified as follows : 1. Dilatation of the Cavities of the Heart.-Under cer- tain circumstances abnormal dilatation of one or all of the cavities of the heart takes place during its diastole ; with this increase of capacity the cavities receive more than their normal quantity of blood, and an extra amount of force is required to expel it. This demand for increased heart-power is supplied by an increase of muscular fibres in the heart-walls. The hypertrophy is developed in proportion to the increase of force required. This is the cause of those forms of cardiac hypertrophy which occur in connection with valvular insufficiency. Under these circumstances the hypertrophy is always ec- centric. The order of development is, first, dilatation, then compensatory hypertrophy. Dilatation is developed during cardiac diastole ; hypertrophy during cardiac sys- tole. 2. Mechanical Obstruction.-Of those forms which are situated in the heart, aortic stenosis gives rise to hyper- trophy of the left ventricle, mitral stenosis to hypertrophy of the left auricle ; pulmonic disease to hypertrophy of the right ventricle ; and tricuspid stenosis to hypertrophy of the right auricle. In the list of mechanical causes are included all those diseases of the arteries which diminish their elasticity or calibre. The walls of the large arte- ries may lose their elasticity from atheromatous degenera- tion, or they may be constricted or dilated, and thus offer obstruction to the blood-current. An aneurismal tumor may develop sufficiently to obstruct the current of blood, or some tumor may press upon and diminish the calibre of the aorta ; under such circumstances simple hyper- trophy will be developed. Twisting of the thorax and deformities of the spine or thorax, etc., may act in the same way. Again, obstruction to the pulmonary circu- lation will give rise to hypertrophy of the right ventri- cle ; in many instances dilatation will precede the hyper- trophy, but in quite a large number of cases the hypertrophy will be primary. Such obstruction may be developed in connection with pulmonary emphysema, fibroid and compressed lung, chronic pieurisy, asthma, hydrothorax, and other chronic diseases which interfere with the circulation of the blood through the lungs. It does not occur in the early stage of pulmonary phthisis, for the pulmonary circulation is not obstructed until the advanced stage of the disease is reached. Hypertrophy of the left ventricle may also result from interference with the general capillary circulation. Examples of this are met with in chronic Bright's disease. Simple hypertrophy of the cardiac walls is one of the most constant attend- ants of the cirrhotic form of kidney disease. Gull and Sutton regard this as secondary to arterio-capillary fibro- sis. In chronic alcoholismus, rheumatic hyperinosis, or any other condition which interferes with the systemic capillary circulation, more or less extensive simple hy- pertrophy of the left ventricle is developed. Anything which increases for any length of time the rapidity and force of the heart's contraction may produce cardiac hypertrophy. Among this class of causes may be included excessive and prolonged muscular exercise, es- pecially in young subjects and in soldiers on the march. Emotional conditions that produce cardiac palpitation, prolonged mental excitement, and the immoderate use of tobacco, strong coffee or alcohol are also causes of car- diac hypertrophy. To this class probably belong those cases occurring in Graves's or Basedow's disease. Peri- carditis is not infrequently a cause of cardiac hyper- trophy, either by inducing dilatation of the ventricles or through the obstruction which is offered to the heart's ac- tion by adhesions. The heart becomes hypertrophied in pregnancy, but returns again to its normal size after de- livery. Sometimes no cause can be found for cardiac hypertrophy. Symptoms.-The symptoms of cardiac hypertrophy are divided by Dr. Hayden into those which are presumptive or equivocal, and those which are positive. Of the posi- tive signs he mentions " the large, full, strong, and sus- tained pulse," as among the most valuable ; " it is distin- guished by the combination of these qualities from the pulse of all other morbid states, and is therefore pathog- nomonic of left ventricular hypertrophy. " When there exists a greater degree of dilatation than of hypertrophy the pulse is less strong, but fuller and more sustained. On the other hand, when the right ventricle alone is hy- pertrophied, the pulse may be small, weak, and perhaps intermittent or irregular. Violent heaving of the prsecor- dium is an equally significant phenomenon-that is, if the presence of an aneurism or other tumor behind the heart be excluded. To quote again from Hayden : "When the left ventri- cle alone is affected, the movement will be perceived to- ward or beyond the line of the left nipple ; and when the right alone is involved, it will appear, though less dis- tinctly, in the interior sternal region, and to a variable distance beyond the right edge of that bone. If both ven- tricles are hypertrophied, the movement of the impulse will be visible over the entire extent of the praecordium, but most distinctly at the point of apex pulsation, and in the dilated form it will be of an undulatory character. " Physical Signs.-The physical signs of cardiac hyper- trophy will vary somewhat in situation and degree with the seat of the hypertrophy, remaining, however, the same in kind. In left ventricular hypertrophy, which is by far the most common, or when the hypertrophy is general, in- spection shows a distinct apex-beat with increased area of impulse, and a decided motion of the chest-wall over, and it may be beyond, the praecordial space. In children there is often a decided and permanent bulging of the praecordium. On palpation the area of the apex-beat is in- creased, the impulse is more forcible, and has a heaving, 568 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. lifting character, which, as on inspection, may be recog- nized over the entire praecordial space, and often imparts its motion to the listener's head. The apex-beat is car- ried to the left of, and below, its normal position, in ex- treme cases, from three to four inches. On percussion, the areas of deep-seated and super- ficial dulness will be increased laterally and downward. Dulness is extended upward only when the auricles are dilated as well as hypertrophied. If the hypertrophy is confined to the left ventricle the increase of dulness will be downward and to the left, ex- tending to the line of the apex-beat. In eccentric hypertrophy the lateral increase of dulness is more marked than the downward. On auscultation the first sound, if not accompanied by a murmur, is dull, muffled, and prolonged, and in many cases greatly increased in intensity. The post-systolic silence is shortened. The aortic second sound is in- creased in intensity in left ventricular hypertrophy, and both second sounds are increased in intensity in general hypertrophy. In extensive hypertrophy both sounds of the heart often have a metallic ring. When the lung is normal there is a diminution or an entire absence of the respiratory murmur over the normal praecordial region, but when extensive pulmonary emphy- sema exists, although the heart may be very greatly hy- pertrophied, the overlying lung may so obscure the symptoms as to cause an apparently weakened apex-beat and diminished heart-sounds. It may be assumed, how- ever, when extensive pulmonary emphysema is attended by venous pulsation in the neck, that there is hypertrophy and dilatation of the right ventricle. In those rather infrequent cases in which the hyper- trophy is confined to the right ventricle, the physical signs will be located to the right rather than to the left. Inspection may show a smooth, rounded prominence of the epigastrium, with perhaps some bulging of the en- siform and lower left costal cartilages. The apex-beat may be diffuse, extending toward the ensiform cartilage. Palpation as well as inspection may reveal a strong epigastric impulse. On percussion the area of dulness which extends downward and to the right, may pass an inch or more beyond the right border. As on the left side, so in the right eccentric hypertrophy, dulness ex- tends more laterally than downward. On auscultation the first sound is more distinct and su- perficial than normal. The pulmonic second is accentu- ated, and the cardiac second sound is not infrequently reduplicated. Differential Diagnosis.-The conditions most likely to be confounded with hypertrophy of the ventricles are : 1. Increased exposure of the heart ("apparent enlarge- ment "), the most common cause of which is retraction of the anterior margins of the lungs. Such retraction usually results from pleurisy or cirrhosis, but in very rare instances may be due to forward displacement of the heart. In the latter case a positive diagnosis could only be ventured on when there is distinct evidence of an an- eurism or tumor behind the heart, constituting an obvi- ous cause for such displacement; or when there are no signs or symptoms of cardiac disease, and no extra-car- diac cause of enlargement, such as Bright's disease. 2. Temporary overaction of the heart, arising from neurotic influence. Hypertrophy is to be excluded in these cases when the praecordial dulness is not increased, and when the apex-beat is in its usual position. The characters of the pulse and of the cardiac contractions should also be noted, and in doubtful cases the presence or absence of any intra-cardiac or extra-cardiac conditions capable of producing hypertrophy will afford important aid. 3. Displacement of the heart downward and to the left may simulate hypertrophy of the left ventricle. It does not, however, like hypertrophy, result in increasing the force of the cardiac contraction, or enlarging the outline of percussion dulness. Pericardial effusion may be dis- tinguished by the triangular shape of the area of dul- ness, with the apex of the triangle upward; it would also be marked by acute symptoms, not found in mere enlargement of the heart. Pleuritic effusion, or aneurism, would be still more readily discriminated. Prognosis.-Cardiac hypertrophy, pure and simple, being "nature's effort to meet a difficulty," never de- stroys life, and can scarcely be regarded as an evil. When affecting the young and athletic, and provided its cause can be removed, as in cases of pregnancv and acute Bright's disease, the enlargement may subside without any injurious consequences. In a large majority of cases, however, the cause is permanent. In almost all instances hypertrophy is compensatory; the urgent symptoms of some other cardiac affection are relieved by it and life is prolonged, Simple cardiac hypertrophy, unless the result of aortic stenosis, may exist for years without the occurrence of any dangerous or very trouble- some symptoms. Slight hypertrophy of the left ventri- cle is very common in those who have led an active life, and who have been compelled to perform active and pro- longed physical labor ; the hypertrophy is no more than is required to maintain an equilibrium in the circulation, and in no way interferes with duration of life. In the young and in athletes, if the cause be removed, the prog- nosis is very favorable. The patient should not be made aware of the presence of such hypertrophy, for although there is no danger attending it, a knowledge of the fact may greatly alarm him. When there is not only hyper- trophy, but also degeneration of the hypertrophied walls -the result of imperfect nutrition-the prognosis is very unfavorable. The prognosis in hypertrophy of the right ventricle is not as favorable as in hypertrophy of the left, because it must inevitably be accompanied by considerable pul- monary obstruction, and consequently is rapidly progres- sive. In Bright's disease, or when there is disease of the arterial coats, the prognosis is unfavorable. The prog- nosis in any case of cardiac hypertrophy depends upon the cause of the hypertrophy, and upon the kind of val- vular or other cardiac lesion coexisting. Treatment.-Although cardiac hypertrophy cannot be removed, still, much can be done to arrest its develop- ment by removing the causes which produce it, or by rendering them inoperative. Patients with cardiac hy- pertrophy must especially avoid alcoholic stimulants, im- moderate eating, active and prolonged physical exercise, and mental excitement. All those conditions which in- terfere with the general circulation must, if possible, be removed. This embraces interference with the abdomi- nal circulation, as well as with the pulmonary and sys- temic. Straining at stool and constipation should be avoided by keeping the bowels active. This condition of the bowels should be maintained chiefly by habits of life and regulation of diet, cathartics being resorted to only in exceptional cases. As little liquid as possible should be taken into the stomach. Any symptom of cerebral hyperaemia must be immediately relieved by those means which diminish the force of the heart's ac- tion. When the pulse is full and strong, and there are evidences of cerebral hyperaemia, it has been the practice of some to bleed, but this treatment is contraindicated, for the presence of anaemia greatly aggravates the dangers arising from cardiac hypertrophy, since it increases irri- tability and excitability of the heart. The symptoms must be very urgent to warrant venesection. Of all the remedial agents which diminish the force of the heart's action I have found aconite the best. When given in full doses it is more reliable than any other means. From two to three drops of Fleming's tincture of the root may be administered every three or four hours. No drug that I have used so fully and promptly relieves the vertigo and other painful sensations that attend car- diac hypertrophy. Hydrocyanic acid, belladonna, and conium are used, but are inferior to aconite. Whenever the dilatation of the cavities exceeds the hypertrophy of the cardiac walls, aconite does harm. Digitalis is contra- indicated, unless there is evidence of heart insufficiency. When digitalis is administered in chronic Bright's disease, although hypertrophy of the left ventricle is one of its 569 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. constant attendants, its administration is for the relief of the kidneys, which, when relieved, give secondary relief to the hypertrophied heart. Besides, in many cases of Bright's disease the heart, although hypertrophied, is not able to overcome the obstruction to the circulation in the small arteries and capillaries, and the tonic effect of the digitalis raises the heart-power to the point where the ob- struction is overcome and the equilibrium of the circula- tion established. Acetate of lead and veratrum viride are much thought of by many American authorities. For painful palpitation, wild cherry bark is the best drug. Morphine is seldom of service. Alfred L. Loomis. is great restlessness, opium may be given in small doses, and counter-irritation over the praecordial space will often give marked relief. Alfred L. Loomis. HEART, MALIGNANT GROWTHS OF. Malignant disease of the heart occurs in the forms of cancer and sar- coma ; both neoplasms are very rare in this situation. Morbid Anatomy.-Scirrhous and encephaloid can- cer are said to occur more frequently on the right than on the left side of the heart, and the nodules are generally situated on the surface of the organ, where they may ex- ist without implicating its fibres. They may, however, be developed within the substance of the heart in vast num- bers (Dupuytren records an instance in which he ceased to count them at the sixth hundredth). When superficial they sometimes give rise to pericarditis, and when located beneath the endocardium they may cause valvular incom- petence. Cardiac epithelioma is scarcely ever met with. Sarcomatous tumors on the surface of the heart have not the same tendency to produce pericarditis as carcinoma. Etiology.-Malignant disease of the heart is usually secondary, rarely primary. It occurs at all ages, but at least one-half of the subjects have been in the middle period of life. It is met with more frequently in males than in females. Symptoms.-Cancer of the heart, in nearly every re- corded instance, has been latent. It is certain that ex- tensive infiltration may occur without giving rise to any symptom which would suggest its presence. Its subjec- tive phenomena are those of eccentric pressure upon the heart and great vessels, but do not afford any indication of its source. When cancer has extended from the me- diastinum or lungs to the heart, dyspnoea, cough, and pain are necessarily frequent symptoms. The physical signs that have been especially noted are tenderness on percussion associated with local pain, peri- cardial friction, and endocardial murmurs due to involve- ment of the valvular apparatus in the new growth. Diagnosis.-A diagnosis of this condition does not ap- pear to have been made during life. Secondary implica- tion of the heart in a case of cancer might, however, be inferred with a near approach to certainty from the ap- pearance of cardiac pain, or any of the physical signs just mentioned. The differential diagnosis, according to Hayden, lies between cancerous tumors and aneurism of the primary portion of the aorta. " Thus, displacement of the heart and the signs of pressure upon the pulmonary artery or superior cava may be due to either, as, likewise, dulness on percussion, superficial pulsation, and pain. But dis- placement by aneurism of the arch of the aorta is never upward, and the signs of pressure are variable in degree and in direction, and more rapid in progress. Absorption of the osseous parietes of the thorax, bulging and external tumor, are peculiar to aneurism, and positively exclusive of mediastinal cancer, and, finally, the pulsation of aneu- rism is heaving, like that of a second cardiac centre. Both are capable of projecting by absorption into the cavities of the heart and the great vessels, and of produc- ing identical auscultatory signs; but the collateral re- sults of such ingrowth differ. In the case of aneurism, the walls of the sac having been previously incorporated with those of the heart, pulmonary artery, or superior cava, communication with the interior implies irruption of its contents and a corresponding derangement of the general or pulmonary circulation, whereas the ingrowth of cancer causes only local obstruction and its consequent auscultatory signs. Cancer is slower in progress, and more frequently associated with haemoptysis and signs of pleural and pulmonary inflammation ; moreover, cancer can usually be discovered elsewhere. The beginning of aneurism is frequently marked by some definite occur- rence, such as pain after a blow on the chest, or a strain, its development is usually rapid and irregular, and unas- sociated with disease of other organs, except atheromatous degeneration of the arteries." Prognosis.-The disease naturally ends in death, and this termination is not unlikely to occur suddenly. Treatment.-This, of necessity, is entirely symp- HEART, INFLAMMATION OF ; MYOCARDITIS. Myocarditis is an inflammation of the muscular structure of the heart, which may be acute or chronic. In both varieties the pericardium or endocardium is primarily or secondarily involved. A myocarditis in which one or both of these membranes was not in some degree involved has not been observed. Morbid Anatomy.-Acute myocarditis usually affects both the muscular and connective tissue of the heart. When diffused, one or more layers of the muscle under- lying the pericardium or endocardium are implicated. In the diffused variety the cardiac muscle is of an opaque yellow color, smaller, and softened. The micro- scopical characteristics consist in the ordinary inflamma- tory changes in the vessels, and the effusion of leucocytes and other inflammatory products into the inter-muscular connective tissue, with swelling, opacity, and rupture of the muscular fibres. These changes may be followed by fatty degeneration and atrophy, by interstitial fibroid changes, or may end in the formation of abscesses. Abscesses which result from acute circumscribed myo- carditis are usually small; they may open into the peri- cardium or into the heart cavities, or they may become encysted and undergo cheesy degeneration or calcifica- tion. Etiology.-Acute diffuse myocarditis when associated with endocarditis, or pericarditis, is usually of rheumatic origin, but it may occur in a rheumatic subject indepen- dent of pericardial or endocardial inflammation. Circum- scribed myocarditis, ending in abscess, is most frequently associated with, or complicated by, some acute infectious disease. Exposure to cold and local injury are among its exciting causes. Symptoms. - The prominent symptoms are, urgent dyspnoea, severe pnecordial pain, and palpitation, with frequent and irregular action of the heart, which finally results in complete heart failure. The radial pulse is at first feeble and frequent, then irregular, and finally im- perceptible. The countenance is pale and anxious, or cyanosed. The mind is disturbed and delirium often pre- cedes, a fatal issue. Physical Signs.-Inspection and palpation show at first violent and frequent cardiac impulse, which gradu- ally becomes imperceptible. The area of cardiac dulness is slightly increased, and the heart sounds at first are short and sharp, but often become feeble and indistinct, the muscular element of the first sound being entirely lost. The symptoms of circumscribed myocarditis are those of rapidly developed heart failure anil great consti- tutional disturbance, as rigors, delirium, and fever, which speedily terminate in death from asthenia or cardiac rupt- ure. Diagnosis.-The diagnosis of acute diffuse myocar- ditis is extremely difficult. When it occurs with peri- or endo-carditis, the marked symptoms of heart failure, such as great dyspnoea and extreme prsecordial distress, may serve to establish a diagnosis. The diagnosis of circum- scribed myocarditis has seldom been made during life. Treatment.-The slightest physical exertion must be avoided ; the heart must be supported and strengthened in every possible way. Digitalis and alcoholic stimulants may be given when there is cardiac palpitation and great feebleness of the pulse. Highly nutritious food must be given in small quantities and at short intervals ; the bow- els should be kept free, and the kidneys active, but severe purgation and profuse diuresis must be avoided. If there 570 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. tomatic, and does not differ from the treatment of cardiac distress from other causes. Alfred L. Loomis. the left ventricle has long ceased to beat. Possibly this longer life of the right ventricle is due to the fact that its walls are of less mass, and that a given degree of stimulus contracts them more easily than the thick walls of the left ventricle. In almost all cases the size of the auricles in full systole is surprisingly small as compared with the ventricles. The movement and shape of the heart in passing from diastole to systole are in great measure dependent upon the superior size and strength of the left ventricle. In Fig. 1616 the right ventricle has been paralyzed by in- jection of aconite, while the left ventricle is made to con- tract by glonoin, one per cent, applied externally, and subsequently by application of hot physiological salt so- lution. The right ventricle lies like a loose cover on top HEART, MOVEMENTS OF. The movements of the heart have been briefly described in the article Blood, Circulation, vol. i., p. 559. Since the preparation of that article the writer has succeeded in taking instantaneous photographs, upon gelatine dry-plates, of the heart mo- tion. This work has never before been accomplished, but it has already yielded interesting results, and it prom- ises to afford a valuable means of illustrating the action of drugs on the heart, and of recording accurately any experimental observations upon the cardiac movements, without the error of the personal equation of the observer. Photographs of full diastole and of full systole are ob- Fig. 1614.-Cat's Heart in Motion, in situ. 1, Full diastole , 2, half systole ; 3, completed systole. tained, with a series of any number of intermediate views. These serve as standards of comparison with pho- tographs of the altered diastoles and systoles which occur under the influence of cardiac stimuli or depressors. The following facts have been demonstrated by a series of several hundred photographs of living hearts beating in situ. The hearts used were those of cats, kittens, rab- bits, pigeons, frogs, and the excised calf's heart. In the majority of hearts there is a uniform shortening of the transverse diameter, amounting to one-fourth or one-third, in passing from systole to diastole, whereas the long diameter varies greatly. The latter is usually short- ened, but it may be considerably lengthened. This is of practical interest in percussing the area of cardiac dulness, and in drawing conclusions from the position of the " impulse-beat " in man. Experi- ments made with an open chest- wall are under abnormal conditions as regards pressure from the lungs and ribs, but in many cases antero- posterior diameter is so much lengthened in systole that it is evi- dent that the impulse-beat, when felt through the chest-wall, is due to the advance of the anterior wall of the heart rather than to the im- pact of the apex (see vol. i., p. 560). In some hearts the apex is actually curved backward away from the chest-wall. The shape of the heart in diastole depends upon the amount of blood which it contains. In a heart dying from venous haemorrhage, the thick-walled left ventricle retains its shape, but the right ventricle is sunken in above by atmospheric pressure, while the little blood which it does contain gravitates toward the apex and bulges out the lower part of the ventricle. Under such conditions successive photographs show the attempts at systole which the right ventricle continues to make after of the firmly contracted left ventricle. The apex is round and blunt, in strong contrast with the pointed apex of a heart of the same kind where both ventricles contract simultaneously. (Compare Fig. 1615.) The strongest movement of the heart, and the greatest contraction of the ventricles are obtained by the stimulus of heat, but in order to obtain a stronger systole than results from ad- ministration of digitaline, glonoin, etc., it is necessary to use a greater degree of heat than can be applied over the pr®cordium in man. The rotatory movement of the heart, which is due to the peculiar arrangement of its muscular fibres, especially Fig. 1616.-Pigeon's Heart in Motion, in situ. 1, Full diastole; 2. right ventricle poisoned by aconite, relaxed ; left ventricle contracted by glonoin, one per cent., externally applied ; 3, same as 2, right ven- tricle further contracted by heat. Fig. 1615.-Photograph of Pigeon's Heart in Dias- tole. With outline of another photograph of systole drawn over it to show elongation of long diameter. those of the left ventricle, occurs when the heart is sus- pended in air or in fluid, independently of any resistance offered by the base of the heart, as is demonstrated by Fig. 1617. Transverse sections, made by quickly cutting the heart in two with a razor or scissors, show that in contracting the ventricles retain their irregular contour, and the papillary muscles, when included in the section, contract synchronously with the walls. Some of the photographs of sections show that the circular fibres of the heart, which, of course, are the only fibres which re- main intact in a transverse section, are capable of entirely 571 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. occluding the lumen of the ventricles without the assist- ance of the spiral or longitudinal fibres. The indepen- dent contraction of the auricles is well seen in Fig. 1618, where, in the frog's heart, the atrium contracts with a strong movement toward the median line, leaving a sharp angle at the upper left corner of the ventricle. The ven- tricle subsequently contracts and diminishes this angle. The manner in which the papillary muscles and chords tendinese stand out in the lumen of the ventricle is clearly demonstrated by the instantaneous views of trans- verse sections. Other methods of observing the movements of the heart are the method of Hesse, by taking casts (see vol. HEART, PY7EMIC ABSCESS OF THE. Pyaemic ab- scess of the heart has been most frequently observed at the base of the left ventricle, and in the papillary mus- cles. In the majority of instances it is associated with peri- and endo-carditis. Morbid Anatomy.-The pyaemic foci are generally multiple. They occur as softened yellowish patches under the pericardium or endocardium, which is covered with inflammatory exudation. On section they appear as collections of dirty puriform matter, in ill-defined cav- ities with ragged borders, varying in size from a millet- seed to a pear. On microscopical examination they are found to be composed of pus and broken-down muscular tissue in a state of granular and fatty degeneration. These masses are in dif- ferent stages of the pyaemic process, and emboli are often found in the min- ute branches of the coronary artery. The surrounding muscular tissue is usually softened. The abscesses may be discharged into the heart cavities and cause abscesses in other organs, or they may open into the pericardial sac, and set up a purulent pericarditis. Sometimes this leads to acute aneurism of the heart, or a fatal cardiac rupture. Etiology.-Pyaemic cardiac abscess occurring in young subjects is most frequently associated with injuries of the bones and joints. In other sub- jects it is more often associated with phlebitis occurring in urethral strict- ure, chronic ulcers, especially about the genito-urinary apparatus, and in cancer. In some cases no primary disease can be dis- covered. Symptoms.-The symptoms of pyaemic cardiac abscess are generally obscured by those of the primary constitu- tional condition. If there is great praecordial distress and cardiac palpitation in one who has pyaemia, with unusu- ally active delirium, pyaemic carditis may be suspected. There are no physical signs beyond those of the attending peri- and endo-carditis. Diagnosis.-Frequent and careful examinations of the heart should be made in every case of pyaemia, and the presence of the physical signs of pericarditis or endocar- ditis, accompanied by great prostration and active deli- rium, will always suggest the occurrence of cardiac ab- scess. Any evidence of an injury to the osseous system, as the exciting cause of pyaemia, is important presump- tive proof of the occurrence of cardiac abscesses. The great difficulty is to determine if a pericarditis occurring in pyaemia is secondary to abscess in the cardiac walls. It can only be said that it is the rule rather than the ex- ception. Prognosis.-Pyaemia complicated by cardiac abscess is generally rapidly fatal. The opening of the abscess into the peri- or endo-cardium hastens the fatal issue. The prognosis under any circumstance is exceedingly un- favorable. Treatment.-The general treatment does not differ from that of pyaemia, and the local measures are the same as in circumscribed myocarditis. Alfred L. Loomis. Fig. 1617.- Calf s Heart in Motion, removed from body, showing rotation of apex. 1, Full dia- stole ; 2, half systole ; 3, full systole produced by heat. 12 3 i., p. 559), and various modifications of the plethysmo- graph, by which the heart is encased in a box contain- ing fluid, which is forced to rise and fall in a communi- catingcapillary tube with each alteration in volume of the heart. The latter method records merely the changes in bulk, not in form, while Hesse's method cannnot be ap- plied to the observation of the action of drugs, because no intermediate casts can be obtained between full dias- tole and full systole. His systole, moreover, is an artifi- cial one (see vol. i., p. 559). The writer has succeeded by means of a modified magic lantern, or " polyopticon," in throwing the image of a heart pulsating in situ upon a screen of tracing-paper, upon which the outlines were quickly sketched. This method is inaccurate and unsatisfactory. The instantaneous photographs, however, are absolutely accu- rate ; they demonstrate changes in form, in bulk (by perspec- tive), and in relative position. They may be kept and studied at leisure, and the negatives may be used in a stereopticon for class-room demonstration upon a large scale. The pulsations may be graphically reproduced by arranging a series of the pictures in a " zoetrope." The great difference in size of the heart (amounting to one-fourth or even one-half), between the normal systole and the additional degree of contraction produced by various stimuli, is an interesting index of the extent of reserve contractile power which maybe exercised to over- come increased arterial resistance. [Note.-The photo-engravings accompanying this article were made from India-ink sketches, which were drawn upon the faces of the blue-print (ferrocyanide) photographs. The blue color was then faded out by KOH, leaving the ink sketch in strong relief. This method secures an accurate outline, with greater distinct- ness than is possible in reproductions of the photographs themselves.] William Gilman Thompson. 1 2 3 Fig. 1618.-Frog's Heart in Mot.on. 1, Full diastole; 2, auricular diastole ; 3, ven- tricular systole. HEART, SIMPLE SOFTENING OF. Syn: Cloudy Swelling. Simple softening of the heart is by many de- nied a place among diseases of the cardiac walls. While it is allied to fatty degeneration, histologically it is entirely different. It differs from granular softening, which in no respect differs from the early stage of fatty degenera- tion, and from inflammatory softening, which by a dif- ferent process leads to the same condition. It is a soft- ening which occurs almost exclusively in the acute infectious diseases-especially typhoid and typhus fevers. Morbid Anatomy.-The muscular tissue of the entire heart, or that of the left ventricle only, assumes a violet color, is soft, friable, and flabby, moulding itself into any shape, like a wet rag. It is not enlarged. Dr. Stokes states that " all the anatomical and vital phenomena of Bibliography. Hesse : Arch. f. Anat. u. Physiol., 1880, S. 328. Thompson : New York Medical Record, March 13, 1886, p. 300. Thompson : Johns Hopkins University Circulars, March, 1886, p. 60. Thompson ; Med. Press of Western New York, March, 1886, p. 235. 572 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. this affection point to the opinion that it is an example of one of the special secondary lesions of typhus fever, and that it is capable of retrocession without disorganization." Whether any change takes place in the elementary struct- ure of the heart in simple softening, is not determined. Dr. Murchison states that the heart in typhus softening is in a state of granular degeneration. Microscopical ex- amination has thus far failed to detect the slightest evi- dences of granular or fatty degeneration. Etiology.-Laennec regards softening of the heart as essentially due to a disturbance of nutrition. Louis re- gards it as the result of a special blood-crasis. The con- ditions under which it occurs lead to the opinion that it is principally the result of nutritive disturbance. Symptoms.-The symptoms, course, and terminations of parenchymatous degeneration of the heart are separ- able from those of the disease in which it originated. The condition of the patient is one of great febrile pros- tration, with cardiac asthenia. The physical signs are : Indistinct or absent apex-beat, feebleness or entire cessa- tion of cardiac impulse, and partial or complete sup- pression of the first sound; the pulse, in correspondence with these indications, is weak, but regular and rapid, the rate amounting, in some cases, to 150 in the minute. These signs, in the average of cases, make their appear- ance on the sixth day of the fever, and they usually cease on the fourteenth day. Fatal cases are not often prolonged beyond the latter date. Diagnosis.-The diagnosis between a softened and simply weak heart is often difficult. The signs of a weak heart, due to some constitutional debility or shock, are rapid in their development and prompt in disappear- ing. The signs of cardiac softening are slowly devel- oped and gradually recede, occupying a period of several days. The pulse at first is quick, but during conva- lescence may fall to 30, and then gradually rise to the normal standard. The first sound of the heart becomes less and less distinct, and the apex heart-beat more and more feeble. According to Dr. Stokes the distinction between a softened and simply a weak heart rests upon the following characteristics : The latter is due to some constitutional difficulty of a very palpable character, to a shock or violent revulsion of some kind. The signs are proportionally rapid in development, and, in the event of a favorable issue, equally prompt in disappearing. The signs of cardiac softening, on the contrary, ad- vance to a maximum and then recede, occupying a pe- riod of several days; they appear with quick pulse, the impulse of the heart becoming less and less distinct, and failing first at the apex. There is usually, but not al- ways, a corresponding loss of the first sound. The im- pulse is re-established before the first sound, and both are perceptible at the ensiform cartilage earlier than at the apex. Prognosis.-Softening of the heart is always a serious condition, and imparts additional gravity to a case of fever, the danger increasing in the same ratio with the evidences of cardiac debility. The return of the first sound under treatment is a favorable omen. Treatment.-The appearance of the above-mentioned signs and symptoms, in the course of a continued fever, is to be regarded as an important indication for the use of alcoholic stimulants, which are, as a rule, well borne in such cases, and act very beneficially. Alfred L. Loomis. ally ecchymosed at its edges ; and its pericardial and en- docardial openings may or may not correspond. In the latter case they are connected by a sort of sinus in the walls of the ventricle. The fissure runs more frequently parallel to, than across, the muscular fasciculi. These are the appearances in a ruptured heart that is the seat of fatty degeneration. They are different when the rupture is secondary to an abscess or to haemorrhagic softening, in which case it may assume the form of an ulceration or perforation. The effect of this accident is the escape of blood from the cavity of the heart into the pericardial sac, which coagulates around the muscular walls, leaving the pericardial sac more or less filled with serum. From more than one recorded case it would appear that a per- manent closure of the fissured opening by a plug of fibrin is among the possibilities. Etiology.-Spontaneous rupture of the heart is always the result of disease. Its chief predisposing cause is chronic softening, due to fatty degeneration or fatty in- filtration, most frequently to the former. It may also re- sult from acute local myocarditis, from thrombosis of the coronary artery, or from the bursting of an abscess ; very rarely from aneurism of the heart or aorta. The im- mediate cause of the lesion is usually some strong mental agitation or physical effort, such as a fit of passion, hurry- ing for the cars, straining at stool, etc., but it sometimes takes place while the subject is at perfect rest. Males are considerably more liable to rupture of the heart than females, and the occurrence becomes compara- tively frequent after the fiftieth, still more so after the sixtieth year. Symptoms.-In but few cases of cardial rupture is the fatal event preceded by symptoms sufficiently marked to attract attention. Sometimes, however, warning is given by phenomena more or less indicative of a diseased con- dition of the organ, such as breathlessness on exertion, palpitation, irregularity of pulse, and faintness. On the occurrence of the lesion death is usually instantaneous ; although when the rupture is a small one, and oblique in its direction, the patient may survive for several hours or even days. The special symptoms denoting a fatal ter- mination are: restlessness, severe prascordial pain, dysp- noea, rapid ; feeble, and fluttering pulse ; vomiting, cya- nosis, pallor, loss of consciousness, and convulsions. The physical signs, even when the patient's life is sufficiently prolonged, can seldom be accurately observed ; they consist only of more or less praecordial dulness, with diminished impulse, muffled, distant, or imperfectly de- veloped sounds, and weak, intermittent pulse. Diagnosis.-A sudden attack of pain in the cardiac region, followed by collapse and difficulty of breathing, is suggestive of rupture of the heart. When the fatal issue is long enough delayed the enlargement of the peri- cardial sac may, perhaps, be detected by percussion. Prognosis.-Spontaneous rupture of the heart has never, so far as is known, been recovered from. Theo- retically, the prognosis is even more hopeless, owing to the existence of serious cardiac disease, than in cases of wounds of the heart. Treatment.-But little can be done in the way of treatment. The patient should be kept as quiet as pos- sible. Hypodermatic injections of morphia and a cold anodyne liniment applied to the pericardial region may afford relief to pain. Stimulants-since they tend to in- crease the extravasation of blood into the pericardial sac -should be administered only in those cases where a fatal collapse threatens. Alfred L. Loomis. HEART, SPONTANEOUS RUPTURE OF. Defini- tion.-Rupture of the heart may result from external violence or disease of the heart-walls. It is the latter class of cases that are denominated spontaneous. Morbid Anatomy.-Spontaneous rupture of the heart takes place most frequently in the left ventricle, owing to the greater liability of its walls to suffer degenerative changes and from the effects of over-distention. The lesion may be complete or incomplete, and the size of the opening varies from a mere slit to an extensive lacera- tion. There is usually only one rupture, but as many as five have been observed, sometimes communicating with each other. The rent is ragged, irregular, and occasiou- HEART STRAIN IN THE MILITARY SERVICE. A disordered condition of the heart, arising from mechanical compression of the chest-walls by tight clothing and belts, and weight of equipments during active, military exercises, manifested by rapid or gradual dilatation of the respective chambers from blood-pressure, and giving rise to transient or permanent alterations of structure and function. The study of the effects of mechanical forces upon the structure and functions of the heart is comparatively of recent date. The first impulse in that direction 573 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which took definite form originated during the war of the rebellion. These disturbances occurred so frequently as to elicit much discussion among medical officers as to their nature, yet under such rapidly varying circum- stances that little opportunity was given for careful study even were they so inclined. The current literature up to that time amounted to al- most nothing. Watson, in the last edition of his lectures, said that the British surgeons serving in India had re- ported the relative frequency of heart diseases, and es- pecially of dilatation of the right ventricle, and that he was inclined to the opinion that this condition was of more frequent occurrence in civil life than was gener- ally supposed. The reasons therefor were not assigned. There was nothing satisfactory in the works of Walshe. Copeland in his exhaustive Dictionary, quoting Hope and Bertin (vol. ii., p. 244), and referring to the causes of dilatation, regarded them as arising chiefly from dis- eased condition of the heart-walls, valvular disease, to ob- structions to the circulation in parts remote, or to muscu- lar debility following zymotic fevers. The mechanical effects of force applied from without were not noticed. Touching the paucity of knowledge on this subject still later, Allbutt remarked in 1871 that " the mechanical causation of heart disease is either omitted, or is treated in a way so meagre as to be worthless," by " both Eng- lish and foreign writers." With nothing, therefore, to guide them, it is not at all surprising that the American surgeons should have been at sea in regard to this question during the earlier years of the war, and that many loose notions should have pre- vailed. They were preoccupied with pressing emergen- cies, too onerous and absorbing for much leisure, and if they were fortunate enough to have an interval of rest, the attractions of surgery had precedence. With these facts in view wTe can readily understand why such expressions as "nervous heart," "tobacco hearts," " coffee hearts," " liver hearts" (meaning the de- pendence on hepatic disorders with which they were fre- quently associated), " malarial hearts," "scurvy hearts," " irritable heart "-an expression not less objectionable than the others-and many others, not necessary to men- tion, were employed. The heart is always irritable in its healthy state ; irritability being a normal property of the muscular structures. In the circumstances under con- sideration, however, the heart is strictly in a pathological condition, having undergone serious changes from the be- ginning by the stretching and' the separation of its fibrils; and in its bearing upon the condition in question the term "irritable" might lead, and has undoubtedly led, to very erroneous conclusions, inasmuch as it leaves the origin entirely in the background. Among the first to study this subject werdDr. J. M. Da Costa, in the hospitals of the armies of the Atlantic Divis- ion, and the writer, in the field and in the hospitals in the armies of the Mississippi Valley, both commencing in the early part of the war. The former published the results, in part, of his investigations in the report of the Sanitary Commission in 1867, and more elaborately in the Ameri- can Journal of the Medical Sciences, January, 1871. The writer sent a synopsis of his results to the Surgeon-Gen- eral's office in 1864, and again reported them in a con- densed paper on the subject, read before the American Medical Association at its meeting in Cincinnati in 1867. Myers, of the Coldstream Guards, followed in 1871, and called attention to the frequency of heart strain and its causes in the British Army ; while Frantzel, in 1873, gave the results of some of his observations during the Franco- Prussian war. Since then the subject has been widely discussed, alike as to its bearing on military and on civil life. In its relations to the latter condition, Dr. Allbutt, of Leeds, has been the most conspicuous and original in- vestigator. The first opportunity the writer had of studying the ef- fect of heart strain occurred May 30th, 1862, the day fol- lowing the capture of Corinth, Miss. After a lively rec- ognizance by two companies of the regiment to which he was attached one-fourth of the men returned in a state of utter exhaustion, while three had dropped out of the ranks, and, at first, were supposed to be dead. Their comrades brought them in, however, and they were the subjects of careful observation for several weeks. Subse- quently, while in charge of one of the large general hos- pitals in the military service, continuously for over three years, abundant opportunities were afforded the writer for a most careful study of the effects of heart strain, for its diagnosis, verified by repeated autopsies, its pathology, prognosis, and treatment. The conclusions then arrived at have been fully confirmed by his military experience up to the present time. The disease originates in a forcible dilatation of the heart by blood-pressure from within. The damage, how- ever, falls chiefly on the ventricles. This may occur sud- denly under great physical stress, or more slowly from causes less pronounced operating through a considerable period. The damage done in the first instance will depend on the degree of the dilatation and the length of time to which the organ is subjected to the distending forces, while in the latter a compensation may be set up in the muscular walls to meet the demands, so that the ailment may remain unnoticed by the patient for months. This sudden dilatation has been recognized by R. Thompson, Daldy, Heitler, Claude Bernard, Gairdner, Osler, Fothergill, Goodheart, Maragliano, and many others ; and it would seem that the mooted question, as to whether or not there can be a sudden dilatation with- out fatal results, is settled in the affirmative. In 1863 it was a presumptuous medical heresy to suggest it. It is the right ventricle, however, which is the most subject, if, indeed, it be not exclusively so, to rapid dilatation, be- cause of its thinner walls and greater proportionate strain, being subjected to the vis a tergo of the venous circulation and the obstructive force a fronts, incident to impaired respiratory activity and consequent back pressure from partial arrest of the blood-flow in the lungs. Dilatation of the left ventricle must be attributed to causes more remote, such as obstruction to the passage of blood through the arterioles of the general circulation caused by muscular pressure, the elasticity of the larger arteries meanwhile easing the immediate strain on the muscular textures of the heart, and thereby lessening the shock. The dilatation is therefore more gradual. These conditions explain the difference in the relative frequency of ventricular dilatations. This is no place for detailing cases, but in order to study the origin of heart strain to the best advantage, and in the simplest form, the brief statement of a typical in- stance may be permitted. A command is required to appear in full dress for parade, review, and inspection. This compels the soldier to be clad in his best fitting uniform, fully equipped, and his dress must be scrupulously neat and tidy. ' To this end, as he wears no suspenders, his trousers are gathered in tightly about the waist to hold them up and in posi- tion, and his coat is buttoned as tightly as it well can be ; over this comes the cartridge-belt, filled with a certain amount of ammunition and drawn in an equally tight manner around the waist; and upon his shoulders he bears his well-filled knapsack, canteen, haversack, and lastly his gun. In this condition he is generally marched upon the ground at a quick pace, and after alignment he is brought to a stock-still rigidity of position to await inspection. It is now that one sees the initiatory signs of the effects of chest compression. First, there is a flush of the face, more especially in the cheeks, chin, ears, and nose, and a deepened color of the lips ; the veins of the neck become turgid, and the respiratory movements lim- ited to the upper portion of the thorax. Soon there is a labored respiration, profuse sweating, then deathly pal- lor, staggering, and, unless caught, the man falls to the ground. Now, what is the explanation of all this ? Simply, by compressing the lower ribs and upper abdomen the nat- ural respiratory movements of the diaphragm are ren- dered nugatory and the costal expansions prevented ; the weight of the knapsack and its strappings holding the shoulders well back, impedes the movements of the upper 574 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. portion of the chest, and with this arrest of the respira- tory action there is an impairment of the circulation of the blood through the lungs. As a consequence there is an accumulation in the right side of the heart and in the venous system, which is seen to extend back to the venous radicles and capillaries. Claude Bernard has suggested that under such circumstances the right side of the heart, especially the auricle and veins, may serve as a tempo- rary reservoir, and dilatation go on to some extent with- out serious injury. The burden thrown upon the right ventricle, however, in forcing the blood through the pul- monary system, is too much for it, and it soon yields under the strain. At the same time there is a lessened amount of blood sent to the left ventricle, the effect of which is to diminish the ordinary supply sent through the coronary arteries for its own nourishment as well as the amount sent through the systemic circulation to the cerebro-spinal centres. Therefore both nerves and heart fail for the want of support. The general effect of this compression of the chest old soldiers understand perfectly. As soon as they see a comrade suffering, they say at once his belts are too tight, and proceed to strip him. In times of hostilities, however, the stress on the heart is vastly increased. Not only are these burdens to be carried on the shoulders and around the waist, but much additional; the celebrated forty rounds may be dupli- cated. Then come the more or less rapid marches, de- ployments, alignments, and finally the stress incident to a battle. It is easy to understand what effect such agen- cies will have upon the circulatory system. They are, however, not the only factors. The influence of the emo- tions and passions, acting through the cerebro-spinal cen- tres, is not less effective upon the heart. Balfour says, we pay the penalty of our higher civilization in the greater influence of grief, fear, and depressing emotions over the inhibitory centres; but he might have added that, from the same condition in life, courage, intrepidity, and determination have an opposite effect, and become the most powerful stimulators to cardiac movements, alike as to their force and rhythm. There is no phase in civil life that is at all comparable to active warfare in overstraining the heart. In the military service we must start with this organ and its appendages in all their integrity, then follow up their alterations as they are de- veloped from time to time by these well-recognized forces acting from without the body, and from within the heart. Men entering the service are supposed to be in the most perfect health, and this supposition is generally well grounded. When, therefore, we see those apparently the most robust failing in this vital organ so frequently, we must seek for some other explanation than in antecedent structural disease of the heart itself or its appendages. We are not entirely without experiments which confirm these views. Gairdner suggests a very simple method for distending the right ventricle at pleasure. He says : If we place the finger over the apex, where the impulse is felt the most distinctly, then lean forward to a stooping position, and hold the breath about one-half the expira- tory interval, and continue this as long as possible, the impulse will gradually vanish as the distention of the right ventricle goes on, until it is finally lost. The pulse at the wrist, however, remains distinct. This pulmonary stagnation is analogous to what occurs daily with the sol- dier, though not to the same degree ; no voluntary effort can do so. We have other evidence of the effect of the compression of the pulmonary capillaries by physiologi- cal experiments.* These are practical distinctions, and a failure to recog- nize them has led to grievous errors, which not only af- fect the efficiency of the military service, but the very ex- istence of the soldier himself, as well as his claim for pension. Re-enlistments are of comparatively frequent occurrence, which should not be allowed, and sudden death has resulted in many instances where, had the sol- dier's condition been known, it could have been avoided. It has been said that the right ventricle is the one most commonly involved. Myers gives the order of occur- rence : 1st, Dilatation of the right ventricle ; 2d, dilata- tion of the left. Frantzel saw in the Franco-Prussian war 19 cases, of which there was dilatation of the left ventricle with hypertrophy, 10 ; right ventricle alone di- lated, 2 ; both ventricles, 3 ; unspecified, 4. The writer's experience agrees with Myers's. Of 152 cases discharged the service during the late war, on the writer's certificate for cardiac disease, there were : Involving tricuspid valves, with dilatation of the right ventricle.. 21 Involving tricuspid valves, without dilatation being fully deter- minable 37 Dilatation without valvular disease 16 Total right side - 77 Involving mitral valves, with dilatation of left ventricle 12 Uncomplicated mitral valvular disease 13 Involving aortic valves 7 Hypertrophy of left ventricle, without special valvular disease de- terminable 26 Total left side - 58 Pericarditis 5 Functional disorders and palpitation 7 Disease of heart of doubtful character, hence not specified as to structures involved, but considered as dependent on muscular debility or anaemia 5 - 17 Total 152 In the recommendations for transfer to the Veteran Reserve Corps there were 22 cases involving the right, and 12 cases the left, ventricle, and there were 26 cases recommended for purely functional disorders arising from undetermined causes, giving a total of 60 cases of this class ; and an aggregate of 212 heart cases out of a total hospital admission of all classes of 10,527, being about 2.1 per cent. Grouping the details as above given, we find the right ventricle involved in some form in 99 cases, and the left in 70. But further on this subject: Out of 320 deaths from dysentery, diarrhoea, and hepatic disorders, there were 41 autopsies. Of these 25, or nearly sixty per cent., had right cardiac dilatations without hypertrophy or valvular lesions. The experience of the writer since the close of the war shows the relative frequency of disorders affecting the right side of the heart to be sixty per cent, of his total cases of heart-disease. Many were old soldiers, however, who had served during the war, but the preponderance still exists in times of peace. Observations go to show that the heart fails more fre- quently during high temperatures than otherwise, and the medical statistics of the late war in this country, in so far as they show anything, seem to point in the same direc- tion. In the British Army Reports for the year ending 1881, and including the three preceding years, the average admissions for diseases of the circulation of all kinds ■were 14.9 per 1,000 mean strength for home troops, while for seven of the principal Asiatic and African divisions the average was 21.6 per 1,000 mean strength, the maxi- ma being at the Mauritius, 45.2, and West African sta- tions, 28.5 per 1,000. These are but general facts, and affect the subject under consideration only so far as to aid * In 1883 the writer read a paper on heart strain before the Detroit Academy of Medicine. It called out considerable discussion. Professor Wyman, of the Michigan College of Medicine, said the subject was new to him, and that he would investigate it. With his well-provided labor- atory, his experience in the schools of Vienna and Paris gave assurance of his competency. The following is his report thereon : "I took a me- dium-sized dog, opened his chest after making tracheotomy, noted the action of the heart, and the relative size of the two ventricles. Then I put the nozzle of a strong bellows into the trachea and distended the lungs with air. Under the pressure thus induced in the air-cells the en- veloping capillaries were elongated and narrowed, so that the blood was dammed up in the pulmonary artery and the right side of the heart, dis- tending the right ventricle to a remarkable degree. I found that an in- crease of pressure in the air-cells produced proportionate increase of pressure in the right ventricle. Subsequent repetitions of this experi- ment on other animals showed that a peculiar pallor would appear in the tongue and membrane of the mouth, when the right side of the heart was over-distended. Then in another trial I distended the pulmonary air- cells by placing a dog in a box, while the air-pressure around the body inside the box was lowered three inches, as measured by barometer. Pal- lor of the tongue was again noticed, and after the animal was taken from the box locomotion was performed with great difficulty. For days sub- sequently the exertion of a scramble for food would provoke dyspnoea." 575 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. us in drawing inferences when taken in connection with others having a more direct bearing. The depressing effects of heat upon cardiac function are well known, and when with these we have undue strain of that viscus, from conditions stated, it can easily be seen what must be the inevitable result. Many cases of insolation are unaccompanied with cerebral disturb- ance except indirectly. Often there is no loss of con- sciousness. But while heat is a very effective predispos- ing factor, it does not account for all. This influence of heat on the heart deserves more attention. It shows that the custom of some commanding officers in drilling their men in a burning midday sun is a dangerous one- far more so, in fact, than that which obtains in ordinary labor in civil life, as in the latter case there are no im- pediments to free respiratory function by confining the chest expansions. Men may labor in the hot sun with reasonable impunity, but soldiers cannot drill at such hours without imminent risk. The effect of overstrain of the heart is seen in two ways, as before stated. First, by an overwhelming dis- tention causing immediate faintness, or complete paraly- sis and death ; or the dilatation may go on more slowly, from lighter daily strain, and with less immediate danger. Where the shock does not terminate in the death of the individual at once, but only in syncope-in respect to which it may be said that it is about the only instance where this becomes a man's friend, as it is a notice of danger-the normal irritability of the heart is in a great measure lost. The cardiac muscles are in the condition of any others of the body in which the fibrils have been stretched unduly and separated, their rhythmic action becoming feeble, tremulous, and imperfect. This con- dition of the heart is one of profound asthenia. If the strain be removed, and the heart have a chance to rest under proper treatment, it may recover its normal size in a short time ; its disordered rhythm, however, will re- main in most instances for weeks, or months, according to the degree of the injury. Several cardiologists have noticed this rapid restoration of the heart to its normal size under conditions stated ; among others, Maragliano, Allbutt, and more particularly Balfour. The following is a tracing from the right wrist of a soldier in the Third Cavalry, taken in the third month after he began to complain. It is typical of nearly all such cases in the primary stage. The heart's action is so feeble that the apex-beat can scarcely be felt, but there is a faint tremulous im- pulse extending from the apex region to the margin of the costal cartilages with each systole ; all of the valvular sounds are very indistinct, and the pulse, ranging from ninety to one hundred and twenty, is so small as to make it very difficult to get a trace. When the strain is not sufficient to push the heart to the last degree of its endurance, but is frequently re- peated, we have changes which, though less pronounced, are none the less damaging. The daily guard-mount, the drill, the sentry duty, or the hard marches, repeat the compression of the chest and the distention of the heart, until finally permanent alterations are induced. It is while this process is going on that the heart has been called "irritable." It is easy to see what a mistake this term leads to in the minds of those not familiar with the subject. The functional disturbances of the organ are but expressions of the damage it has received, and not a manifestation of some unknown or fancied cause arising in the nervous system. The second stage is seen under two phases : one, in sim- ple dilatation ; the other, in dilatation with some hyper- trophy. The third stage is seen in two aspects also : first, dilatation with decided hypertrophy, and the second, where there is hypertrophy without dilatation, the cavi- ties being very nearly their normal size. We have had an opportunity of watching a case through all its stages, ending in the latter condition, within the last three years. At present, however, there is some tricuspid insufficiency and regurgitation. As a rule, there is no valvular disease in the second stage. We have made six autopsies where death took place from paralysis in this stage-one of which was un der chloroform-and in not one was there any valvular lesion. There is one point in the heart's action which may be noted in this connection, viz., the tremulous or wavy systolic movement. It is manifested so long as dilatation remains. In the first state it is only seen as the disease approaches the second, while it entirely vanishes ■when the cavities are reduced to their normal size by hyper- trophy. It is also the period of greatest danger-not that the heart is itself in a condition to make it so ; but, rather, with the feeling of improvement, the subject is likely to commit acts of indiscretion which strain the heart again suddenly, and, though the strain may be continued only for a few minutes, paralysis may supervene and the heart stop beating instantly and finally. Death is instantane- ous and without warning. The pulse at the wrist and the cardiac movements cannot be discerned scarcely a mo- ment after unconsciousness occurs. The paralysis is like that seen in chloroform poisoning. If the process goes on under favorable circumstances, it ends, as a rule, in two ways-partly in contraction of the walls of the heart, and partly in hypertrophy. The latter sometimes extends to the whole organ, while in other cases it is limited to the damaged portion only. When hypertrophy is developed the danger is measurably past, though some discomfort will be felt, at times when the heart is overtaxed, through life. But under the most favorable conditions it disqualifies the soldier for hard service. The same mode of life that originated the dis- ease will continue to operate against him. It will be seen, also, how important it is that, in granting certifi- cates of disability for discharge, the condition of the heart should be carefully noted, even though the more apparent cause be quite sufficient for the soldier's dis- charge. That it is frequently associated with diarrhoeas anti dysentery has been well shown. The autopsies, however, show that it may be much more frequent than clinical experience would indicate. So common was this condition found, that instructions were given that in all the diarrhoeal and dysenteric cases in which the cardiac disturbances were noted the treatment pari pasu should be directed to the heart; and this plan was adopted with almost unvaried salutary results. These facts were noticed and reported by others (" Med. and Surg. Hist. War," Med. Vol., Pt. II., pp. 315, 536). There was, however, no relation of cause and effect traceable between them. The time elapsing before hypertrophy is well estab- lished cannot be fixed by general rules. Goodheart thinks he has seen an enormous hypertrophy take place in a month in a case in civil life. It may be set down as an established fact, that it does not occur at that rate in the army. If a moderate hypertrophy is developed in four to six months, it is a good recovery-that is, a re- covery so far as to enable the subject to attend to all the ordinary affairs of life without much discomfort. Myers seems to be of the opinion that recovery never takes place, and we fully agree with him, with the single exception, that where the heart recovers its normal dimensions soon after sudden strain, though this may have led to syncope, but was not prolonged, full restoration may occasionally be seen. Where, how'ever, the strain has been more or less continuous for a considerable period, and in a mod- erate degree, the changes effected in the heart structure are permanent. To show w hat effect military life has upon the heart, I herewith submit some of the tracings taken from 93 able- bodied men in the order in which they appeared in the company rosters. They are classified in periods accord- ing to their terms of enlistment. Of this number there wrere 16 who had served over fifteen years, not one of whom gave the normal tracings of a healthy heart. I also submit 16 tracings taken from those who had served over ten and under fifteen years. This list embraces the entire number of that class, and from this it will be seen that 11 of the number, or over seventy-three per cent., were clearly abnormal. Of those who had served be- Fig. 1619. 576 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. Fig. 1620.-Group I. 42 19 41 18 37 15 39 17 Tracings taken from soldiers of more than fifteen years' service. tween five and ten years there were 38, and of these, 20 furnished tracings of a similar character, or over fifty-two per cent. Of those who had served under five years there were 22, and of this class there were 13, or over fifty-seven per cent., which showed the same anomalies. The tracings of the last two groups are omitted for the want of space. One of them, furthermore, was not avail- able on account of aortic regurgitation. We have other evidence show'ing the compression of the chest. This tracing (Fig. 1622) of B. S., Co. " K," Twenty-fourth Infantry, was taken October 26, 1884, on the right wrist, sitting ; pulse, 65. He was then required to march two hundred yards in double time, and the following tracing (Fig. 1623) was immediately taken ; pulse, 85. He was then loaded down with his equipments and gun, in the usual condition for inspection and drill, and re- quired to go over the same distance in double time, when the following tracing (Fig. 1624) was taken ; pulse, 96. It will be seen that in the first instance, in going over the ground in double time, there was very little difference in the diastolic curves, the arterial pressure remaining about the same. So soon, however, as the natural expansion of the chest was limited by his belts and weight of his equipments, the arterial pressure was re- duced to almost nothing in consequence of the lessened amount of blood sent to it by the left ventricle, and there must have been an enormous accumulation in the venous system and the right side of the heart, owing to impaired pulmonary circulation froip deficient oxygen and the in- ability of the right ventricle to overcome the obstruction. Many other experiments confirm the above. And what is more, these tracings have been supplemented by over two hundred taken in all the varying phases of health and disease among soldiers, and which show that they are the more common expressions of the circulations of these men. As to the periods of greatest danger, it may be said that one is at night, during those hours when the periodical distress returns, and when the respiratory movements are the most sluggish ; and the other is when, upon rising from a recumbent position, the column of blood in the upper part of the body is suddenly thrown back upon the enfeebled ventricles, thus at the same time diminishing the brain pressure. ■ Three of the deaths noted in this paper occurred while rising from the bed, one in the night at the hour of the ustial distress. The first two deaths were caused by shock from sudden pressure of the blood col- umn on the heart, with a corresponding lessening of the brain pressure, while in the third instance, owing to slower respiratory action, blood accumulated in the right cavity until the ventricle could no longer bear the strain. Again, death may occur immediately after violent exer- cise, as running, or lifting, or jumping, when there is an undue amount of blood thrown suddenly upon the heart. It has been known to take place upon the drill ground when men were supposed to be in tolerably good health. Diagnosis.-In regard to the diagnosis of these cases, much of the ground has been covered in the foregoing remarks, which it is not necessary to repeat. One thing, however, must be kept constantly in view, viz., the dis- tinction between purely functional disorders and cases of heart-strain. As to the principles governing the first, T. Hayden lays down a most excellent rule. He says : "It must be made upon evidence partly positive and partly negative, taken in connection with personal history," to which may be added, in cases of overstrain, the habits of life and the environment of the soldier. In the earlier stage, and in the commencement of the second, a careful observance of these rules will do much to remove any obscurity. The first thing a soldier usually complains of is his in- ability to bear pressure of his belts. He will say, "that 2 83 3 91 6 72 17 60 38 18 45 23 42 19 41 22 Fig. 1622. 15 96 2672 36 90 37 62 36 18 42 19 40 20 38 18 Fig. 162.3. 42 72 43 78 63 72 65 66 38 18 42 20 38 18 32 15 Fig. 1624. 76 72 83 72 87 68 82 72 Total examined, 16. Fig. 1621.-Group II. Served from ten to fifteen years. 40 12 38 13 29 10 31 11 1 70 5 68 7 66 12 60 34 12 34 14 33 10 37 14 1980 28 60 31 70 33 74 29 10 38 14 36 11 29 10 3896 40 60 41 66 86 68 32 14 37 15 43 10 32 10 82 70 86 60 90 68 78 72 Tracings from right wrist; posture, sitting ; clad in loose blouses; time, from 7 to 9 p.m. Explanation.-Numbers above show age and length of service ; num- bers below show number on roster and rate of pulse. For instance : The numbers accompanying the first tracing show that the man is forty-two years of age, that he has served nineteen years, that he is No. 2 on the company roster, and that his pulse is 83. 577 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. they put him out of breath ; " and when asked to locate the seat of pain, he will do so frequently by designating nearly the whole of the middle portion of the body. This is often the case during the first stage, that is, before the dilatation has become permanent, while in the second stage it is the rule. If required to be more explicit, he will quite as likely place his hand over the region of the spleen or lower border of the heart, and again, over the epigastrium or hepatic region ; he will also complain of occasional sharp, stitching pains in the region of the heart. In the case seen on the northern border, in mid- winter, severe lancinating pains beneath the praecordium were felt with the initiatory strain. Besides the symp- toms mentioned, the patient will also say that there is pain in the upper part of the left chest, neck, or shoulder, this sometimes extending to the elbow; or he will com- plain of his food distressing him, of loss of appetitp, some- times of diarrhoea, or of light dysentery, and that he has no strength. His general appearance is such as to lead to the impression that he is suffering from digestive dis- turbance, engorgement of the liver or spleen, or from a mild form of malarial disorder, or is possibly malingering. He rarely refers to the heart as the seat of the trouble, and as his complaints are of the most common order, there is nothing specially in them to indicate what is their source. If asked how long he has been suffering from shortness of breath, he will generally say that he does not know when he first noticed it, but that it has been coming on gradually for some time, and is getting worse ; or, if more definite in his reply, he may refer to an occasion when there was no special circumstance to account for it, or again, he may state it with precision. After further questioning he perhaps may say that at some remote time he had had an attack of faintness while on parade, or on the march, or from exposure, " but as it soon passed off, he paid no attention to it." One man said he had repeated attacks of faintness two and one-half years before while on parade, which were supposed to be due to malarial fever. After resting in the hospital a couple of months he was returned to his company, where he had been able to perform his usual garrison duties up to the date when first seen by the writer. There was then dilatation with hypertrophy of the right ventricle, and hypertrophy of the left; there was also oedema of the lower extremities, and about five per cent, of albumen in the urine. He had passed into the third stage. Of course the question arises, was his heart in sound condition at the time of enlistment, six months before he had the first attack ; but, as he had passed the scrutiny of two medical examiners, and as his general condition was excellent, the inference is fairly drawn that it was at that time in a normal state. Occasionally there is vertigo and an indescribable dis- tress in the thorax ; at night this becomes intolerable, and sometimes, when the patient first lies down, then later, or after midnight, the distress may give rise to the greatest apprehensions. It is scarcely angina in the usual acceptance of that term. It is often described as a smothering sensation-a sort of dyspnoea. It is almost a constant symptom from the earlier stages, and continues as long as dilatation exists. In the first stage the pulse is very weak, while in the second it is fuller, compressible, still frequent, and easily hastened by exercise ; is jerky, intermittent, and nearly always dicrotic. When the strain has been felt chiefly in the right side of the heart, little importance can be at- tached to the pulse, except as indicating an enfeebled organ throughout, in other words, general asthenia. It is in this condition of the heart that we see the tremulous movements in the space between the xyphoid and costal margins, or at the sixth and seventh intercostal spaces near thereto ; the same being easily felt on palpation with each systolic action. In this location the tremulous pulse becomes a distinguishing feature between dilatations of the respective ventricles. In fact, in dilatations of the left ventricle it is often absent, while in dilatation of the right it has always been present-if not discoverable while the patient is in a state of repose, it may be easily demon- strated by making him take a little exercise. This symp. tom also separates the cases from those of a purely func- tional nature. In reference to the physical signs of heart strain, only such will be noticed as appertain to this subject especi- ally, and in the simplest forms, uncomplicated with other organic lesions of the cardiac structures, or of the lungs. It is the only way in which a true conception of its na- ture can be obtained. But it must be remembered that antecedent lesions, except in rheumatism, are rare, and therefore exceptions. Men are not on duty under such circumstances. Chronic bronchitis and malarial fevers, however, do command attention, for men are often re- turned to duty before they are entirely restored to health, and when the heart is weak. In the first stage the auscultatory signs are negative, except in respect to the single state of asthenia. There are no valvular lesions, no bruits or murmurs-all these are conspicuously absent. It is frequently difficult, un- less we employ a binaural stethoscope, to hear the normal sounds of the heart; indeed, quite as difficult as it is to get a radial tracing of the pulse ; nor can we sometimes get such a tracing until after the administration of dig- italis. It is only after the heart has passed out of this stage that we get any evidence of organic mischief. It is then that the systole becomes very short. The heart seems to contract in half the time required for its normal action, and the time between the first and second sounds is also lessened, while there is necessarily a prolongation of the diastolic interval. The rhythmic movements may range anywhere from forty-five per minute in the recum- bent position, to one hundred and fifty during moderate exercise, or even in a standing position. The large num- ber of radial pulse tracings heretofore submitted, will perhaps convey a better idea as to the systolic interval than is obtainable in any other way. In the tracings the suddenness of the systolic stroke is well shown, even among the healthiest. Over the region where the tremulous movements are seen there will be heard a loud, rough, rasping, systolic sound, of low pitch. Compared with the normal ven- tricular sounds of the left side, the difference may range anywhere from a half to a full tone in the diatonic scale. As a rule, it is heard loudest about half an inch to the left of the costal margin, opposite and a little be- low its junction with the sternum, and again very dis- tinctly anywhere on a horizontal line one inch below, and extending to the right apex. With a narrow instrument and by depressing the space between the costal margin and the xyphoid process, while the mouth of the stethoscope is turned in the direction of the ventricle, the sound can be made out still more distinctly ; this, however, can only be done in the case of moderately thin subjects. In the earlier stages the sound is often weak, yet distinctive as to roughness, and in every case seemingly very superficial. This sound has been regarded by many writers as an evi- dence of hypertrophy, but it is a great mistake. In two fatal terminations from cardiac paralysis, and where we had previously examined the heart and carefully noted its condition, there was not the least evidence of hyper- trophy. And the same was true when death had oc- curred from dysentery or diarrhoea. In not a single in- stance did the ventricular wall exceed two lines in thickness, and in most cases not more than one line, or a line and a half. Nor were there any valvular lesions to account for it. The cause must therefore be due to something else, and this seems to be found in the circula- tion of the blood among the chordae tendinae in their atonic state and lax tension, in which condition they are thrown into slower vibration-hence the low pitch ; or it may possibly be due to their greater length, which also is in accordance with well-known physical laws. This sound and its variations may be quite closely imitated by taking apiece of narrow, thin, silk ribbon and dexterously adjust- ing it between the lips just open enough to admit of a forced expulsion of the breath in a thin stream, when the ribbon can be made to vibrate almost in the identical pitch that we hear in the right ventricle. As this sound vanishes as the condition of the heart improves, or re- mains in accordance with the dilated state of the organ, 578 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. we can think of no other reasonable explanation. We are aware that other theories have been put forward, but they are not satisfactory; the facts, as they appear among soldiers, do not sustain them. In cases of recovery, when the cavity of the right ventricle has approached its normal size, this rough sound gradually lessens so that it may not be noticeable until the cardiac move- ments have been stimulated by active exercise, when the pitch will be higher. But if the dilatation remain, with or without hypertrophy, the rough sound will also remain at its low pitch. When the hypertrophy, how- ever, is such as to reduce the size of the cavity to nearly its normal state, then the pitch corresponds with that of the opposite side and is no longer distinctive. Pulmonary accentuation is sometimes present, especially if the car- diac trouble originated in lesions of the respiratory ap- paratus. It is never heard in the earlier stages except in imperfect circulation of the left side. But it may be de- veloped at any time by the application of tight belts and exercise. With this condition of the heart there is more or less venous turgescence and stagnation in the capillaries. The hands will be cold and livid ; the color disappearing under pressure, slowly to return. There is superficial turgescence of the veins of the chest, and a red flush over the entire surface, which also disappears under pressure and sometimes with pitting. The lips will range from cherry-red to a livid hue, and the ears will likewise be congested. Frequently this flushed condition of the face gives the appearance of robust health, accompanied, as it usually is, with a well-developed physique. On one oc- casion, because of this appearance of health, between twenty and thirty men were ordered to join their com- panies in the field by an examining board, when, upon a subsequent more careful examination, the fact was ascer- tained that there was not a healthy man among them. This capillary stasis with pitting and disappearance under pressure is an excellent guide in separating heart-strain from purely functional disorders, and it is a constant symptom as long as dilatation remains. It is not, however, distinctive as against other organic lesions of the heart. Treatment.-The treatment of heart-strain is of the simplest character. The first and most important point to be attended to in the earlier stages is the removal of the cause, so far as may be done, and the securing of absolute rest. Medicines will amount to little unless this condi- tion be obtained. The liability to a sudden fatal termina- tion in these stages has been already referred to. In the earlier condition, or that of simple asthenia, digitalis and strychnia are most important remedies. Taken in con- nection with tonics we have nothing comparable to them to restore the tone of the heart and reduce its rhythmic activity. How long the treatment must be continued will depend upon the response of the organ to their action. So long, however, as dilatation remains they cannot safely be stopped. There is no agent to take the place of these, unless it be, perhaps, convallaria majalis, but of that we have no experience. It is not a part of army medical supplies. When hypertrophy has been well established, which is indicated by the firmer cardiac impulse and by the strength and fulness of the pulse, and while the trem- ulous action continues, aconite may be cautiously re- sorted to. It must be used with great care, however, until the third stage is developed, for sometimes the most sudden and otherwise unaccountable depression will fol- low its administration even in minimum doses. Vera- trum viride is a most dangerous agent at all times. In our earlier experience, when Norwood's -tincture was all the rage, and was resorted to in the treatment of almost every acute disease, the effect of this agent on the heart was invariably bad. So far from lessening the frequency of the pulse, it increased the latter to the extent even of from eighty-five or ninety per minute to one hundred and fifty. And the same results were observed even wThen it was administered as an antipyretic in high febrile or in- flammatory cases. Soldiers, as a rule, do not bear the action of this agent well under any circumstances. Where cardiac sedatives are required, aconite and gel- seminum have the better effect. For the nocturnal distress belladonna, hyoscyamus, and cannabis indica are to be preferred in the order named. We have never seen a case benefited by either opium or potassic bromide. On tlie contrary, they have generally added to the distress, and both these medicines should also be excluded in the treatment of the intestinal fluxes and hepatic disorders, when this condition of the heart is coexistent. If opium, or its usual preparations, arrest the flux or relieve the pain for the time being, they gen- erally leave the patient the worse for it in the end. Bel- ladonna and hyoscyamus are to be preferred, while in order to arrest the fluxes nitric acid and cinchona or sul- phuric acid and quinine in small doses answer far better. Where the liver is involved, nitro-muriatic acid and bark are indicated, and mercurials very rarely. When the di- arrhoea is due to the impeded circulation through the heart by reason of its asthenia, nitric acid and bark act with excellent effect upon the tonicity of the capillary circulation on the intestinal surfaces, and nitro-muriatic acid is equally prompt in its action on the disordered cir- culation and secretion of the liver. These facts have been demonstrated again and again. Sometimes astringents are demanded, and of this class we know of none equalling oxide of zinc in doses of from five to ten grains. It is both astringent and tonic, and is best administered in mucilage. Tannin is generally obnox- ious. Great care is required in the diet. Solid meats should be excluded, but light soups and broths are allow- able. Milk and farinaceous foods contained in various preparations answer the best. The functions of the stom- ach are generally disordered, hence gastric digestion is rarely well done. This is frequently shown in the acrid eructations. It is better, therefore, to tax it as little as possible until the tone of the heart is restored. In all these cases the patient should be assured that with reasonable care he will ultimately recover, so as to be able to attend to his usual duties, excepting such labor as is calculated to overtax the heart. Such assurance will go a great way in removing the despondency in which such patients are likely to indulge, and will promote the action of our remedies. Pensions.-We have before referred to the bearing of heart-strain on venous and capillary engorgements of the digestive tract, and indirectly on claims for pensions. The rules adopted in the department are arbitrary and unjust, and it is almost impossible to comply therewith. When a claim is made, based on disabilities of these classes, the applicant is at once informed that he must show that he was a sound man when he entered the army. Again, it must appear that the disease did not originate after leaving the service, and that it was through no fault of his own. Now, what chance is there for an old soldier of five, ten, fifteen, or twenty years' service, to go back and hunt up evidence showing the state of his health be- fore enlistment. Sometimes men were discharged for chronic diarrhoea, chronic hepatitis, or dysentery, and nothing was said about the heart trouble. But in the course of years the latter becomes annoying, and he puts in his claim. It is rejected on the ground that the disease did not originate in the line of duty, or while he was in the service. Again, claims are presented based on period- ical diarrhoeas or dysenteries recurring during the warmer months, while absent during the colder. This class is of- ten associated with former heart-strain, and pension ex- aminers should be careful to note the condition of the heart, and ascertain whether any trouble existed immedi- ately after leaving the army service. When we remem- ber how few medical officers during the war recognized the true nature of these cardiac disorders, and how many still fail to do so, it can readily be seen what injustice may have been done, and will continue to be done, until this matter is more fully understood. This is not so much due to neg- lect on the part of young surgeons to investigate this class of cases, but rather to the bias inculcated in their instruc- tion. We have repeatedly seen this in the service. It is rare, indeed, that a young medical officer has any just con- ception of the influence of compression of the chest upon the heart, and especially so during military operations. And the remark applies equally to what Allbutt has said 579 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon mechanical causation of heart disease in civil life. Really the subject reaches into every grade of society, to women as well as to men. The sudden syncopes occurring among the former should be, as before stated, accepted as notes of warning that compressions of the chest cannot be borne during active exercise with impunity. Morse K. Taylor. the blood contained in them, those formed around em- bolic fragments which have been carried to the heart from peripheric veins, and, finally, the globular vegetations, cysts or polypi, attached to the endocardium, and differ- ing from coagula considerably in appearance, though not in nature. It is so common an occurrence to find clots in the heart after death, and their effect on the central organ of circu- lation is so easily imagined, that, when post-mortem ex- aminations first began to be made, an overwhelming im- portance was attached to their presence. The coincidence of lesions of the walls and valves of the heart was over- looked, and all those symptoms which are really due to the heart disease were attributed to what was only its terminal accident; indeed, the ill-health which for fifteen or twenty years may have antedated the heart disease was similarly explained by the presence of a clot which was supposed to have embarrassed the circulation during this whole period of time.1 In 1739 a reaction set in against this extensive and too simple pathogeny, when Pasta declared that the blood could not coagulate during life, and that all heart-clots were formed after death. A controversy was initiated, which engaged the attention of the most illustrious phy- sicians of two centuries.2 Morgagni and Senac finally established the modern doctrine of a dual origin of the clots, some of which are formed during life, and become an efficient cause-of death, while others are formed only during the death agony. The conditions favoring or determining this dangerous accident belong (a) to the heart itself, (b) to the peripheric circulation, or, finally, (e) to the blood. Etiology.-(a) The cardiac lesions, liable to become complicated by thrombosis, either impair the contractility of the heart-walls, roughen and abrade its lining mem- brane, or obstruct the flow of blood through its orifices. The first condition is found in myocarditis, acute (in- fectious) or chronic (fibroid disease), with or without the frequent consequence of this lesion, namely, general dila- tation or partial aneurism of an auricle or ventricle. Wherever the muscular tissue of the heart has become converted into a fibroid substance, the power of contrac- tion is proportionately destroyed ; the altered segment re- mains as an inert island in the midst of the waves of mo- tion which incessantly animate the surrounding muscle. At this point the blood-current fails to receive its proper share of impulse, and is liable therefore to slacken, and in slackening, for reasons to be presently explained, is liable to coagulate. Hence layers of fibrine of greater or less thickness are frequently found lying on those parts of the inner surface of the auricular or ventricular wall which correspond to a fibroid patch in its substance. At such points the endocardium is frequently thickened, or even abraded, and then the second cause of blood coagu- lation also exists to intensify the action of the first. If that portion of the heart-wall which is altered by fibroid disease has become dilated so as to form an aneu- rism, cardiac thrombosis is inevitable, for such pouches are invariably lined with laminated fibrine, and sometimes completely filled with solid masses of it. Such solid masses sometimes occupy the cavity of the ventricle,* when this has suffered general dilatation (cardiac aneu- rism of older authors). In a specimen at the New York Hospital museum, an enormously dilated heart contains such a globular mass the size of an ordinary orange. These masses sometimes soften at the centre, and in as- suming the appearance of purulent cysts have become the subject of most prolonged pathological discussions.3 These cysts have been referred to inflammation of the endocardium, developed to the point of suppuration, or it has been supposed that the coagula, which had been formed under some (unknown) influence, became puru- lent, when the patient suffered from a "pyogenic diathe- sis." Stokes explained the cysts by a cardiac phlebitis.4 Bouillaud believed, on the other hand, that pus which HEART, SYPHILOMA OF. Syphilitic disease of the heart is by no means a rare condition, lesions having been found in a large number of instances in which their spe- cific nature was positively determined. It belongs among the " tertiary" manifestations, and is never met with ex- cept when other well-marked evidences of syphilis are present. Morbid Anatomy.-Two forms of specific disease of the heart have been established by post-mortem exami nation-the gummatous, and he fibroid. The first is marked by the presence in the substance of the heart of nodules, grayish or yellowish in color, firm and solid like cartilage, at an early stage of their growth, but when older becoming soft and cheesy. They are not circum- scribed, but are continuous with the myocardium, and are usually described as infiltrations. They are generally multiple, and may be found in any part of the heart. Ac- cording to Oppolzer, these gummata may soften and burst into the cardiac chambers, thereby causing general infarction ; sometimes, however, they undergo calcareous degeneration. They may also lead to acute aneurism of the heart, or to ulcerative endocarditis, but more fre- quently the cheesy products are in great measure ab- sorbed. Their elementary structure presents no charac- teristic feature. The second form of syphilis of the heart -the fibroid patch-is sometimes well defined and local- ized, resembling fully developed syphilitic interstitial in- flammation of the ordinary type. In other specimens, irregular masses of indurated fibroid tissue are found upon the walls and within the substance of the heart, while the serous membranes covering them are opaque, thickened, and puckered. Similar appearances may be detected in other viscera, thus determining the nature of the disease. Syphilitic endarteriftis (obliterans) may also occur in the vessels of the myocardium, and give rise to infarction of the walls of the heart. Other cardiac affections connected with syphilis are chronic aneurism of the walls, distortion of the ostia and their appendages, and, more frequently, adhesions of the pericardium. Symptoms.-Among the subjects of syphilis of the heart, a certain proportion (according to Dr. J. M. Bruce, in Quain's " Dictionary of Medicine "), will be found to labor under the symptoms of chronic heart disease-such as dyspnoea, cardiac distress, palpitation, and pulmonary complications-and will present the physical signs of car- diac enlargement, and perhaps of valvular incompetence. ' ' Prsecordial uneasiness, syncopal attacks, and remark- able infrequency of the pulse have been prominent feat- ures in several recorded cases." The remaining number either die suddenly, with few, if any, symptoms referable to the heart, or they succumb to syphilitic marasmus, with or without some evidence that the heart is involved. Diagnosis.-Specific cardiac disease may be diagnos- ticated without much hesitation in the absence of any more probable causes, like endocarditis or Bright's dis- ease, when well-defined symptoms or physical signs, such as those just mentioned, are met with in a syphilitic sub- ject. Prognosis.-In view of the curability of the constitu- tional disease, the prognosis of cardiac syphiloma is more favorable than perhaps that of any other heart affection. Treatment.-The usual anti-syphilitic remedies are indicated, with any medicinal or hygienic measures which may be demanded by the general condition of the patient. Alfred L. Loomis. HEART, THROMBOSIS OF (HEART-CLOT). Cnder this general title may be grouped together the fibrinous coagulations formed within the cavities of the heart from * In one case a laminated clot almost filled the dilated left auricle, leaving only a narrow central channel. There was stenosis of the aortic, mitral, and tricuspid valves. Tr. Path. Soc., London, 1880. 580 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. had been carried from an inflamed vein to the heart de- termined coagulation of the blood in this organ. In 1851 Charcot showed that these so-cailed purulent cysts did not sustain pus, but a puriform liquid composed of proteic granules, fat-globules, white blood-corpuscles, and an amorphous detritus resulting from the disaggrega- tions of fibrine.* During the terminal period of an acute or chronic gen- eralized myocarditis, the heart-power fails gradually dur- ing some days or even weeks ; and clots are then usually formed in the heart, especially on the right side.f In the acute myocarditis of infectious diseases, espe- cially diphtheria, these clots have been considered the im- mediate cause of death.5 But the cardiac symptoms are more probably due to the infectious myocarditis, of which the thrombosis is only a consequence. (See article Fi- broid Disease of Heart in this Reference Handbook.) The second cardiac cause of thrombosis is endocarditis, for roughening and abrasions of the lining membrane of the heart easily become an efficient cause of the deposi- tion of fibrine, which may be converted into the nucleus of a clot of large dimensions.6 Fibrinous vegetations are usually clustered around the ulceration in the acute ul- cerative variety of endocarditis.1 The formation of the clot depends partly on mechanical conditions, partly on an exudation from the diseased membrane. The third cardiac condition is stenosis of one of the orifices of the heart, with consequent slackening of the current of blood which must pass through it. The auri- cle is usually dilated, so that the effect on the blood- current of inefficient contraction of the auricular walls is added to that of the valvular obstruction. Although stenosis occurs with by far the greatest frequency at the mitral orifice, auricular as well as ventricular clots are more frequent on the right side of the heart. This shows that the state of cardiac contractility is of more impor- tance in the production of heart-clot than is stenosis; while the liability of the right cavities is heightened by their position at the focus of reception for embolic parti- cles from the periphery. Cardiac thrombosis frequently complicates croupous pneumonia, being almost invariably present in the fatal cases, and probably the immediate cause of death. The lesion has in these cases also been attributed to mechani- cal obstruction to the circulation in the lungs outside of the heart. It is probable, however, that the same altera- tion of the blood which determines the fibrinous exuda- tion in the lungs predisposes strongly to similar exu- dations in the heart, which therefore should be regarded as an extension of the same morbid process. In this case, also, the contractility of the heart is liable to be directly impaired by interstitial myocarditis, or by poisoning of the excito-motor ganglia (Loomis), j: (b) In healthy hearts clots may form when a fragment of fibrine from a distant vein is carried to the right auricle or ventricle, or to the pulmonary artery. The embolic fragment is only the nucleus around which fi- brine may be deposited. The most frequent causes of the venous thrombosis, which may lead to heart-clot, are phthisis and the puerperal state. Richardson also enumer- ates pertussis, peritonitis, ovarian operations, erysipelas, and scarlet fever. This author remarks that the increased heat of the peripheric veins in these last two diseases dangerously favors the formation of clots, already threat- ened from the alteration of the blood. A special cause of heart-clot is the entrance of air into the right heart, which is especially threatened by wounds of the jugular veins, such as sometimes occur during sur- gical operations on the neck. A bubble of air churning in the blood causes rapid clotting, and consequent arrest of the heart's action from obstruction in the pulmonary artery. (c) The third cause of heart-clot is such an alteration of the blood as directly determines the separation of fibrine from it, now at the periphery, now at the centre of the circulation. The theory of coagulation has been a celebrated field of pathological controversy. From the rapid clotting of the blood after death the phenomenon was attributed sim- ply to loss of vitality. But the blood of cadavers is often fluid. Blood drawn from the body may be kept in an un- injured vein and sheltered from the air until putrefaction occurs without coagulating. Conversely, the living blood often coagulates in the body when the lining membrane of the circulatory canals is altered in texture, and if for- eign bodies or air gain admittance to the circulation. Alkalies, and especially ammonia, prevent coagulation, and hence Richardson concluded that coagulation was due to the presence of an acid, perhaps not always the same.8 It is, however, the researches of Schmidt,9 some- what modified by Hammarsten,10 which have established the modern doctrine of coagulation. According to Schmidt, fibrine does not pre-exist in the blood in a " soluble" form to be " deposited ; " but only the fluid fibrine-factors, which unite to form solid fibrine in the presence of a ferment which is absent from living circu- lating blood. The factors are the fibrino-plastine, or para- globuline, and the fibrinogen, both present in the blood- plasma. The ferment which causes the ordinary post- mortem clotting of the blood is liberated from the white blood-corpuscles as they die; in drawn blood, coagulation begins in the immediate neighborhood of white corpus- cles, and in living blood-vessels an accumulation of white corpuscles in veins precedes thrombosis, or may entirely constitute it.* Hammarsten claims to have proved that paraglobuline is not essential to coagulation, but only fibrinogen and a ferment (see also Gamgee, " Physiol. Chemistry," 1885). The theory of the action of white corpuscles remains un- changed. By it are explained those cases of thrombosis which are associated with a relative excess of white cor- puscles, -which may rapidly die in the blood, as occurs in pyaemia, empyema, and certain cachexiae, as phthisis. In leucocythaemia the white corpuscles do not die, and there is no thrombosis. It seems probable that in several mor- bid states it is their characteristic ferment which initiates the action of that of the white corpuscles. In diphtheritic croup and croupous pneumonia the fibrine is, for a time, detruded from the circulation as fast as it is formed ; but, finally, forming in the heart, it becomes the immedi- ate cause of death. Similarly may be explained the cardiac thrombosis of puerperal fever and of cholera. But, in the latter, the ten- dency to blood alterations is increased by the draining away of the watery parts of the blood in the serous evac- uations.! In puerperal fever a special predisposition to thrombosis exists, when, from insufficient retraction of the uterus, its sinuses are not completely obliterated, but remain filled with blood, which becomes coagulated. (d) Still anbther cause of cardiac thrombosis seems to exist in the slow cardiac contractions which occur after lesions of the brain, as was shown by the experiments of Faure.11 Tardieu notices the frequency of heart-clots in persons killed by wounds on the head, and Senac long ago commented on their occurrence in cases of violent death. They are probably due to the slackening of the heart's action, from stimulation of the cardio-inhibitory centre. Pathological Anatomy.-Two classes of heart-clots exist-the ante-mortem, alone possessed of clinical signifi- cance, and the clot formed during the death agony, or just after death. The latter variety of coagulum is red, black- ish, or yellow and greenish, with rosy points, but never completely decolorized. These clots are soft, non-strati- fied, and non-adherent, though they may be more or less entangled in the chordte tendinese. Found in all four * Observation confirmed by Lebert and Rokitansky, and all subsequent observers. + See case by Whipham, Lancet, 1873. Also case of chronic interstitial myocarditis in a profoundly anaemic woman. Stevenel, These de Paris, 1882, Ues Myocardites. + Aran relates a remarkable case of heart-clot in a child, who succumbed to it in the course of a tuberculous broncho-pneumonia. The concretion was the size of a pigeon's egg, and weighed four grammes. * Zahn: Ueber die Thrombose, Virchow's Archiv, 1882. According to Hayem, threads of fibrine may be seen to form around dying red cor- puscles also. t In two cases related by Dawson of death from " idiopathic heart- clot," in soldiers at Scutari, the thrombosis was probably due to cholera with initial collapse. 581 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cavities, they are yet more frequent on the right side. These clots are composed of fibrinous fibrillae, blood-cor- puscles, and a few non-granular leucocytes. The true, clinical, ante-mortem clots, whatever be their size, contrast with those just described by their dense white color, often laminated structure, firm consistency, and the adhesion of a part or all of their surface to the endocardium, especially at some eroded point. When in cylindrical masses these clots have been called cardiac polypi, as the globular masses have been called cardiac cysts. (See ut supra.) One form resembles friable paste, or fat cheese (Laennec).12 These clots are composed entirely of fibrine, from which the corpuscles have been separated. It has been asserted that they were capable of organization by penetration of blood-vessels to their interior, as has been observed in vascular thrombi.13 But this organization has never been demonstrated in the case of cardiac coagula.14 Symptomatology.-Notwithstanding the mass of lit- erature on cardiac thrombosis, it is difficult to find cases which illustrate its clinical symptoms. These are sudden and tumultuous, and of brief duration ; or they are slow and insidious in their development. The first form be- longs principally to the cases in which an embolus has been carried to the heart from the periphery, and in which the heart may be quite healthy. In the second group the thrombosis is formed within the heart, and complicates previously existing chronic cardiac disease, or an acute infectious myocarditis. A special set of symptoms is liable to complicate those which are directly cardiac, when embolic fragments have been carried from the right ventricle into the branches of the pulmonary artery. The symptoms of pulmo- nary embolism are superadded to the cardiac symptoms proper. These, in the typical acute cases, are severe dyspnoea, tumultuous and distressing action of the heart, and signs of progressively increasing failure of the circulation. In the absence of previous valvular disease, auscultation does not usually detect murmurs at the heart; yet these are occasionally heard, if the clot obstruct an orifice.* The normal heart-sounds may be muffled and confused, the first sound being weakened, when the cardiac systole is much embarrassed. The area of dulness is not in- creased by the clot, yet is frequently large from previous dilatation of the cavities. The pulse is rapid, small, fili- form, and, finally, intermittent. Clot in the right heart causes notable obstruction to the nervous circulation of the head and neck, whose tis- sues become cyanosed, turgescent, even oedematous. It is said that the sonority of the lungs is increased, from the relative excess of air when the supply of blood is cut off. When the clot is in the left heart, on the other hand, the lungs become congested ; resonance is dimin- ished, there are subcrepitant rales, and occasionally hae- moptysis. The violent and acute symptoms of heart-clot are developed in the course of acute cardiac inflammations, croupous pneumonia, or pleurisy, the puerperal state, pyaemia, and ulcerative endocarditis, f The post-partum clots originate, as has been said, in the transport of fibrinous fragments to the heart. They are especially liable to obstruct the pulmonary artery, even as far as its bifurcation. There is, in consequence, an abrupt cutting off of the blood-supply to the lungs, which causes the same overwhelming distress as is oc- casioned by obstruction to the air-supply; under these circumstances the patient may even die quite suddenly upon sitting up in bed, and before any symptoms have become developed.j: In diphtheria, on the contrary, the symptoms are most insidious, beginning during apparent convalescence as a mere debility, which rapidly increases to fatal prostra- tion. The circulation becomes feeble and languid, the respiration hurried yet sighing, but without oppressive dyspnoea or cyanosis. Life is quietly extinguished in a few days. Clots are found in nearly all the heart cavi- ties, and to them several observers have attributed the death. * The recent discovery of infective myocarditis in diphtheria suggests that this lesion existed in the cases mentioned, but was overlooked through ignorance of its possible existence, and that the clots were secondary to such lesion of the muscular tissue. In ulcerative endocarditis, minute coagula are formed around the ulcerations ; they do not obstruct the cardiac circulation, yet threaten all the dangers of infective em- bolism. In a truly chronic heart-clot, the symptoms should re- semble those observed in the remarkable case of cardiac neoplasm reported by Douglas.f Not a few cases of cardiac thrombosis are related in which the left auricle wras nearly filled by clots ; yet no symptoms had been observed other than those of the initial stenosis which coexisted.15 In the ventricles, the largest concretions are nearly always associated with partial aneurism; the symptoms have been those of gradually failing contractility of the heart. The most important complication of either acute or (relatively) chronic cardiac thrombosis is embolism of the viscera or of the extremities. Visceral embolism and metastatic abscesses are especially liable to occur in ulcer- ative endocarditis, and, as already stated, the danger is out of all proportion to the size of the heart-clot. But no form of the affection is exempt. The sudden occurrence of dyspnoea, or exacerbation of previously existing car- diac distress, followed by severe and often excruciating pain in an extremity, indicates the development of these accidents. The first symptoms are soon followed, if the peripheric embolus be large, by signs of gangrene of the limb whose artery has been obstructed ; and the patient does not long survive. Such accidents have been noted in puerperal women. .Embolism of a cerebral artery is indicated by cerebral accidents, usually paralytic. Frequent in chronic organic heart disease, with ventricular dilatation and clot, these embolic paralyses have been seen also during typhoid fever,16 and during a myocarditis of anaemic origin4 Treatment of Cardiac Thrombosis.-The only treatment that has been seriously recommended on theo- retical grounds is the internal administration of ammo- nia.11 Ammonia will prevent coagulation of the blood when present in it in the proportion of 1 part to 1,000. Richardson claimed to have demonstrated that the cause of the normal coagulation of the blood was the loss of the ammonia contained in it during life. This theory is now obsolete ; but the author continues to advocate the ammonia treatment of cardiac thrombosis, giving the liquor in ten-minim doses in an ounce of water, repeated at short intervals. Gerhardt advises saline spray 18 of bi- carbonate of sodium, from one-half to one and one-half per cent. Absolute rest in the recumbent position, cardiac stimu- lants, as brandy and ether, § are the resources upon which probably more reliance must be placed in these formid- able accidents. If the clot be small, it is not impossible that it might be carried forward piecemeal to the lungs, or to a peripheric artery ; and if it be non-infective, that the patient would escape with a temporary infarctus, pul- monary or peripheric. Cases have been observed in the course of croupous pneumonia19 of the puerpual state,20 and of diphtheria,21 in which all the symptoms of cardiac * Thus in Stokes' case of clot, with cholera, a loud bellows-murmur existed at the aortic orifice through which the clot passed. t Lancereaux: Mem. Soc. Biol., 1862. Osler describes cases of mul- tiple embolism in ulcerative endocarditis, in which there was no heart- clot at all. Trans. Internat. Congress, 1881. t Bowman: Brit. Med. Jr. 1873. In this case, however, the sudden death was evidently due to fatty heart; the heart-clots found were ter- minal. * Meigs: Am. Jr. Med. Sciences. Beverley Robinson : These de Paris, 1871. Keating, quoted by Robinson, art. Thrombosis, Pepper's System of Medicine. A case of recovery after apparently identical accidents is related in the Arch. Gen.. 1884, t. L, p. 490. t Edin. Med. Jour., 1868. See also case by Kottmeier, Arch. Virch., 1862, Bd. 23, and by Zander, ibid, 1880, Bd. 80. This last case caused no symptoms until a few weeks before death, though a fibroma the size of a duck's egg almost filled the enlarged right ventricle. t Stevenel relates a most interesting case. Des Myocardites. These de Paris, 1882. § Not digitalis. 582 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. thrombosis occurred, yet gradually subsided, and the patient went on to complete recovery. aorta and pulmonary artery by a septum, the continuation of which in like manner divides the heart itself ; the valves being formed by outgrowth from the walls. In abnormal development of the septum of the common arterial trunk, as regards site and direction, according to the most recent views, is to be found the key to all the other non- inflammatory congenital changes, which are merely the necessary consequences imposed by growth and develop- ment (Orth : " Handbuch der Spec. Path. Anat."). It is in the course of the pulmonary artery that those lesions are met with which are most compatible with life. Lebert speaks of a person who reached the age of sixty-five in spite of congenital stenosis of that vessel. Atresia is generally speedily fatal; stenosis may be found in the infundibulum, ostium, or the artery itself, in any one, two, or all three combined; but if the contraction be not too extreme, and be balanced by sufficient perforation of the ventricular septum, the life of the owner may not be seriously compromised, at least for a time. Phthisis, set up at or soon after the age of puberty, is very apt to be the direct cause of death. The imperfection of the sep- tum seems to be due to the increased pressure in the right ventricle caused by the contraction of the pulmonary orifice ; and it may be stated as a general law that mal- formation at a cardiac orifice can be compensated only by malformation elsewhere. The degree and localization of enlargement of the heart will depend, of course, on the degree and localization of the lesion, as well as on the completeness of the compensatory malformation. In- sufficiency of the valve is more apt to be due to inflam- mation than to pure faulty development. Aortic sten- osis, far more rare than pulmonic, is also compatible with life of some duration, and in such a case it may be very difficult to determine whether the lesion was really congenital or acquired. Malformation may be con- fined to one or involve several valves, varies greatly in degree in different cases, and is so liable to be modified by secondary endocarditis that a large variety of patho- logical combinations and conditions is met with. The number of the valve curtains at any orifice may be congenitally increased or diminished; an increase does not seem usually to be productive of mischief. The cur- tains also sometimes contain, especially near the free border, small perforations, mere mention of which suf- fices. By far the most frequent cause of valvular disease is endocarditis, which is as rare in the right heart after birth as in the left before, though Orth maintains that, as a primary affection, it is equally common on the two sides during fcetal life ; secondarily it occurs oftener on the right side, because malformation is there more common. Endocarditis may be broadly divided into two main forms, the acute and the chronic, the former including the simple and the ulcerative, or, as Osler prefers to call it, the malignant. It has been thought that malignant en- docarditis is a very rare form of disease, and necessarily fatal; and that its distinctive mark is the presence of micrococci, not only in the diseased portions of the endo- cardium, but also in multiple embolic abscesses derived therefrom. Some late authorities (Klebs, Koster) report that they find in any and every case of recent endocar- ditis low organisms, and the opinion seems to be gaining ground that acute endocarditis is, in all its forms, an es- sentially mycotic process, its malignancy or non-malig- nancy depending probably, in large measure, on the char- acter of the organisms. However this may be, we know that endocarditis may be malignant or infective without causing ulceration or multiple abscesses ; that the malig- nant form is prone to attack valves which have undergone sclerotic changes ; that it is much more common than has been supposed ; and we have reason to believe that it is not necessarily fatal. With time, and patient and earn- est work, we shall know more. Inflammation of the endocardium and of the valves may also be subacute, and is then apt to result in injury to the valves, though its products may be absorbed and leave no deformity behind. The chronic, called also the "sclerotic" or "contract- ing," form, is an insidious process which often produces Beverley Robinson: Art. Card. Thrombosis. System of Med., Pepper, 1886. Parrot: Polypes du Coeur, Art. Coeur. Diet. Encycloped. Laennec: Concret. Globuleuses, (Euvres, 1826. Cruveilhier: Anat. Path., liv. 28. Zahn : Thrombosis, Virch. Arch., Bd. 62. Faure: Heart-Clot, Arch. Gen., 1864. Richardson : Coagulation Blood, Prize Essay, 1858. Fr6dault: Arch. Gen., 1847. H6rard : Endocard. Ulc6reusc, Gaz. des Hop., 1865. Raynaud : Nouveau Diet., 1868. Douglas : Polypoid Tumor Heart, Edin. Med. Jour., 1868. Bouillaud: Arch. Gen., 1823. Corvisart: Essais sur les Maladies du Creur, p. 172. 1806. Decorniere: Endocard. Puerperale. Paris, 1869. Ibid. : With Card. Thrombosis, Med. Record, November 7, 1885. Stevenel: Des Myocardites, These de Paris, 1882. Morgagni : Epist. iv. Beverley Robinson : These de Paris, 1871. Thrombosis in Diphtheria. Meigs: Ibid., Am. Jour. Med. Sciences, 1864. Ibid., With Recovery, Arch. G6n., 1884, t. i. Aran: Arch. G6n., 1844. Despres: Ibid.. 1864. Faure: Ibid., 1864. Richardson : Med. Times and Gaz., 1873. Watts: In Acute Endoc. London Med. Gaz., 1844. Dawson : Med. Times and Gaz., 1873. Fayrer : Ibid, (after Urethral Fever). Whipham : Lancet, 1873. Weigert: Arch. Virch.. Bd. 79. Virchow: Handbuch, 1854. Charcot: Mem. Soc. Biol., 1854. A. Schmidt: Pfliiger's Archiv., Bd. v., 1872. Hammarsten: Ibid., Bd. 14, 1877. Mary Putnam-Jacobi. 1 Morgagni: Epist. xxiv. 2 Grisolle: Traite de Path. Interne, t. ii., p. 390. 3 Laennec : Traite d'Auscultation, 1826. 4 Diseases of Heart, 1854, p. 120. 5 Meigs, Am. Jour. Med. Sciences, 1864. Beverley Robinson, These de Paris, 1871, Thrombose Cardiaque dans la Diphtheric. 8 See interesting case by Watts, London Med. Gaz., 1844. 7 Herard, Gaz. des Hop., Juin 15, 1865. B Coagul. Blood, Prize Essay, 1856. 9 Ueber die Faserstoffgerinnung, Pfliiger's Arch., Bd. v. and vi. 1872. 10 Pfliiger's Archiv, Bd. 14, 1877. 11 Arch. G6n. 1864. 13 Loc. cit. 13 Fredault: Arch. Gen. 1847. 14 Raynaud : Nouveau Diet, de Med., art. Coeur. 16 Irvine : Path. Trans., Loudon. 1880. 16 Bull: Soc. Anat., October, 1875. 17 Richardson: Loc. cit. 16 Quoted by Robinson, loc. cit. 19 Personal observation. 20 Ibid. 21 Fourth Case by Meigs, loc. cit. Bibliography. HEART, VALVES AND ORIFICES OF, CONGENI- TAL AND ACQUIRED DISEASES OF. Under the term valvular disease are included those changes in the valves or the heart itself which result in an impediment to the onward flow of blood through one or more of the cardiac orifices-stenosis-or in the establishment of a back cur- rent through the same- regurgitation. Etiology.-Valvular disease is sometimes congenital, and is then generally found on the right side of the heart, which, during foetal life, furnishes the greater part of the power for carrying on the circulation. A full discussion of all the congenital changes which have been observed would be out of place here ; with few exceptions, they are incompatible with any but the briefest life, and hence do not come under the notice of the practising physician. These exceptions, however, are extremely interesting and deserve brief attention. Congenital valvular disease has two modes of origin, malformation and inflammation, which latter may occur, even primarily, in foetal as well as in extra-uterine life. It was Rokitansky who origi- nally called general attention to the important part played by foetal endocarditis, to which he subordinated malfor- mation, stricto nomine ; his later researches, however, led him to change his views on this point, and re-establish malformation as the chief etiological factor. Endocar- ditis may be primary, but is usually secondary, and is especially prone to attack an orifice the normal develop- ment of which has been interfered with. It is an aid to the proper understanding of these malformations to re- member that at a very early stage of development the heart is represented by a simple tube, as it were, con- nected with a single vein below, and a single artery above. This common arterial trunk is then subdivided into the 583 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. very serious changes without attracting the notice of the physician or the patient; it is unattended by pyrexia, and may originate in an acute or subacute attack, or arise in- dependently, or be due to an extension of the atheroma- tous process from the ascending aorta to the aortic valves. A slow connective-tissue growth is set up, which follows the general law- of such tissue and contracts with age. The valves thus become stiffened, distorted, the seat of calcareous degeneration, and thus unfitted to perform their functions. Like changes may take place in the pap- illary muscles and chordae tendineae. This form of dis- ease, when of rheumatic origin, is more likely to attack young people, and the mitral valve ; when connected with atheroma, affects rather the aortic valves, and is found in persons whose tissues are degenerating from age, excesses, gout, or other causes. The above rule is, how- ever, by no means absolute. Syphilis is much more apt to be manifested on the parietal than on the valvular en- docardium. In gout the urate deposits are found some- times in the substance of the thickened valve. In chorea, the exact relationship of which to rheuma- tism still remains an unsettled question, the disturbance of the heart sometimes does not pass off with the convul- sive movements, but remains in the form of genuine valvular disease. According to Fagge, the changes which may be found in the valves in fatal cases of chorea, are indistinguishable from those of acute rheumatic en- docarditis. ■ There is no question that a healthy valve or valve-seg- ment may be torn from its attachment to a greater or less extent, by sudden and violent strain. The case is not so clear as to the direct effect on the valves of long-con- tinued and oft-recurring strain, the close connection of which with functional disturbance of the heart, and nu- tritive changes in its ■walls, seems to have been well estab- lished by Da Costa, Seitz, and others. Some authorities- Allbutt, Fothergill, Rosenstein-maintain that the in- creased violence with which the valve-segments are closed in the hearts of some classes of laborers-hammermen in foundries, for instance-sets up atheromatous and sclerotic changes, especially in the aortic valves. Peacock reports that mitral disease is much more common in the miners of Cornwall than in those of the North of England, and, as their manner of life is nearly identical in other respects, attributes this to the fact that the former are usually compelled, at the close of an arduous day's labor, to reach the outer air by climbing up ladders, sometimes the work of an hour. The latter, on the other hand, work in mines with a nearly horizontal shaft, or are brought out by mechanical means. If these views are correct, it is diffi- cult to understand why we do not meet with similar changes in the pulmonic valves in cases where obstruc- tion to the circulation at the mitral orifice or in the lungs has long been compensated by an hypertrophied right ventricle. Valvular disease is certainly much more common in men than in women, a fact which tends to show that ex- ertion may be a factor in its production. In Bright's dis- ease strain is brought to bear on the heart in another way, but there are other factors, such as the altered condition of the blood, not to be left out of account in considering the affection of the valves which so often accompanies this malady, especially the chronic interstitial form, with its increased arterial tension and enlarged left ventricle. Regurgitation may be brought about purely mechani- cally, without any structural changes in the valve save enlargement, temporary or permanent, of its ring of at- tachment ; dilatation of the commencement of the aorta may thus be the cause of incurable aortic regurgitation ; dilatation of the great cavities of the heart of mitral and tricuspid insufficiency. Finally, there remains a certain number of cases in which a cause for valvular disease cannot be assigned, at all events in the present condition of our knowledge of the subject. The Morbid Anatomy of valvular disease is essenti- ally that of endocarditis, the products and effects of which are the same in foetal life as after birth. The mass of vegetations in the interstices of which are deposited leu- cocytes and fibrinous material, and which iu typical cases so much resembles a cockscomb, may obstruct the blood- current or interfere with the closure of the valves ; ul- ceration may break the valves down, separate the segments more or less from their attachments, or form valvular aneurism ; while in the more chronic forms the cur- tains, thickened, fused, and distorted by connective-tissue growth, or unyielding from calcareous degeneration, readily give rise to stenosis and regurgitation in every conceivable degree. The changes in the valves, however, necessitate other and secondary changes in the heart itself, other organs, and the body as a whole. These secondary effects will now be considered generally, the special peculiarities be- ing reserved, as far as possible, for discussion in connec- tion with the special lesions with which they are asso- ciated. The Heart.-Whether the onward flow of blood is impeded at any orifice, or whether blood flows back again into a chamber which it has once quitted, the immediate and general effects are identical, namely, an abnormal distribution of the blood, which accumulates behind the seat of the lesion, and is insufficiently supplied to those parts beyond it. The pulmonary capillaries being very large and not furnished with vaso-motor nerves, readily dilate under heightened pressure and allow the transmis- sion of this pressure to the venae cavae, and thus to the whole venous system. A valvular lesion then, in a word, causes primarily increased venous, and diminished arterial, pressure with, as a necessity, consequent slowing of the circulation-a condition of things which must go on from bad to worse, unless what is known as "compensation" is speedily established in more or less perfection. The features of compensation vary somewhat with the condi- tions to be met and the obstacles to be overcome ; but it may be described in general as such an increase in the power, or power and capacity of the heart combined, that the arteries are filled, the over-distended veins relieved, and a new balance of the circulation struck ; a balance which is more or less perfect and lasting according to the seat and degree of the lesion, its progressive or non- progressive character, and the demand for heart-power on the part of the individual. Hypertrophy of the cardiac muscle is thus the postulate of a restoration of the equi- librium of the circulation, and, if this is attained, under favorable circumstances a long period'may elapse before the effects of the valvular disease extend materially be- yond the heart itself. Indeed, in rare cases, where the injury to the valves is slight, the general nutrition good, and the patient so situated that he can maintain it without at the same time overtaxing the heart in any way, and the injury remains stationary, life may not be shortened even by a day, the end coming at advanced age, through other disease which has not been so much as accelerated by the old lesion, as far as we can see. This is not, however, the rule. The lesion was originally so grave, or the patient's recuperative powers such that compensation could not be perfect at first; the lesion is slowly progres- sive or intensified by one or more relatively acute attacks; the muscular structure of the heart becomes the seat of inflammatory or nutritive changes ; arterial degeneration calls for still greater heart-power, and perhaps invades the coronary arteries themselves; intercurrent disease, especially in the lungs, excessive muscular exertion, a faulty manner of life, poverty, anxiety, and the like, make demands on the heart already deprived of some of its reserved force, or impair the general nutrition-through such means the compensation is ruptured. Under rest and suitable treatment a fresh balance may be struck at a level more or less below the first, and for a time every- thing may be quiet. Again the compensation gives out, and may possibly again be restored, but sooner or later the limit is reached up to which repair is possible. Any- thing like compensation is permanently lost and, more or less slowly, the action of the heart ceases altogether. Following Beau, cardiac failure is termed asystolie by the French writers. In direct consequence of the slowing of the circulation thrombosis may occur within the heart, especially in the auricles and auricular appendages, whence a portion of 584 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. the thrombus may be swept off in the blood-current and plug a branch of the pulmonary or general arterial sys- tem, according as the embolus is derived from the right or the left heart. Embolic infarction of the lungs may be single or multiple, and does not necessarily give rise to any symptoms, but it often occasions sudden dyspnoea, pain in the chest, more or less bloody expectoration, and a slight chill (Rosenstein), although it is rarely attended by fever. A benign embolic infarction not infrequently is absorbed and leaves only a pigmented cicatrix behind it. Septic emboli, however, derived from an ulcerative endocarditis, produce multiple small abscesses as well as larger infarctions, which latter may become gangrenous and, by breaking through into the pleural cavity, cause pneumothorax. Embolism in the general arterial system originates not only in cardiac thrombosis, but also in papillary endocarditis, portions of the vegetations be- coming detached. The results, however, are the same. Embolism of the brain is apt to be followed by hemi- plegic symptoms. Of the internal organs, the spleen and kidneys are the favorite seats of infarction, the occurrence of which may be betrayed by sudden and severe pain in the region of those viscera, but is very frequently per- fectly latent as far as symptoms are concerned. Haema- turia and a subsequent transitory albuminuria are some- times encountered. The plugging of a main trunk of an extremity may give rise to gangrene of the part; or thrombosis may result from the sluggish venous circula- tion in the territory of the plugged artery, and a portion of the thrombus, becoming free, may stop a large branch of the pulmonary artery, or even that vessel itself. As in the lungs, so in other organs suppuration very rarely takes place in and about a cardiac embolus, except in septic cases. In mitral disease especially, the lungs are scarcely less immediately exposed than the heart itself to the conse- quences of a damaged valve. The venous congestion of these organs gives rise to dyspnoea in every conceivable degree. Moderate congestion shows itself also by a dry cough, or by a bronchial catarrh with expectoration, and sibilant and sonorous rales, to which the signs of pulmon- ary oedema are added as the congestion increases. Hae- morrhage from the bronchial mucous membrane may oc- cur, or the greatly distended blood-vessels may rupture and pour out their contents into the tissue in the form of the haemorrhagic infarction or pulmonary apoplexy, not to be confounded with that produced by embolism, though an anatomical distinction cannot be made with certainty in every case. ' Here, too, there may be bloody expectoration ; and inflammatory or necrotic changes in and about the infarction, though still relatively rare, are more common than with benign embolic infarction. The extent of the lesion, and its situation as regards the sur- face of the lung, are the main points which determine the presence or absence of physical signs. If the con- gestion lasts a long time the capillaries in the alveolar walls become ectatic, project into the lumen of the alveoli, and thus encroach upon the aerating surface of the lung. In consequence of the chronic hyperaemia there is increased growth of the connective tissue, and small capillary haemorrhages taking place, the blood pigment is deposited, not only in the connective tissue, but also in the alveolar cells. The lungs thus become more dense and acquire a peculiar color, brown induration, so-called ; with this more or less emphysema is usually combined, the result of the labored respiration. (Edema of the lung is generally associated with serous transudation into the pleura-hydrothorax-which is bilateral, though apt to be greater on one side than the other. The Liver.-The venous stasis in this organ may cause considerable enlargement, the edge extending even below the level of the navel, and producing often a marked subjective sense of fulness and discomfort at the epigas- trium. This enlargement is apparent rather than real, there being atrophy of the liver-cells from pressure and fatty change. If the congestion is of some duration, that combination of fatty degeneration and passive hyperaemia known as the ' ' nutmeg " liver results. Catarrh of the bile- ducts may interfere with the flow of that fluid and intensify the difficult digestion produced by the congestion of the whole portal system. The swelling may be so great in the common bile-duct as to lead to jaundice from obstruction. The combination of moderate icterus and cyanosis pro- duces a peculiar green coloration of the skin, the upper portions of which change to yellow after death, the blood gravitating downward. In the rest of the portal system the effects of passive con- gestion are often very marked, especially in the produc- tion of distressing disturbances of digestion. A catarrhal condition of the mucous membrane of the stomach pre- vents the proper secretion and action of the gastric juice ; flatulence is thus favored, the diaphragm pushed up, and the heart interfered with in a way which it is apt to re- sent even in the healthy state. A simultaneous deficiency in the bile favors intestinal decomposition and flatulence ; the bowels are usually confined, but we may, in the later stages, meet with serous diarrhoea. The congestion may be temporarily relieved somewhat by bleeding from hae- morrhoids, and haemorrhage sometimes takes place even from the gastro-intestinal mucous membrane. In women, if there be great venous fulness, menorrhagia or metror- rhagia occurs, but if the general blood mass is small there is usually amenorrhoea. In both sexes alike nose-bleed is not infrequent, and may be so severe as to require plug- ging of the posterior nares. The Kidneys.-The secretion of these organs furnishes us with most valuable evidence as to the condition of the circulation and the relative tension in the arterial and venous systems. One of the first results of decreased ar- terial tension is diminution in the volume of the urine, which becomes high-colored and deposits lithates freely, the excretion of solids remaining about the same. Here matters may rest for a time as far as the kidneys are con- cerned. But if the venous stasis be more than very moderate in degree there is transudation of albumen, and casts may be found on microscopic examination. A very few red blood-disks may also be found, but haematuria indicates something more than mere passive congestion (Rosenstein). The amount of the albumen depends largely on the degree of hyperaemia, unless secondary acute in- 'flammation has been set up or the patient is near his end. Passive congestion is,' therefore, characterized by a di- minished amount of urine, with a high specific gravity and a moderate amount of albumen, an association not apt to be met with in other conditions of the kidney. As in other organs, so here, long-continued hyperaemia sets up connective-tissue growth, and we consequently find in long-standing cases a somewhat granular kidney. Life is rarely sufficiently prolonged for the production of the typi- cal kidney of interstitial nephritis, the origin of which is the same as, or antecedent to, that of the hypertrophied left ventricle and secondary valvular changes which ac- company it. Infarction, characterized occasionally by haematuria, has already been alluded to. As regards the nervous system, it is chiefly in the brain that important changes secondary to valvular disease are found. Embolism has been already mentioned. Apo- plexy may be the cause of death in aortic disease, the degenerated cerebral vessels being unable to withstand the strain put upon them by the hypertrophied left ven- tricle. In death from gradual cardiac failure there is often some oedema of the brain, the venous congestion leading to which may cause confusion of ideas and som- nolence, though the urgent dyspnoea banishes sleep or permits it only in brief snatches. Uraemic convulsions sometimes occur; so also that peculiar change in the respiratory rhythm, called "Cheyne-Stokes' respiration." In aortic stenosis particularly, fainting fits, relieved by a low position of the head, are directly traceable to defec- tive arterial tension. (Edema, first noticed toward the end of the day, be- gins at the ankles, the parts farthest removed from the centre of the circulation, and where, in the erect posture, the force of gravity comes most into play. Thence it may extend up the legs to the genitals and invade the whole subcutaneous cellular tissue, but is always most marked in the dependent portion of the body, appearing in the face to any extent only in extreme cases. The 585 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nutrition of the skin is then so impaired that large blebs may form, and be followed by an erysipelatous blush, suppuration, and sloughing. Bed-sores are liable to form on parts where constant pressure is exerted. Serous transudation also takes place into the cavities of the peri- toneum, pleura, and pericardium, aggravating, but often at the same time shortening, the period of suffering. More or less dyspnoea is always present in cardiac fail- ure, even before the above-described changes in other organs have appeared, readily explained by the sluggish circulation in the lungs. The degree of the dyspnoea differs, of course, widely in different cases and in differ- ent stages of the same case. More or less orthopnoea may appear comparatively early, and in the later stages the patient is often compelled to pass many nights in succession in a chair, bringing into play the accessory muscles of respiration. Cyanosis is also present in varying degree ; from the faint bluish tinge about the lips, noticeable only by the trained eye, to a general purplish hue of the skin and visible mucous membranes, which could not escape the most unobservant. Coldness of the extremities is more or less marked. All these signs and symptoms depen- dent on serous congestion appear earlier and are more strongly marked in cases of mitral than in those of aortic disease. In the latter, when compensated, for a long period there may be no difficulty of breathing whatever, even on exertion. I have known a man with free aortic regurgitation and massive hypertrophy amuse himself when camping out in summer with his companions by matches in swimming under water. Not only does the powerful left ventricle tend to preserve the normal ten- sion in the arterial system and thus supply the vis-a-tergo to the capillaries and veins, but in aortic disease sudden death-from apoplexy, for instance-is not very uncom- mon. If, however, the end is reached through gradual failure of the heart, the mitral and subsequently the tri- cuspid valves yielding to the increased dilating force and becoming insufficient, the steps of descent are essen- tially the same. For this reason scarcely any distinction has thus far in this article been drawn between the two sets of lesions. In aortic disease failure is apt to be longer delayed, but to run a shorter course when it does set in. In mitral disease, on the other hand, even when the compensation is good, moderate exertion is apt to cause difficult breathing. Air enters the lungs freely enough, but the proper interchange between it and the blood is impeded. The subjects of this form of disease are therefore more curtailed in their manner of life. But little remains to be added as to the symptoms of valvular lesions in general. Palpitation depends rather on faulty innervation, upward pressure of the diaphragm from abdominal distention, dyspepsia of gouty or other nature, and the like, than on the injured valve itself. Palpitation may indeed be said to cause more distress in functional than in organic heart disease, as a rule. Pain is inconstant and subject to no rule. Angina, when pres- ent, is usually associated with aortic lesions and degener- ative changes in the heart-wall, the coronary arteries, and the aorta. The picture of a patient dying from gradual cardiac fail- ure, with general dropsy, is strongly marked and impresses itself on the memory in all its distressing features. But when the compensation is merely disturbed for any cause, or only beginning to fail, an accurate diagnosis is scarcely possible without the physical signs elicited by a careful examination of the heart itself. In aortic disease, espe- cially with perfect compensation, the lesion may be dis- covered accidentally, its existence being suspected by neither the physician nor patient. It is a curious fact that the very forcible action of the heart in such cases should sometimes in itself awaken in no way the attention of the individual. We pass on, therefore, to the consideration of the special lesions in turn, chiefly with reference to Diagnosis.-Aortic Stenosis is rarely found alone, be- ing generally combined in varying proportion with re- gurgitation. When the valve segments are so fused that they form a sort of diaphragm with a central orifice, the amount of blood which flows back into the ventricle cannot be very large. The lesion involving an impeded passage of blood from the left ventricle into the aorta, the increased pressure within the former tends to enlarge its cavity, i.e., dilate it. This tendency can be overcome solely by in- creased force of the ventricular contraction through hyper- trophy of the muscle, a hypertrophy which, to be truly compensatory, must be in exact proportion to the degree of the obstruction. Thus the wall of the left ventricle may attain the thickness of an inch. If the stenosis is pure, or nearly so, there is usually but little dilatation, which is measured rather by the freedom of a combined regurgitation. As long as compensation is preserved the left auricle and right heart suffer no material change. The physical condition then being hypertrophy of the left ventricle, and a constriction at the aortic orifice which can be thrown into vibration by the blood-current, the physical signs are as follows : Inspection and palpation show a slight prominence of the cardiac region, an apex- beat lower than, and somewhat to the left of, the normal position, a strong impulse, occasionally a thrill in the sec- ond right interspace near the sternum. Percussion af- fords confirmatory evidence of the increase in the vertical diameter of the heart, and auscultation reveals a systolic murmur of maximum intensity near the sternal border over the second right interspace or third costal cartilage -the aortic area. The murmur is propagated into the aorta and great arterial trunks given off from the arch, and may sometimes be followed down the left vertebral groove a greater or less distance in the dorsal region ; it is apt to be harsh in character and may be musical. The aortic second sound is feeble. Owing to the constriction at the outlet, a longer period is required for the emptying of the ventricle, the pulse is therefore slow, rises gradually under the finger, and, the propulsion-force being in- creased, is hard ; it is generally regular. A typical sphygmographic tracing shows a long and perhaps broken ascent, a blunted summit, and ill defined secondary waves in the descent. The most marked symptoms peculiar to this lesion are attacks of fainting, or even of epileptiform convulsions, attributed to the cerebral anaemia. With good compensation there may be no symptoms whatever for many years, the patient enjoying all the time full bodily activity. Sooner or later, however, even if the condition of the valve remain the same, no other valve becomes diseased, and no severe intercurrent disease dis- turbs the compensation, the walls of the left ventricle di- late, and more or less gradually the signs of venous stasis appear. Aortic regurgitation is found alone much oftener than is stenosis. The atheromatous or inflammatory changes in the valve-segments, which prevent their proper closure as the ventricle begins to dilate and the wave of arterial recoil strikes them, allow a flow of blood backward from the aorta into the left ventricle during diastole. The cavity is thus dilated by receiving a supply from two sources instead of only from the auricle, and in this lesion dilatation is more constant as well as greater in degree than in aortic stenosis. In the former the increased dis- tending force is exerted upon a relaxing, in the latter upon a contracting muscular cavity. At the end of dias- tole the left ventricle contains an overplus of blood which can be so thoroughly expelled as to maintain the propor- tion between the general arterial and venous pressures only through hypertrophy of the wall. Thus is compen- sation brought about. The physical condition is marked increase in the size of the left ventricle from combined dilatation and hypertrophy, dependent on a back current through the aortic orifice causing vibration during dias- tole. The physical signs which betray this condition are prominence of the cardiac region-sometimes very strik- ing-a powerful heaving impulse, and an apex-beat de- cidedly lower than, and more or less to the left of, the normal seat, perhaps in the seventh interspace and the anterior axillary line. The change in the size of the left ventricle brings this portion of the heart forward and downward in the main, increasing the vertical diameter. Percussion verifies the results of inspection and palpation, and shows that the right border is little, if at all, changed. Auscultation gives a prolonged, generally soft and blow- 586 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. ing, murmur throughout the diastole over more or less of the cardiac and immediately adjoining regions. The seat of maximum intensity varies, being sometimes in the aortic area, sometimes below this point over mid-sternum, rarely not far below the clavicle; not infrequently the murmur is comparatively feeble, or even inaudible, in the aortic area, but very loud and distinct about the fourth left costal cartilage. This variation seems to depend somewhat on the thickness of the layer of lung which overlies the heart. The murmur is always propagated downward, in the direction of the current producing it, toward the ensiform cartilage. It may replace or only obscure the second sound, according to its intensity, the transmission of the pulmonic second, and the involve- ment of all the aortic segments, or of only one or two ; it is not heard in the back. The first sound at the apex also varies in character. It may be very loud and boom- ing, somewhat impure, accompanied by a murmur not dependent on mitral regurgitation apparently, but on vi- brations in the valves set up by the very powerful ven- tricular contraction, or it may even be lost altogether. Traube explained the absence of the first sound by the gentle closure of the mitral valve under the heightened intraventricular pressure before the actual beginning of the systole. This lesion and the consecutive enlargement of the heart involve striking peculiarities in the arterial pulse. An increased column of blood is forced into the arteries, distending them unduly ; but the column is not sustained, a portion of the blood returning to the ven- tricle. The distention is, therefore, quickly followed by collapse, due not only to the return of blood, but also to the heightened recoil of the elastic coat; thus, all the visible arteries, and others which are usually not vis- ible, spring violently forward during the systole, and dis- appear as rapidly during the diastole. If, as usually happens after the lesion has existed for a certain time, the arteries have become lengthened and tortuous, a lat- eral movement takes place in them, as may perhaps be most distinctly seen in the brachial, or the temporal, or, with the ophthalmoscope, in the central artery of the retina. Thus, the diagnosis of aortic insufficiency may, in well-marked cases, be made with almost absolute cer- tainty simply after a rapid glance at the patient. The aorta may then become permanently distended and easily felt in the interclavicular notch above the sternum, while atheromatous changes in the arteries generally, as well as in the aorta itself, are favored by the abnormal differences of tension to which they are subjected. The sensation conveyed to the finger placed upon an artery corresponds exactly with the above. The pulse is quick, large, rises and falls away rapidly-the water-hammer pulse, or pulse of Corrigan. By laying the fingers across the wrist firmly the radial and ulnar, and even the interosseous, arteries may simultaneously be felt strongly pulsating. These peculiar features of the pulse may be intensified by raising the arm vertically above the head of the pa- tient, thus favoring the collapse by the addition of the force of gravity exerted on the column of blood between the wrist and the heart. Over the carotids and sub- clavian a systolic thrill may often be felt, and heard as a murmur ; "this is not necessarily due to stenosis, but may be caused simply by the violence of the systole, just as an apex systolic murmur, under similar circumstances, may or may not indicate mitral regurgitation. Over the periphe- ral arteries generally, even those of relatively small size, a systolic sound is to be heard, and in very strongly marked cases a double sound may be present in the crural (Traube). The double sound of Duroziez, not limited to extreme cases, is called forth by exerting pressure on the artery. It will be readily understood that many of the above signs depend directly on the compensatory hypertrophy, and grow less distinct, or disappear, with its decline and fail- ure. A patient with aortic regurgitation has often a ruddy appearance, and can exercise freely without dis- tress. In some cases the lesion seems to be overcompen- sated, and in these especially there may be uncomfortable throbbings and other sensations in the head. It is thought that compensation fails earlier, through innutrition of the heart-wall, in those cases in which the anatomical changes befall the valve-cusps corresponding to mouths of the coronary arteries. A striking and most agonizing symp- tom met with at times in aortic disease is angina pectoris- intense paroxysmal pain in the cardiac region extending down the left arm ; great anxiety and a sense of impend- ing death accompany it when well marked-indeed, it sometimes proves directly fatal. Angina is not especially characteristic of valvular disease, but occurs also in other conditions. In the late Dr. Arnold, the famous head- master of Rugby School, angina was the first and only symptom of a fatty heart with healthy valves, and caused death in recurrent attacks in two hours. Uncombined aortic regurgitation is of all valvular lesions the most strongly marked, and easy of diagnosis. Other termi- nations are in cerebral haemorrhage and general cardiac failure, as already described. Mitral stenosis is found uncombined with insufficiency not infrequently. Whether due to papillary growths, contraction and rigidity of the flaps from connective-tis- sue growth and calcareous degeneration, fusion of the flaps over a greater or less extent, and the production of the "button-hole" and the "funnel-shaped" mitral, or combinations of these conditions, the lesion causes in proportion to its degree an accumulation of the blood and increased tension in the parts behind the injured valve. The feeble walls of the left auricle can do little, and the pulmonary capillaries nothing, to counteract the height- ened pressure ; so it is in the right ventricle that com- pensatory increase in power must chiefly be sought. This portion of the heart is, therefore, dilated and hyper- trophied, the wall at times acquiring a thickness equal to that belonging normally to the left ventricle, and displac- ing the latter in the formation of the apex. When in- cised, the right ventricle may gape open and remain rigid, instead of collapsing, as it usually does in the nor- mal heart. The increase in the left auricle may be suf- ficient to bring it forward immediately under the chest- wall. The left ventricle, in typical cases, is smaller than the normal, the blood-supply and internal pressure being diminished by reason of the contracted orifice; and the aorta itself is sometimes of lessened calibre for the same reason. These last-mentioned changes are most marked in cases of long standing, especially in adults who dur- ing childhood became subject to the valvular disease. In other cases the left ventricle is moderately hypertro- phied, a condition which can be referred to arterial de- generation or contracted kidney, if these changes are present; in the absence of these, Friedreich suggested that the heightened pressure through the veins is transmitted through the capillaries to the arterial system, and von Dusch supposed the stenosis to have arisen subsequently to the existence, for a considerable period, of mitral insuffi- ciency. The physical condition is then constriction of the left auriculo-ventricular orifice, with secondary enlargement of the left auricle and right heart. Inspection shows prominence of the cardiac region only when the disease comes on in early life, but an undulating pulsation is of- ten to be seen over an unusually large area in the region of the apex, and the beating of the left auricle is some- times visible above the fourth rib to the left of the ster- num. The impulse is often fairly strong, but is produced by the right more than by the left ventricle, sometimes exclusively by the former. A well-marked thrill of vari- able duration, but distinctly preceding the impulse, is often to be felt in the mitral area ; this sign is better ap- preciated if the fingers be laid lightly on the part and but little pressure exerted. Irregularity is an indication of defective compensation. Percussion shows an increase in the transverse diameter ; distinct dulness extending toward, and sometimes reaching, the right nipple, and the blunted apex lying farther to the left than in health. Any notable increase in the vertical diameter, with low- ered apex-beat, points to enlargement of the left ventricle. On auscultation at the apex, or midway between that point and the left sternal border, in clear cases, a vibra- tory, or even blubbering, murmur may be heard, either throughout the diastole or limited to that portion imme- diately preceding the systole-presystolic ; in either case 587 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. it ceases abruptly before the first sound, which is apt to be, in pure cases, short, sharp, and similar to the second sound. The presystolic, or auricular systolic, murmur is explained as follows : The flow of blood into the left ven- tricle during diastole is relatively, though not absolutely, passive, the ventricle exerting a certain suction-force ; the current may, however, not be sufficiently strong to throw the diseased mitral currents into vibration. But at the end of diastole the left auricle, increased in size and power, contracts upon its contents and momentarily raises the blood-pressure so that a murmur is produced. The murmur of mitral stenosis is never propagated far from the seat of origin, and is sometimes strictly lim- ited to a very small area. It may be inaudible when the patient is at rest, but distinctly present after exertion. [Sometimes, again, and these are the cases in which the diagnosis may be difficult, no murmur at all is heard, even after exercise or on change of position of the pa- tient. In the same case the murmur may be distinct at one time, and entirely absent at another. In the absence of murmur much importance should be attached to a re- duplication of the second sound, especially when com- bined with irregularity in the heart's action. In still other cases the presystolic murmur seems to be repre- sented by a slight thump not easy to describe, but quite characteristic, just preceding the first sound. While compensation lasts the pulmonic second sound is accent- uated, in consequence of the heightened pressure in the pulmonary circuit. Broadbent divides mitral stenosis into three stages : In the first the characteristic murmur is present with pul- monic accentuation, and sometimes reduplication of the second sound ; furthermore, the second sound is audible at and beyond the apex. With this condition of affairs he has never known serious symptoms to arise from the heart. The second stage is marked by the disappearance of the second sound at the apex, and by a change in the character of the first sound, which acquires the charac- teristics of the second ; in this stage symptoms referable to the heart are present. In the third stage the presys- tolic murmur disappears, and the sole remaining sign of the condition of the valve, present at or near the apex, is the loud, short, sharp first sound, with or without a tri- cuspid systolic murmur; in such cases the state of the heart may be entirely overlooked, although the danger is imminent. The same observer remarks on the frequent absence of dropsy in mitral stenosis; indeed, careful students of heart disease have long been struck by the apparent ca- priciousness of dropsy in valvular affections, and Walshe thought that there must be some active cause, apart from and outside of the heart, which has a large share in de- termining serous transudation. Broadbent thinks that cyanosis and dropsy, occurring in mitral stenosis, indicate tricuspid regurgitation as a complication. To produce dropsy, pressure in the capil- laries as well as obstruction in the veins is required ; the capillary flow may be sluggish, but transudation through the walls does not occur unless there is vis a tergo in the arteries, and this depends on the left ventricle, which in mitral stenosis is small, and, owing to the constriction, receives a defective supply of blood. Some writers dwell upon irregularity of the pulse as more common in, and more characteristic of, the lesion under discussion than of other forms of valvular disease. In the experience of the writer, this feature is indicative rather of faulty innervation or of disturbed compensa- tion ; if the latter is good, the pulse in mitral stenosis is not remarkable for irregularity. In consequence of the smallness of the left ventricle, the arterial tension is low and the pulse small; it is also apt to be somewhat quick- ened in rate. With good compensation the patient is gen- erally pale; with poor or defective compensation he is more or less cyanosed. Mitral insufficiency is by far the most common of val- vular lesions, and is found uncombined with stenosis in a fair number of cases. The secondary effects on the heart itself are the same in kind, whether the flow of blood through the left auriculo-ventricular valve be ini- peded during diastole, or whether a portion of the blood which should be propelled into the aorta finds its way back to the left auricle, which then is supplied from two sources instead of one. It is true that in pure regurgita- tion enlargement of the left auricle does not often reach the extreme degree which it does in marked stenosis ; and the left ventricle, in cases of mitral incompetence, is usu- ally dilated and hypertrophied, although its -work would seem at first sight to be diminished. This latter fact has been explained by the augmented energy and volume of the current into the ventricle, the cavity of which is thus dilated; but, at the same time, the muscle is stimulated into increased action, the result of which is hypertrophy. The physical condition is then a back current through the mitral valve during the systole, and enlargement of the heart predominating in the left auricle and the right ventricle. On inspection, the praecordium may-espe- cially in young subjects with yielding chest-walls-or may not be prominent, according to the degree of cardiac enlargement; and an impulse, stronger though perhaps not less extended than in stenosis, may be seen and felt. In pure cases the apex-beat is not often lower than the sixth interspace, but may be well outside of the nipple. Epigastric pulsation is, as in stenosis, also often marked, the action of the right ventricle being transmitted through the diaphragm to the left lobe of the liver and the neigh- boring parts. Percussion shows the increased size of the heart, dulness extending sometimes nearly to the right nipple. On auscultation, a systolic murmur replaces, or more or less obscures, the first sound, is loudest at or near the apex, and is propagated toward the left, often as far as or beyond the lower angle of the scapula. In some cases it may even be followed completely round the chest. During compensation the pulmonic second sound is ac- centuated. The pulse is not proportional in strength to the apex-beat, a portion of the blood intended for the peripheral arteries returning to the auricle. It is soft, and regular in proportion to the efficiency of the new balance of the circulation. In failure it becomes irregular and intermittent, often to a very high degree. There is noth- ing thoroughly characteristic about the pulse tracing, though the sphygmograph will detect irregularity sooner than the finger. Patients with mitral disease are pale, but free from cyanosis as long as compensation is satis- factory ; as this fails, pain in the cardiac region, cyano- sis, pulmonary congestion, and oedema come on, and the pulmonic accentuation is lost. Over-distention of the right ventricle causes incompetency of the tricuspid, the signs of which will be considered shortly, and after this a fresh balance of the circulation is rare, though not inevitably unattainable. Valvular disease of the right heart is so rare in most of its forms that a much more cursory description will suf- fice. Primary changes here are usually congenital, though in rare cases an endocarditis of the left heart attacks also the tricuspid valve. Atheroma, so common in the aorta, is almost unknown in the pulmonary artery, certainly to such an extent as to produce deformity of the valve. Our knowledge of the diagnostic signs of pulmonic lesions is, therefore, somewhat theoretical, being derived largely by analogy from the signs which we know to be distinctive of valvular changes in the left heart. That such reason- ing is not unwarranted is proved by the fact that an exact diagnosis has been made in certain instances. Schrotter, for example, detected during life insufficiency and steno- sis of the pulmonary artery, which was confirmed by the autopsy, and was caused by the pressure of a large aneu- rism of the ascending aorta. In stenosis of the pulmonic orifice the signs should show enlargement of the right heart-a low degree of which may suffice in congenital cases, relief to the ventricle coming from patency of the foramen ovale or defective septum ventriculorum-and a systolic murmur in the pul- monic area not propagated into the carotids or subcla- vians. Regurgitation through this orifice should manifestly also show right-sided enlargement, with a diastolic murmur in the pulmonic area, or over mid-sternum, propagated downward. All the characteristic signs in the peripheral 588 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. arteries associated with aortic insufficiency are, of course, lacking, and the only danger is in confusing the murmur with that of mitral stenosis. Tricuspid Stenosis.-According to Rosenstein, no case of this lesion uncombined with other valvular lesions is on record ; in combination it is more common than has until recently been believed. Fenwick has collected seventy cases, and in every one of these there was mitral stenosis also; in twenty-five per cent, of the cases aortic stenosis was likewise present. In fifty per cent, of the cases there was a clear history of rheumatism ; nearly all were in patients more than twenty years of age, and sixty two of them were females-all of which points speak against the con- genital origin of the lesion in these cases. Fourteen of the cases collected by Fenwick came un- der the observation of Duroziez, who confesses that in the only case in which he made the diagnosis during life he had no opportunity of verifying it after death. The difficulties of diagnosis are sufficiently obvious. Mitral stenosis in itself results in enlargement of the right heart, and the murmur which it produces occurs at the same time as that due to tricuspid narrowing. In a case re- corded by Hope, there was no murmur at all during life- a fact which should not surprise us when we remember that in a similar condition at the mitral orifice the mur- mur is often absent. Tricuspid insufficiency is of greater clinical importance than any or all of the other lesions of the valves of the right heart. As a primary and the sole valvular change, it is of great rarity ; but as a secondary and mechanical result of mitral disease, through over-distention of the right cavities, it is not very uncommon. In such a case the flaps may be perfectly healthy in structure, but can- not close by reason of the dilatation of the ring of inser- tion. This condition may also result from failure of the right ventricle in cases of great and long-standing ob- struction to the pulmonary circulation, due to emphy- sema, interstitial pneumonia, and the like. The apex- beat, if visible, is more diffuse than is normal, and extends farther to the right; percussion shows transverse enlarge- ment and dulness over the right auricle ; but the pulmonic second sound is not generally accentuated, even if there be concomitant mitral disease. The murmur is systolic in time, is of maximum intensity at the right apex, and is not propagated to the back as is the murmur of mitral regurgitation ; should this lesion also exist, the murmurs may often be distinguished by their differences in pitch and quality. If there is still doubt, this may generally be swept away by careful inspection of the liver and of the veins of the neck, to which we should always turn for confirmatory evidence in these cases. The systolic blood- wave caused by the ventricular contraction is transmitted through the incompetent tricuspid orifice into the auricle, and thence to the contents of the veins emptying there- in. The hepatic veins, being devoid of valves, present no impediment to the wave, and the liver itself may then be felt distinctly to pulsate synchronously with the heart; this sign must, however, not be confounded with the motion which an enlarged right ventricle, separated only by the diaphragm from the left lobe of the liver, some- times imparts to that organ. The internal jugular veins, on the other hand, have valves beyond which the pulsa- tion cannot extend unless they also have become incom- petent, the delicate walls yielding to the greatly increased internal pressure. A true pulsation in the jugulars is to be distinguished from false pulsation and undulation by compressing the vein by the finger ; if the motion be caused by the contraction of the right ventricle, it will per- sist after compression between the finger and the heart, but cease above the finger ; it thus constitutes an important, nay, conclusive, sign of tricuspid leakage. Occasionally the venous valves are seated nearly or quite an inch above the mouth of the vein, and pulsation, while the valves still hold, may then be seen just above the sternum. In cases of mitral stenosis Broadbent thinks that marked oedema and cyanosis point clearly to tricuspid leakage. Combined Lesions.-When the heart is acting rapidly, feebly, and irregularly, it may be impossible to accu- rately differentiate the signs of two or more valvular lesions, but if compensation is fair and the heart pretty steady great precision may often be attained. A more or less acute inflammatory process may attack more than one valve at the same time, or one at one time, another subsequently; the disease may extend by contiguity from the aortic valves to the aortic flap of the mitral ; the mitral and tricuspid valves may become insufficient in consequence of the failure of the compensatory hyper- trophy in the left and right ventricles, respectively. Most murmurs are not strictly limited to the immediate neigh- borhood of their seat of production, but encroach upon the territories of one another ; therefore, whenever there is any reason to suspect that the case is not a simple one, the murmurs must be studied with special care as regards their time, point of maximum intensity, propagation, and pitch and quality; while the secondary effects of each lesion on the size of the different chambers of the heart are borne in mind, as well as the modifications in these changes in dimension necessitated by the combina- tion of lesions. For instance, the left ventricle is larger when regurgitation complicates stenosis at the aortic or mitral orifices than when the latter condition is pure. It should be remembered that in aortic regurgitation, with massive hypertrophy, there may be a systolic mur- mur in the aortic area, propagated into the great arterial trunks without the necessary presence of stenosis ; and a murmur, likewise systolic, at the apex, without mitral regurgitation ; also, that in mitral stenosis there is often no murmur at all. Indeed, it is not as generally recog- nized as it should be, that a murmur in the cardiac region is in itself of comparatively slight significance, being only one link in the chain of evidence which convicts a valve. A few words should be said as to the diagnosis of con- genital valvular lesions. There may be no difficulty whatever in recognizing the intra-uterine origin of the changes, although it may not be an easy, and is often an impossible, task to determine their exact nature and seat. In other cases, chiefly perhaps those attributable to in- flammation rather than malformation, the diagnosis as regards time of origin may be very difficult or impossi- ble, even for the pathologist after death. Endocarditis may attack the left heart before, or the right heart after, birth, though the reverse obtains in the great majority of cases. The whole number of cases of congenital valvu- lar defects on record is not very great-Stolker collected fifty-seven of stenosis and atresia of the pulmonary ar- tery, a number which Lebert thinks could be doubled- and many of them are of comparatively small value, owing to imperfect observation either during life or post mortem. A second difficulty lies in the fact that the murmurs heard in these cases are open to a source of error in their interpretation, from which those belonging to the acquired lesions of independent life are free. We know that the most frequent malformation, stricto nomi- ne, is stenosis of the pulmonary artery, with which-, save in cases where the change is very slight, is combined as a necessary consequence compensatory relief to the circulation by means of an open ventricular septum, or foramen ovale, the passage of blood through which may produce vibration and murmur precisely as through a constricted or insufficient valvular orifice. The his- tory of the case may hence assume greater importance in the formation of diagnosis than in those cases with acquired lesions. In a young person of more or less stunted development, who from earliest childhood has been cyanotic and short of breath, with clubbed fin- gers and toes, and who is free from any history of rheumatism or rheumatic pains, the other physical signs of valvular disease point with almost absolute certainty to lesions of the right side of the heart, dating from intra-uterine life. There are again other cases, widely differing in character from those just mentioned, which can be safely classed as congenital. A young person, namely, may present none of the rational signs of heart disease, and the heart may be but little, or not at all, enlarged, and yet a persistent and very loud murmur may be heard at the base of the heart and more or less over the chest, not attributable to aneurism or any other 589 Heart. Heart. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cause outside of the heart itself. In such cases the de- fect is either a slight one-the loudness of a murmur is no index of its gravity-or the compensation is so perfect that no inconvenience results, perhaps for a long period of time. The murmur is usually systolic, and if con- nected with changes at the pulmonic orifice is not, of course, transmitted into the aorta and its branches ; a thrill can often be felt at or near the base ; true jugular pulsation points to tricuspid insufficiency. To close the chapter of congenital valvular disease, it may here be stated that the prognosis is very unfavorable as regards long life ; bad cases die at or very soon after birth ; others linger for some years, but no real compensation is estab- lished ; others, again, die of tuberculosis or of failure of the compensation, which cannot keep pace with the de- mands of growth at or about the age of puberty ; and a very few reach adult or middle life more or less comfort- ably. Treatment is comprised in the careful carrying out of hygiene in its minutest details. The Prognosis turns on the extent of the lesion, its progressive or non-progressive character, the complete- ness of the compensation, the ability and willingness of the patient so to arrange his manner of life and occupa- tion as to maintain nutrition, and at the same time make no greater demands on his heart than in its more or less crippled condition it can respond to with safety. The extent of the lesion, if compensated, can be pretty accurately gauged by the degree of enlargement of the heart; and the character as regards progression is to be determined by the previous history of the case, or by watching it closely. The degree of the compensation is to be judged by careful consideration of the rational and physical signs, and the general nutrition of the patient. Every healthy individual starts in life with a balance to the credit of his heart, as of each and every other organ. Valvular lesions are, with rare exceptions, incurable, and are thus losses of principal which can never fully be made good. If the patient can be brought to realize this fact, is sensible enough to face it squarely, and is also able and willing to act accordingly, he may live as long as if his heart were sound, provided that some intercurrent disease does not illustrate the proverb that it is always the unexpected which happens. Drasche has re- ported and collected some cases which show conclusively that both aortic and mitral insufficiency may disappear, and it is possible that this happens oftener than is at present supposed. An explanation is thus offered for the contradictory opinion sometimes given by different phy- sicians at different times as to the presence or absence of valvular disease. Aortic disease is not inconsistent with a moderately ac- tive out-of-door life, and may even be benefited by it; as the result of endocarditis in the earlier years of adult life, this form of lesion may be of little or no inconveni- ence for a long period. Mitral disease is less tolerant of strain-, and for that reason partly a rupture in the com- pensation can oftener be restored. In general, the out- look is better if only one valve is affected than if two or more are involved. In combined valvular and renal cases it is important to determine as accurately as possi- ble the condition of the kidneys. Simple congestion of these organs is far less serious than pronounced structural change ; when the heart disease is secondary to that in the kidneys it is almost sure to advance. In every case of valvular disease, especially if there is any evidence of de- fective compensation, the daily quantity of urine excreted should be ascertained, and a careful chemical and micro- scopical examination made as an aid, not only to prognosis, but also to treatment. Moderate oedema of the extremi- ties coming on at night in a patient who is up and about, and disappearing before he rises in the morning, indicates deficient compensation, but is not generally of very seri- ous import. If, however, there is well-marked anasarca, and serous transudation has invaded the internal great serous cavities, the prognosis, though not always hopeless, is very grave. Treatment varies chiefly according as the compen- sation is good, defective, or seriously ruptured. If the compensation is good, there are three ways in which patients come under our notice: they have been under our treatment for the endocarditis which caused the mischief ; the lesion is discovered accidentally; or, led to seek advice by the discomfort arising from de- ranged compensation, they are restored by treatment to their measure of health. In either case treatment becomes almost exclusively hygienic. Plenty of fresh air, nour- ishing but simple food at regular hours and in such quan- tities as can be digested, sleep, warm but light clothing, careful attention to all the bodily functions, and such exercise as experience shows is well borne, are the chief indications. On the other hand, excess of all kinds is to be shunned, as well as anything else which tends to lower the general nutrition or make undue demands on the heart. Anaemia is to be guarded against in every way, as the safety of the patient depends on a well-nour- ished heart-muscle and the predominance of hypertrophy over dilatation. Tobacco, tea, and coffee are better omit- ted, or used with moderation. Young people in America, as a rule, need no wine or alcoholics ; older people may be benefited by wine, or spirit and water, in moderation. Violent emotion, or great excitement of any kind, is to be avoided. An occupation of an interesting kind is very important, as the patient should not dwell upon his dis- ability, and it is certainly better, if the happy mean can- not be struck, that he should overdo a little than that he should find life a burden, and render it such to his friends. It is in the wise adaptation of advice to the cir- cumstances of each case, which always differs from every other case, and in securing the intelligent co-operation of the patient, that the art of medicine largely consists. No routine method will attain the highest success. After a careful study of the patient, his peculiarities, position, and surroundings, it should be our aim to put him un- der the best conditions by him attainable. This involves a course which is not favored by all writers on valvu- lar disease, but which the writer firmly believes to be the true one. The patient, if young or in the prime of life, should, namely, be taken into tile confidence of his attendant, the nature of his trouble explained to him, and the conditions which it entails. The immediate effects may be depressing for a time, but if the patient has any force of character he will soon face the situation and set himself to learning what his limitations are. This requires a little time, like everything else which is worth learning at all. There are some cases, even of mitral disease, in which the above rule is best observed by breaking it; each case must be judged on its own merits. In cases of aortic disease due to atheroma in persons past middle-life the instances are more numerous in which it is advisable to conceal the cardiac condition from the pa* tient himself in whole or in part. At this period the dan- gers, in the upper classes at least, are rather from over- eating and drinking and too sedentary a life than from excessive bodily exertion and over-excitement. There is, moreover, in aortic disease, a more real danger of sudden death than is connected with mitral affections; and in popular language heart disease and sudden death are still almost interchangeable terms. This makes it desirable in many cases to dwell upon the erroneousness of that idea. The expression to the patient of as favorable a prognosis as the case will possibly allow may be regarded as an im- portant aid to treatment. Child-bearing is apt to exert a very unfavorable influence on valvular disease, and, with reference to length of days, it is consequently better for women, as a rule, not to marry. For otherwise healthy men, with good compensation, marriage is not contra- indicated. Even after the establishment or the restoration of com- pensation, it is often desirable to continue the adminis- tration of digitalis for a time in a tonic dose, the period varying with the features of the case. If there be any anaemia, iron in some form is indicated, but must not be allowed to constipate the bowels. That which generally brings patients to the physician is deranged or defective compensation ; manifested by pain in the cardiac region, palpitation, and, especially in mi- tral cases, shortness of breath. The aim of treatment is, of course, to restore the compensation, and the means 590 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart. Heart. through which this end is to be accomplished are rest, careful attention to nutrition, with regulation of the bodily functions and the administration of a cardiac tonic, at the head of which stands digitalis. Rest and suitable diet alone are often quickly followed by remark- able improvement, but the judicious use of drugs not only hastens recovery, but also renders it more lasting. The degree of rest required must be determined for each case, but it is safer to err on the side of keeping the pa- tient too quiet. Strict confinement to bed, with or with- out massage, which, when skilfully applied, aids the cir- culation, is often desirable. Fresh, pure air, and plenty of it, is of the greatest importance, not only as a stimu- lant to the nutrition, but as a relief to the dyspnoea, if present. Where carriage exercise is not admissible, the patient may be covered up in bed or moved gently to a sofa and placed By an open window in the sunshine. It is not as generally understood as it should be, how well a delicate person will bear a sun and fresh air bath of this kind; it makes no difference-save perhaps in the num- ber of wraps-how low the thermometer may be, pro- vided that the sun shines directly on the patient and strong wind can be kept off. Moderate pain in the cardiac region can very often be relieved by belladonna plasters, but if the pain is at all severe, a hot flaxseed poultice, sinapism, or other mild counter-irritant, may be used with benefit. A small blister or two, produced by pouring a little of the strong- est ammonia into a thimble loosely packed with cotton, is sometimes followed by prompt and marked relief, but large blisters are not to be recommended. Pain which is very severe, or does not yield to external treatment, should be met by diffusible stimulants and morphia either by the stomach or subcutaneously. The above re- marks apply rather to dull and more or less persistent pain. Paroxysmal pain of anginous character demands nitrite of amyl by inhalation, .12 to .30 gram(Tf|_ ij. to v.), or nitroglycerine, .060 to .20 gram (TQ. j. to iij.) of a one per cent, solution, or nitrite of sodium, .12 gram (gr. ij.), by the mouth. The effect of the two latter seems to be more lasting than does that of the former. Should the palpitation require separate treatment, bromide of potas- sium often proves serviceable. If the appetite is poor and the tongue coated, a bitter tonic, combined with a mineral acid and a laxative, may be given. For aortic cases with degenerated vessels it is very important to in- sure free and gentle alvine discharges, lest apoplexy be caused by straining at stool. In serious failure of the compensation, with venous stasis and dropsy, minute attention to the general feat- ures is even more imperative, and skilful management is not infrequently crowned with astonishing results. Food is to be given only in the most assimilable form, and often in small quantities frequently repeated. The congestion of the portal system and defective flow of bile impair digestion, and digestion is the key to the situation in many cases. If the patient and his heart-wall cannot be nourished, he cannot hold out long, and gastric or in- testinal flatulence forcing up the diaphragm greatly in- creases his sufferings. If cyanosis and the other signs of venous congestion are very marked, especially if they have come on with relative rapidity, venesection should be done without delay. Under such circumstances the removal of a few ounces of blood may change the whole aspect of the case, the overloaded right ventricle regain- ing the power of propelling its contents. A large vene- section can rarely be productive of anything but harm in the long run, though it may afford temporary relief. The right auricle has been tapped with the aspirator without manifest injury, but this is not a procedure which is likely to be much practised, the same end be- ing far more safely attained by opening a vein. The application of leeches over a swollen liver sometimes acts very well. Free catharsis may produce great relief, even when the patient seems much exhausted, the respi- ration gaining in freedom and the pulse in force in con- sequence of it. Elaterium, .010 to .020 gram (gr. | to |), the compound jalap or scammony powders, 1.30 to 2 grains (gr. xv. to xx.), are effective agents; with the latter may be combined gamboge, .065 gram (gr. j.), if desired. Diaphoresis by means of the hot- air bath, or bottles filled with hot water and enveloped in flannel wrung out of hot water and applied along the legs, is of great service in some cases as a means of re- ducing the dropsy. The best diuretic is generally digi- talis. Alcoholic stimulants should, as a rule, be used in that form which is best borne, though gin has the advan- tage of a distinct diuretic action. It is sometimes good treatment to puncture or incise the legs and allow the serum to drain away in this manner. If the kidneys are sound the fluid is not irritating, and, with careful atten- tion to cleanliness, rarely causes erysipelas or sloughing ; extra safety in this respect can be insured by the use of Southey's drainage-tubes. Hydrothorax or hydropericardium, if considerable, may be tapped without hesitation. Effective stimulation to the laboring heart can often be afforded by the appli- cation of moist or dry heat to the cardiac region. When there is great respiratory distress it is sometimes a very nice question to decide as to the subcutaneous use of morphia, which kills by paralyzing the respiratory cen- tre. The refreshment to be gained by sleep is to be bal- anced against the danger that sleep may lapse into death. It is impossible to frame a general rule. Fothergill finds stimulation to the respiratory centre by strychnia or bella- donna useful in these cases. The use of digitalis has been alluded to several times, but requires more extended consideration. As to the pre- cise manner in which this drug acts on the heart the au- thorities are not unanimous, but that it does in some way aid the action of the organ and increase the efficiency of its contractions cannot be questioned. Some writers think its use is contra-indicated in aortic regurgitation, as by slowing the heart and lengthening the diastole the amount of blood thrown back into the left ventricle is in- creased and dilatation favored. In the opinion of the present writer the indications for the administration of digitalis are to be sought, not so much in the localization or degree of the valvular defect, as in the condition of the compensation-the heart-wall-as shown by the rational and physical signs taken together. Even when the com- pensation appears to be good it is sometimes desirable to give small doses, with a view of maintaining the favorable condition. Where the patient can be watched, .025 to .050 gram (gr. ss. to j.), or its equivalent in the tincture or infusion, can be given thrice daily ; but for continued administration to patients at a distance it is safer to pre- scribe only two doses a day at intervals of twelve hours, as is advocated by Balfour. The danger of saturation is then extremely small, and the drug may be kept up for years if desired. A case of mitral disease very recently came under the notice of the writer in which .030 gram (gr. ss.) was taken for three years, thrice daily, with great benefit. The greater the disturbance of the compensa- tion the more is digitalis needed, and it should be given thrice daily, or every three or four hours, according to the urgency of the case. Different individuals vary so widely in their tolerance of this remedy that it is very difficult to lay down a general rule as to the dosage in ruptured or failing compensation. With a new case it is better, unless there is great urgency, to begin with mod- erate doses and increase them carefully in amount, fre- quency, or both, until the desired effect is obtained, or until there is evidence that saturation is reached or the drug disagrees with the stomach. In every such case the daily quantity of urine should be closely watched, as a most valuable indication of the saturation of the system is afforded by a diminution of the renal secretion. Digitalis is by far the most valuable direct cardiac tonic, but we meet with persons who cannot take it, and cases in which it seems to lose its effect. Of late years the number of known drugs similar to digitalis in action has been much increased. The best and longest known of these are : convallaria (of the extract, .30 to 1, gr. v. to xv.); its ac- tive principle, convallamarin (.016 to .032, gr. | to |); caf- feine or its citrate (.30, gr. v.) ; and helleboreine (.005, gr. -/y). Very recently the sulphate of sparteine (.13, gr. ij.) has been highly recommended by See, and stro- 591 Heart. Heat. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. phanthine by Fraser, who has been experimenting with the African arrow-poison for some years, from which this sub- stance is derived. The drug is still very difficult to obtain in the market, and expensive, but promises to become very useful, and, if this promise is fulfilled, will fall in price. It seems probable that it may have an advantage over digitalis in not acting on the walls of the blood-vessels, but only on the heart, when properly administered. In the above remarks on treatment it has only been at- tempted to give expression to the more general principles by which it should be governed. Full details are impos- sible here, and are not necessary; each case requires its own combination of therapeutic measures. Frederick C. Shattuck. cumstances, however, the physical signs should afford important information. Prognosis.-The prognosis in any form of injury of the heart is always unfavorable-the degree of danger being estimated by the severity of the immediate symp- toms. Recovery, however, is said to have ensued in no less than twelve per cent, of the recorded cases. Bullets have remained encysted in the substance of the heart for as many as twenty or thirty years. Traumatic rupture of the heart is said to have invariably proved fatal. Treatment.-In the treatment of w'ounds of the heart exploratory probing should be scrupulously avoided. The positive indications are : first, to favor the formation of a clot in the wound, with a view of staying further loss of blood ; second, to prevent its displacement when formed; and, third, to watch for and promptly meet symptoms of inflammation. Complete fest, both of body and mind, is indispensable, and should be constantly maintained for days and weeks after all apparent local effects have passed away. Restorative measures should be guardedly employed, in view of the danger of second- ary haemorrhage from reaction. Nervous excitement may be moderated by a judicious use of bromide of potassium, morphia, chloral hydrate, and belladonna. If there is a large blood-extravasation or extensive serous effusion into the pericardium, paracentesis is sometimes demanded, but should be performed with great caution. Alf red L. Loomis. HEART, WOUNDS OF. Although not properly clas- sified with diseases of the muscular walls, wounds of the heart require some mention in connection with such dis- ease, on account of the medical interest attaching to them. Anatomical Characters.-The heart may be wound- ed without any apparent injury to the pericardium, and, conversely, the latter may be wounded without injury to the heart ; but in almost every instance on record both the organ itself and its investing membranes have been implicated. Incised and punctured wounds of the heart may pass either directly or obliquely through the muscu- lar fibres. Bullet-wounds may tear away portions of the organ, either at its borders or from the thickness of its substance. In all varieties of injuries the wound is found plugged with coagula, and its edges are either infiltrated or ecchymosed and torn. The valves and their append- ages are frequently involved in the injury. The right ventricle, from its situation, is the part most commonly wounded ; next in frequency, the left ventricle. The auricles, being protected by the sternum, are least ex- posed to mechanical injury; but when wounded are al- ways penetrated, owing to the extreme thinness of their walls, and yield the most copious and fatal haemorrhage. Etiology.-Wounds of the heart may be inflicted with a great variety of weapons and implements, as well as by projectiles. Foreign bodies, more particularly needles, sometimes enter the tissue of the heart, either directly through the chest-wall or from the oesophagus. Traumatic ruptures and contusion chiefly result from falls, crushing accidents, and blows. Symptoms.-A wound of the heart, when not immedi- ately fatal, is denoted by the following symptoms and signs : pallor, faintness or complete syncope, uneasiness or actual pain about the site of the wound, external bleeding, which may be very slight, even while a fatal haemorrhage into the pericardium is in progress, or more copious, -if proceeding from a wound of an intercostal artery or of the lung ; general anxiety, clammy perspi- ration, and other symptoms of collapse. The sounds of the heart are indistinct; percussion elicits either com- plete dulness or tympanitic resonance, according as the pericardium is distended with blood or air. In the latter case there will be cough and haemoptysis, or haematemesis and passage of blood by stool. The mind is usually clear to the end. After the second day the danger of death from haemorrhage may be regarded as passed. From the second to the fourth day, however, pericarditis is to be apprehended, which may be followed as when occurring idiopathically by serous effusion, adhesion, suppuration, or ulceration. Penetrating wounds, if not immediately fatal, may give rise to endocarditis, and, more remotely, to disorganization of the valves, to softening and ulcera- tion of the heart, or to aneurism of its walls. Finally, embolism of the systemic or pulmonary arteries may likewise arise from this cause. Diagnosis.-Wounds of the heart can usually be recog- nized without difficulty by the situation of the external injury and the severity of the symptoms. But whether the cardiac fibres have actually suffered is a point not always easy to determine, since the symptoms may point to that conclusion and yet the organ itself have wholly escaped. On the other hand, the right ventricle has been penetrated without the occurrence during several weeks of collapse or any alarming symptom. Under these cir- HEAT, ANIMAL. To the touch some animals are warm, others cold. Relying on this rough test, it has, from ancient times, been the custom to divide animals into two groups, the cold-blooded and the warm-blooded. In this division mammals and birds compose the latter group, while the former comprises the remainder of the animal kingdom.- A scientific expression was given to this fact by Bergmann, when he showed the essential dif- ference between the contrasted groups to be that the cold-blooded animals varied their temperature with that of the surrounding medium, while the warm-blooded ones maintained a constant temperature which was independent of it. In accordance with this view, he called the former poikilothermous, or those with a changeable temperature, and the latter homoiothermous, or those with a constant temperature. This expression represents the truth, for we shall later see reason to believe that, under the ordi- nary conditions of existence, all living matter has a tem- perature above that of the surrounding medium, and the only good ground for a division according to temperature is based on the observation that in some cases, e.g., mam- mals and birds, the organisms are so constituted as to be able to keep their body temperature constant. Thermometry.-The temperature of a body is the re- sultant of the heat received by the body, or generated within it, and that lost. Of the means for measuring temperature we can here give but a rudimentary account. (Vide Thermometer.) Temperatures are taken with ther- mometers, the forms and principles of which vary. In biological work the ordinary mercurial thermometers are most used. Where very fine differences are to be ob- served the metastatic thermometer of Walferdin is em- ployed. For yet smaller differences the thermo-electric method is applied. For getting the temperature of vari- ous cavities within the living body, Kronecker and Meyer made use of tiny "overflow" thermometers, and several devices have been introduced for obtaining a continuous record of temperature for twenty-four hours or more. Temperature of Lower Forms.-The temperature of living matter has its ultimate physiological source in the metabolic activities of the organism. As these activities be- come more intense, or as the mass of the organism in which they occur increases, they become easier to demonstrate. The actively growing parts of plants range from 0.1° to 0.01° C. (0.1*8 io 0.018° F.) above the air. Gavarret gives the difference of temperature in certain invertebrates over that of the medium in which they were as follows: Crustacea 0.6° C. (1.08° F.). I Echinodermata. 0.40° C. (0.72° F.). Cephalopoda... 0.57° C. (1.02° F.). Medusa;.. 0.27" C. (0.48° F.). Other uiollusca. 0.46° C. (0.82° F.). | Polypi ...'. 0.21° C. (0.37° F.). 592 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heart* Heat, It must be kept in mind that for all organisms there is an optimum temperature, namely, one at which the meta- bolic processes are most successfully carried on. Below this, metabolisms are depressed ; above it, they are first stimulated and then depressed. As the heat production and the consequent temperature depends on this process, it follows that in the case of poikilothermous animals, with a temperature below the optimum, the difference be- tween the temperature of the organism and that of the medium gradually diminishes, while, when the temper- ature is raised above the optimum, the increase of tem- perature following the increased metabolism in the ani- mal is less rapid than the increase in the medium, and so the difference again tends to disappear. In certain ani- mals with moist skins, from which evaporation takes place rapidly, the temperature may even become less than that of the surrounding medium. When considering the tables in which is shown the excess of temperature in various poikilothermous animals over the medium, these facts must be kept in mind ; though it is probable that the temperatures at which the observations were made were in the neighborhood of the optimum. The following table has been collated from several sources-Davy, Gavarret, and Kidder1 : Name. Temperature of medium. Temperature of medium. Excess. Excess. Locality. Observer. Celsius. Fahrenheit. Celsius. Fahrenheit. Flying-fish . . . 0.2 0.36 Rectum. Davy. 41 Pike 3.9 7 Cod 4-5.5 7.2-9.9 0.5 9 44 Kidder. Cod 4-5.5 7.2-9.9 2.5 4.5 Venous blood. 4k Hake 5.5 9.9 1.3 2.34 Rectum. 44 Hake 5.5 9.9 5.4 9.72 Venous blood. 44 Eel pout 1.6 3.3 2.88 Rectum. 44 Eelpout 4.94 Venous blood. <4 Dogfish (with young) 5.5 9.9 24 4.32 Rectum. 44 Dogfish (with young) 6.4 11.52 Venous blood. 4 4 Mature young dogfish 5.5 9.9 11.4 20.52 44 44 Frog 0.04-4 ■ 0.072-7.2 Carlisle and Dutrochet. Tortoise 2.78 5 Martine. Tortoise 1.22 1.3 Walbaum. Python bivitastus 10-12 18-21.6 In the folds. Proteus angineus 4.7-10.2 Czermak, Sr. Lacerta viridis 4-7.34 7.2-13.2 With reptiles the poikilothermous animals end, and with birds the homoiothermous begin. Among the birds are found the highest normal temperatures observed. The following table is mainly from Rosenthal : to remove the vagueness which usually adheres to that expression. Some observers have sought to give the tem- perature of man as it would be if, for an instant, the temperature remained constant and the heat were equally distributed throughout the body. This attempt to ex- press the temperature for conditions which never exist is plainly of little value. It is of use, however, to know the average temperature of some one part of the body, for instance, the rectum or axilla ; but when this temper- ature is given it should be exactly designated, and not vaguely presented as the temperature of the body in gen- eral. In the following discussion, where the locality at which the temperature was taken is not specially indi- cated, the rectum is to be understood as the place. Topographical Temperatures.-For the reason just given, topographical temperatures, and specially the tem- peratures of the cavities, are of the most importance. The cavities having the smallest normal variations are naturally to be preferred for determinations. In man these localities are the vagina, urethra (female), rectum, axilla, mouth, fold of the groin, external auditory meatus, closed hand, etc. Holding the thermometer in a stream of passing urine, or putting it in fresh urine, has been recommended as a means of getting the internal tempera- ture, but the method possesses no special advantage. Ob- servations have also been made on the temperature of the stomach and oesophagus in man, by means of flexible electro-thermometers. Temperature of Cavities.-The temperature of the vagina is given by Landois as 38.3° C. (100.9° F.). It is slightly warmer than the rectum, and from 0.5° to 1° C. (1.8° F.) above the axilla. The urethra (female) has a temperature similar to the vagina. The male urethra is liable to very great variations, and hence not suitable for this purpose. The rectum has a temperature from about 37° to 38.1° C. (98.6° to 100.5° F.). Roemer states its va- riations at 1.21° C. (2.17° F.). It is found to be from 0.5° to 1° C. (0.9° to 1.8° F.) above the axilla. It will thus be seen that the vagina, urethra (female), and rectum have temperatures very nearly alike. The temperature of the mouth is given (Landois) as 37.19° C. (98.94° F.), and is stated to be 0.25° to 0.5° C. (0.45° to 0.9° F.) above the axilla (Bacquerel and Brechet). While under ordinary circumstances temperatures taken in the mouth are reli- able, they cease to be so when there are marked and sud- den changes in the surrounding medium. For the axilla Landois gives as the mean of 505 observations 36.49° C. (97.68° F.); Liebermeister, 36.89° C. (98.4° F.); and Wun- Name. Temp. Celsius. Temp. Fahren- • heit. Locality. Observer. Goose Sparrow Dove (caged) Dove (free) Fowl Fowl Dove Fowl Sparrow (young).... Sparrow (grown).... Dove Various little birds.. Swallow 41.7 42.1 42.1 ( 43 ( 43.3 42.5 (42.2 } 43.9 42 41.5 41.67 41.69 42.98 44.03 44.03 107 107.7 107.7 109.4 ) 109.94 j 108.5 107.'.16 1 111 1 107.6 106.7 107 107 109.4 111.2 111.2 Rectum. U it tt u Davy. Prevost & Dumas Depretz. Pallas. From Richet2 the following condensed table is taken. The number of observers whose observations are incor- porated is so large as to make the naming of them im- practicable here. All temperatures were taken in the rectum. Name. No. of Ob- servations. Temp. Celsius. Temp. Fahrenheit. Dog 162 39.25 102 6 Rabbit 204 39 55 103 19 Guinea-pig 128 39 17 102 4 Sheep 39 39 5 103 1 Calf 4 39 5 103 1 Ox 16 39 7 103 4 Hog 13 39 7 103 4 Fox 14 39.2 102 5 Ape 5 38.1 100.5 Horse 78 37.75 99.9 A curious anomaly in mammalian temperature is of- fered by the monotremata. N. de Miklonho-Maclay3 has recently reported the following : Echidna hytrix (aver- age of three observations in the rectum), 28° C. (82.4° F.); Ornithorhynchus paradoxus (average of two observations in the rectum), 24.8" C. (76.6° F.). Temperature of the Human Body.-When speak- ing of the temperature of man, it will be well, if possible, 593 Heat. Heat. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. derlich, 37° C. (98.6° F.). The fold of the groin is some- times used, but it has no special advantage, and gives temperatures like the axilla. The external auditory me- atus is also sometimes used, but its temperature is low and very variable. The closed hand has, according to Roemer, a normal variation of 6° C. (10.8° F.), and so is of little use. Fresh urine has a temperature of 37.3° C. (99.1° F.), and that of the stomach is given by Rosenthal as about the same as the rectum. In the preceding para- graph it will be noticed that the temperature differences stated as existing between two cavities do not exactly tally with the difference as found by subtracting the tem- perature given for one cavity from that given for the other. This is the natural outcome of taking figures pre- sented by different authors. It simply indicates that the result of all such observations is only approximate, and must always be regarded so, even when stated in figures, which often, as in the present case, bear with them an air of perfect accuracy which they do not really possess. Temperature of the Skin.-The temperature of the skin is difficult to obtain, for when the bulb of a thermom- eter is simply laid on the skin it gives a reading which is too low, owing to the rapid radiation ; when it is covered over and kept in position for a long time, then the tem- perature registered is too high. With a thermometer the bulb of which was half covered with a poor conductor and kept in contact with the skin but a short time, Davy found, at a room temperature of 21° C. (69.8° F.), readings between 32° and 35° C. (89.6° to 95° F.) for different parts of his own skin. It is mainly for the value which they have in indicating the manner in which heat is lost by the body that the skin observations are of importance. The temperatures of the symmetrical parts of the body are rarely alike. On the head the weight of evidence indi- cates the left side as the warmer. When inflammatory processes are going on in the deeper parts, the skin over them is said by many observers to show an increase in temperature. The differences do not always occur, how- ever, and are not usually well marked. Temperature of Internal Parts.-Observations on the temperature of the internal parts have been made mainly on the lower animals, but there is every reason to think that the general relations there found apply to man. For certain reasons the greatest interest attaches to the temperature of the blood in the right and left ven- tricles of the heart, for if there was either a marked pro- duction or loss of heat by the blood in passing through the lungs, then there should be a decided difference of temperature in the two ventricles. Since breathing satu- rated air at the body temperature does not affect the rela- tive temperature within the two ventricles, it is inferred that the air is normally almost completely saturated and warmed before it reaches the alveoli; and as the blood is warmer in the right ventricle than in the left, it is also inferred that no heat production of any moment occurs in the lungs. Gamgee has shown, however, that a very slight rise in temperature accompanies the arterialization of the blood. The general result of many researches on this question directly due to the cooling of the blood by the inspired air, but to the fact that the thin-walled fight ventricle lies close to the liver and is somewhat warmed by that gland, while the left is so situated as to have a slightly greater tendency to lose heat. The glands have their temperature increased during their activity, as was long ago shown for the salivary gland by Ludwig and Spiess. The following table is from Rosenthal, the observations being on dogs exclusively . Locality. Temp. Temp. Remarks. Observer. Aorta V. portarum.... V. portarum.... V. hepatica.... V. portarum.... V. hepatica R. heart L. heart V. hepatica V. cav. inf R. heart Liver Rectum Liver Rectum Cel. 38.7 39.2 39.9 39.5 39.7 41.3 39.2 39.1 40.37 ( 38.35 1 39.58 37.7 ( 38.7 1 38.9 39 (40 | 39.9 ( 39.2 1 39.4 Fahr. 101.6 102.5 103.8 103.1 103.4 106.3 102.5 102.3 104.6 101 103.2 99.8 101.6 102 102.2 104 103.8 102.5 102.9 . End of digestion. Beginning of diges- tion. During digestion. Digestion. Claude Ber- nard. J Heidenhain. Jacobson and Leyden. The temperature of the blood is given in the average as 39° C. (102.2° F.). In the internal parts the venous blood is warmer, while at the periphery it is colder, than the arterial. Influence of Climate.-Davy, Brown-Sequard, Ey- doux, and Souleyet observed a rise of body temperature in passing from a temperate climate to the tropics. This rise was at most 0.5° C. (0.9° F.). Boileau explains it as probably due-in the case of Davy at least-to slight fever. According to Landois, observations on more than four thousand individuals show that when one passes from a warmer to a colder climate but little fall in tem- perature takes place, while in passing the other way there is a slight rise. A discussion in the Lancet* 1878, indi- cates that physicians find the temperature of both Euro- peans and natives alike in India, and the same as in England. We may conclude, then, that the proper tem- perature, if influenced at all by climate, is only varied a trifling amount. In the temperate zone the temperature falls 0.1° to 0.3° C. (0.18° to 0.54° F.)in the winter season (Landois). A variation so far within the normal daily variation would have but little significance, however, even if unquestionably demonstrated. Daily Variations.-Within the period of tiwmty-four hours there is a decided variation, which takes place rhythmically. During the day the temperature gradually rises, reaching a maximum about 5 to 8 p.m. ; from this time on it falls gradually, reaching the minimum from 2 to 6 a.m. The following curves are plotted from a table given by Landois : is that the temperature of the right heart is a few tenths above that of the left, but that this difference is not Fig. 1625.-Jurgensen, .... Jager. • Indicates the taking of food. For Jiirgensen at 7, 12 a.m., 3, 7 p.m. For Jager at 7, 12 a.m., 4, 8 p.m. This variation, as expressed by these curves, is prob- ably to be considered as the result of the general condi- 594 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heat. Heat. tions of ordinary life, for when they are reversed, and a man works by night and sleeps by day, the curve is also reversed. From the study of rabbits, Maurel5 concludes that in them, at least, the taking of food is the cause of the rise, for when they are fed during the day the rise oc- curs in the evening, and when fed at night during the next day. He also found that it took some days to make a complete change from a morning to an evening rise. An individual who is working has, as a rule, a higher di- urnal, and a lower nocturnal, temperature than one who remains at rest. Influence of Race.-So far as known, there is no deviation in temperature for the different races of man- kind. Influence of Age.-Several observers have made out a slight variation of temperature according to age. This is probably to be explained in part by the variation in the metabolisms of the body as life advances, and in part depends on unknown causes. The foetus and new-born child are slightly warmer than the mother (Preyer). Af- ter the bath the temperature of the new-born falls, and reaches a minimum about ten hours after birth ; it then rises. Sommer found the average rectal temperature of 101 cases, before omphalotomy, to be 37.72° C. (99.8° F.). After the bath it fell to 37° C. (98.6° F.) or below, and during the following ten days varied from 37.25° to 37.6° C. (99° to 99.6° F.). In infants the daily variations are more considerable than in adults, but less regular. From fifteen to sixty years of age there is a fall of 0.5° C. (0.9° F.). Further observation on this point is much needed. Influence of Sex.-In adults, sex per se has no in- fluence on the temperature, but females, as a rule, have a slightly lower temperature than males, both when new- born and adult. Influence of Exercise.-As might be expected, ex- ercise causes a rise. Obermeier notes a rise of 1.2° C. (2.16° F.) after rapid marching for one and a half hour. Hemig has observed that when lying quiet the tempera- ture in the axilla is some tenths lower than when sitting or standing, and Bonnat8 reports a rectal temperature of 39.5° C. (103.1° F.) in an athlete after prolonged exertion. Other Influences.-Mental exertion has been shown to raise, not only the temperature of the head, but that of the whole body. Menstruation does not affect tempera- ture. Pregnancy does so slightly, especially when ad- vanced, for then, owing to the heat production by the foetus, there is a slight rise in the uterus. During the pains of parturition the temperature rises 0.2° to 0.25° C. (0.36° to 0.45° F.), to fall again during the pauses. The change of atmospheric pressure has no influence on tem- perature which has yet been demonstrated. The temperature of substances taken into the stomach produces but little direct effect. A litre (1.76 pint) of wa- ter at 50° C. (122° F.) would, under the most favorable circumstances, raise the temperature of a man weighing 60 kilos (132 lbs. Av.) only 0.17° C. (0.3° F.). Substances which have a physiological action can, however, produce considerable variation. Strong coffee is stated to raise the temperature after an hour 0.2° to 0.4° C. (0.36° to 0.72° F.). Alcohol causes a fall. The injection of gases into the body cavity of animals has been found (v. Recklinghausen and Simons) to produce a marked lowering of tempera- ture, in some cases amounting to 10° C. (18° F.). The explanation offered for this effect being the changed con- dition of the visceral blood-vessels. Influence of Food.-Ingested material must be con- sidered as a source of animal heat, in so far as it under- goes chemical changes within the body. In the absence of a supply from without, the formed tissues are them- selves oxidized, and thus the temperature is maintained. This being the case, it cannot be determined d priori how much the taking of food will increase the tempera- ture, for the body oxidations are, at present, an uncertain factor, and the influence on them of the ingestion of food is not sufficiently made out. Digesting food first passes into solution, and this process has been determined by Maly1 to be accompanied with the absorption of heat. In accordance with this fact, there has been found a slight diminution of temperature in animals on first taking food, followed by a slight rise above the normal, 0.2° C?"(0.36° F.), corresponding with the period of completed absorp- tion. No direct influence of the taking of food has been made out on the daily variations of temperature in man, owing probably to the complicated compensations above mentioned. A full meal after a fast of thirty to sixty hours causes a rise of temperature, but these rises are not regular, owing probably to this same tendency to compensation. Long-continued fasting, amounting to inanition, does not produce a regularly progressive fall, as will be seen from the following case of a starving cat (Bidder and Schmidt): Fifteenth day without food, aver, temp 38.6° C. (101.4° F.). Sixteenth " " " 38.3° C. (100.9° F.). Seventeenth " " " 37.64° C. ( 99.7° F.). Eighteenth " " " 35.8° C. ( 96.4° F.). Nineteenth " " " (death).... 33° C. ( 91.4° F.). According to Chossat, during the first three-fourths of the hunger period the temperature falls on the average 0.2° C. (0.36° F.) each day, while in the last fourth it falls very rapidly. When it reaches 23° to 24° C. (73.4° to 75.2° F.) death occurs. The decrease in temperature is a powerful factor in causing death by starvation, and if it be prevented life can be maintained much longer without food. Post-mortem Rise of Temperature.-After death the temperature of the body (rectum) is sometimes found as high as 44° C. (111.2° F.). This rise is, without doubt, mainly due to the continuance of the body metabolisms for some time after the circulation stops, and thus heat is produced after the main mechanism for its elimination has ceased to act. The rise sometimes observed just be- fore the death agony is probably to be explained in the same way. Effect of Low Temperature.-Pure water freezes at 0° C. (32° F.). Water containing salts and other mat- ters in solution, at a lower temperature. Living matter has a portion of its water frozen at a few degrees below 0° C. (32° F.). While, as the temperature decreases or con- tinues low for a longer time, more and more water sepa- rates out and is frozen, and thus, as the temperature falls, the protoplasmic matter continually becomes poorer in water. This separation may be carried only so far that on slow thawing the water is gradually recombined with the unfrozen portions of the protoplasm, or it may go on to such an extent that the reabsorption cannot take place, and the substance begins at once to disintegrate, no mat- ter how slow the thawing may be. Protoplasm.-Simple protoplasmic organisms can be hard frozen, according to Englemann, and on thawing again become contractile. Kuhne saw the same thing. This statement holds also for the cilia of ciliated cells, and Mantegazze states that he was able to revive human spermatozoa which had been cooled to -17° C. (1.4° F.). Kuhne has shown that frog's muscles after freezing at -7° to -10° C. (19.4° to 14° F.) can, when carefully thawed, be made to contract again. Bacteria.-Many bacterial organisms can be subjected to very low temperatures for a great length of time without injury, as low as -83° C. (-117.4° F.) having been contin- ued for one hundred hours (Coleman and McKendrick)8 and -130° C. (-202° F.) for twenty hours (Pictet and Gung).9 Higher plants can be frozen to varying extents and recover perfectly when slowly thawed. Before em- bryogenesis the eggs of a large number of animals can be cooled many degrees below the freezing-point without causing any abnormality in the subsequent development (Preyer). PoikilothermousVertebrates.-The question whether poi- kilothermous vertebrates can be frozen and revived has al- ways been one of interest. Hunter did not succeed in do- ing it. Coleman and McKendrick8 have recently reported that a frog frozen at -11.1° to -16.6° C. (12° to 2.1° F.) could sometimes be recovered. It is probable that in the natural state many poikilothermous vertebrates revive af- ter being frozen, but the difficulty of imitating natural con- ditions-especially the gradual cooling preliminary to the freezing-are such as render most laboratory experiments 595 Heat. Heat. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. unsuccessful. In passing from the poikilothermous to the homoiothermous animals, it is fitting here to make mention of those animals which enjoy a seasonal sleep during that time when food fails them. Although there are animals which are thus dormant through the rainless summers of certain regions, as well as those which lie hid- den during the winter in northern latitudes, it is the lat- ter cases only which have been carefully studied. These hybernating mammals are during the winter poikilother- mous, while for the rest of the year they are homoio- thermous, thus forming a link between the two groups. Among the homoiothermous animals a near approach is' made to the poikilothermous by the young of those which are very immature when born, namely, the naked birds and the blind-born mammals. Horvath cooled down such creatures to 5° C. (41° F.), and they recovered without assistance, while it was found that adults cooled only to 18° C. (64.4° F.) could not recover when left to them- selves. As a rule, small homoiothermous animals are found to have a more variable temperature than large ones-a state of things to be expected. That animals in the arctic regions maintain their proper temperature, even when the difference between their own temperature and that of the surrounding air is from 60° to 80° C. (108° to 144° F.), is abundantly shown by the observations of Parry, Black, and others. Man.-According to Senator and several other ob- servers, in the case of man even a small decrease in the temperature of the medium causes a decrease in the proper temperature, unless some alteration is made in the mode of life, food, or clothes to suit the new condi- tions. For naked man Senator finds that the proper temperature is not affected in air which ranges from 27° to 37° C. (80.6° to 98.6° F.). Rosenthal finds that ani- mals cooled to 24° to 26° C. (75.2° to 78.8° F.) die. The temperature of drunken individuals often falls very low, however. In a case given by Peters it was 26° C. (78.8° F.) in the vagina ; the woman recovered. The very low axillary temperatures given in some cholera cases are open to the objection that often the vagina, for example, is some degrees (7° C., 12.6° F.) above the axilla. Cool- ing by baths is found to be followed by a rise of tem- perature after five to eight hours. It amounts to some 0.2° C. (0.36° F.) in the rectum. As is well known, man, properly protected and fed, can endure without injury the rigors of an arctic winter. Effect of High Temperatures.-Mere heating of liv- ing matter, in so far as it is unaccompanied by any funda- mental alteration, causes simply an increase in metabolism. The injurious and ultimately destructive effects of high temperatures depend on the fact that they alter the con- stitution of certain substances in living matter. The al- teration often takes place gradually, and it becomes thus intelligible how the length of time that living matter is exposed to a given temperature is a factor in determining the changes brought about in it. Protoplasm.-The spontaneous movements of proto- plasm generally cease, according to Englemann, at from 30° to 46° C. (86° to 114.8° F.). About 46° C. (114.8° F.) is usually fatal to plants growing in the water. The fatal temperature in the air is about 52° C. (125.6° F.). Hoppe- Seyler, however, observed certain algae living at a tem- perature of 60° C. (140° F.). Dried oats have sprouted after being exposed to a temperature of 120° C. (248° F.), and the spores of certain bacteria stand boiling for some time. Poikilothermous Animals.-The eggs of poikilother- mous animals are, as a rule, sensitive to increase of tem- perature, though frogs' eggs can support 30° C. (86° F.) for a day. The excised frog's muscle passes into heat rigor at 40° C. (104° F.), this being due to the coagulation of a non-spontaneously coagulating body (Kiihne). Frogs themselves and other poikilothermous animals are unable to stand heating to a higher point. Homoiothermous Animals.-Hens' eggs can withstand a temperature of 42° C. (107.6° F.). The life of the mam- malian embryo is in danger if the temperature of the mother reaches 42° to 42.5° C. (107.6° to 108.5° F.). A rise of 6° or 7° C. (10.8° to 12.6° F.) in the body tempera- ture is generally fatal to mammals, and, as a rule, small animals bear increased temperature less well than large ones. Animals which have been for a long time over- heated to 42° to 44° C. (107.6° to 111.2° F.) are subse- quently found to have a subnormal temperature, 36° C. (96.8° F.), which may continue for days. Birds can stand a slightly higher temperature than mammals, 48° to 50° C. (118.4° to 122° F.), while 42.5° C. (108.5° F.) for any length of time is usually fatal to man. The so-called paradoxical temperatures, often reaching 46° C. (114.8° F.), reports of which were given in the Lancet, 1878,10 deserve mention in this connection. After sifting them there is found a residuum of cases in which the most obvious explanation of the thermometric reading is that it truly represents the temperature. But before any use at all can be made of such observations, more of them are needed to exclude all possibility of error. In determining how high a temperature of the medium man can stand the prime fact is the quantity of moisture present in the air, for the greater its amount the less high the tempera- ture which can be supported. Boerhaave stated that no animal breathing by lungs could live in a medium above the temperature of its own body. This idea was soon re- futed by experiments on man in hot countries. Many experiments were also made in England, and, finally, Blagden succeeded in enduring a temperature of 127° C. (260.6° F.) for eight minutes. The temperature which can be supported in a saturated atmosphere being, of course, much less, 45° to 54° C. (113° to 129.1° F.). Heat Production.-The activity of living matter has been shown on examination to be accompanied with the production of heat, the difference between that pro- duced by a green plant and a bird being very great, yet in all cases demonstrable. Theories.-The theories of heat production which pre- ceded that now held were, with the exception of the neglected one of Mayow (1668), all wide of the truth, and may here be passed over. Lavoisier, to whom we are indebted for our fundamental ideas on this subject, found that animals absorbed O and gave out CO2. This is essentially the process of combustion, and as such must be considered to give rise to heat. The amount of heat developed by the combustion of a gramme of carbon be- ing known, it was only necessary to observe whether the quantity of CO2 given out or of O used by animals ac- counted for the heat produced, in order to test the cor- rectness of the theory. It was evidently the idea of both Lavoisier and his immediate followers that the oxida- tions took place in the lungs themselves. This point could not be scientifically settled, however, until the dis- covery of the gases of the blood by Magnus in 1845. Calorijnetry.-The calorimeter is an instrument so ar- ranged that the heat given off by a mass of matter, e.g., an animal's, shall be made to warm a known quantity of some other substance, usually water, ice, or mercury. The energy required to raise 1 kilo. = 2.2 pounds of wa- ter, for instance, from 0° C. to 1° C. = 32° to 33.8° F., be- ing known, it becomes thus possible, by determining the temperature and volume of the water in the calorimeter, to measure the quantity of heat given off in heat units. According to the nature of the investigation different heat units are used. Those employed are as follows: The quantity of heat required to raise 1 kilo, water from 0° C. to 1° C. = 1 Caloric = Ca.: the quantity of heat required to raise 1 gramme water from 0° C. to 1° C. = 1 small caloric = ca.; the quantity of heat required to raise 1 milli- gramme water from 0° C. to 1° C. = 1 microcaloric = mca. The following figures will all be given in small caloric = ca. It is to be noted that the ice-calorimeter was the form first used by Lavoisier, but it is now abandoned, for physiological work at least. The common form of the water-calorimeter is something as follows: Beginning at the outside, we have first a layer of some non-conducting- material, and within this a jacketed box, the jacket be- ing filled with water. Inside the box is placed a cage containing the animal, and so arranged that the creature cannot come in contact with the walls of the box. A measured current of air is kept continually passing' through the cage, and its composition is determined both 596 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heat. Heat. before and after its passage. The purpose of this con- trivance is that, under known conditions, ail the heat given off by the enclosed body shall be taken up and held by the water in the calorimeter, thus making it pos- sible to deduce from the temperature of the water the quantity of heat produced in a stated period. The sources of error in this method are twofold-one being in the instrument, the other in the animal. The temperature of the animal at the end of the experiment may differ from that at the beginning. It may not con- tain at the end the same quantities of O and CO2 which it did at the beginning, and the conditions under which it is placed are generally more or less abnormal. Finally, the instrument does lose heat, and that, too, in an irregu- lar manner. None of these objections is, however, fatal to the method. Specific Heat.-By means of calorimetric methods the specific heat of the various tissues has been determined. The specific heat of the entire human body is probably somewhat less than an equal weight of water = 0.83 (Liebermeister). One of the earliest uses of the calorimeter was to de- termine the heat equivalent of various alimentary sub- stances. As combustion within the body is simply slower than that without, the amount of heat in both cases should be the same as that found by the calorimeter. The most reliable of the earlier investigations on sub- stances, some of which were food-stuffs, are those of Farve and Silbermann. Their observations unfortunately include the heat equivalent of but few substances as they are consumed in the body. They demonstrated, however, the very important fact that the heat equivalent of com- plex substances could not be obtained by summing up the heat equivalents of their various elements when burned in a free state, or, in other words, that the heat developed by the combustion of a combined and a free atom is not the same. Frankland made a careful study of such substances as are used for food, but there is reason to think that his figures for the most part are a trifle too low. A very care- ful study of the heat equivalents of many non-nitroge- nous substances has been made by v. Rechenberg,11 and for the nitrogenous ones by Danilewsky.12 Perhaps the most careful figures are those by Rubner,13 who has criti- cally examined the results of his predecessors. He gives the following : One gramme dry substance: Muscle albumin insoluble in water 5,754 ca. Muscle 5,345 " Haemoglobin 5,949 " One gramme of ash-free substance : Fat (hog) 9.423 " Urea 2.523 " Cane-sugar 4,018 " This table is by no means extensive, and is simply given as a sample of the best results. Those wishing to make use of such figures for calculation should consult the original papers. Supposing the above, however, to be correct, then to determine the heating power of a sub- stance, say albumin, in the organism, the heat equivalent of its form in the excreta must be subtracted from its equivalent as given in the table. The older and cruder method was to consider that each gramme of albumin gave rise to about one-third of a gramme of urea, and the corre- sponding number of calorics was then deducted, leaving the equivalent sought. This has been shown by Rub- ner 13 to be in many ways incomplete, since the faeces specially have to be reckoned with in this calculation. To give an example : One gramme of muscle albumin as in table gives... 5,754 ca. „ I Urine =1094.5 ca. I , „ Excretlons 1 Faces = 185.4 - f =1'2&0 ca' For swelling of albumin in water.. 28.8 ca. For solution of urea 21.5 " For a closer discussion of the details here involved, the reader is referred to the article on Nutrition. The temperatures of most animals below the homoio- thermous vertebrates indicate that the heat production in them is small, and that it varies with the temperature. Among the homoiothermous vertebrates, heat production is early indicated in the development of the individual by the fact that live eggs, at the optimum temperature, are slightly warmer than dead ones, and also by the fact that the foetus is warmer than the mother. Parts which Develop Heat.-As has been pointed out, heat is most largely produced where the metabolisms are most active, and this indicates where we must look for the heat production of the body. The study of muscle shows that a single contraction of the excised gastrocnemius of the frog (Heidenhain) raises the temperature 0.001° to 0.005° C. (0.0018° to 0.009° F.) for each twitch, while a tetanus continued for two or three minutes causes a rise of 0.14° to 0.18° C. (0.25° to 0.32° F.). The possession of this heat-generating power and the large bulk of the mus- cular system make it most probable that it is the main source of animal heat. When the muscles are in action the heat produced is much greater than when they are at rest, yet even then there is a slow metabolism continually going on. Next to the muscles the glands are the chief producers, and here the liver, both on account of its size and its incessant activity, is predominant. The central nervous system, too, may be considered as a source of heat, but is not to be compared in importance with either of the foregoing. In other tissues the heat production goes on, of course, in direct proportion to their metabolic activity. Since the temperature of homoiothermous ani- mals is nearly constant, the amount of heat lost and pro- duced in a unit of time must be approximately the same. It has been calculated that the amount of heat produced by a man would, if none were lost, raise his entire body some 2° C. (3.6° F.) an hour. Heat-production Calculation. - By calculation Helm- holtz found the heat production in an average man to be about 2,732,000 ca. in twenty-four hours. Ranke calcu- lated the heat production for varying diets, e.g.: Meat diet 2,779,524 ca. Mixed diet 2,200,000 " N-free diet 2,059,506 " Fasting 2,012,816 " The older estimations, as those of Dulong and others, are of no value, because they are based simply on the carbon and hydrogen contents of the food-stuffs, the combustion of which, in the free and combined states, yields, as we have seen, very different results. Calorimetric Observations.-Making use of an ice-calori- meter, Lavoisier sought to measure the heat given off by an animal, and to determine whether the O taken in and the CO2 produced in the same time accounted for it. His result was that the CO2 accounted for ninety-six per cent, of the heat given off. This was very near the truth, but resulted from a balancing of errors. Later La- voisier found that there was less O given off as CO2 than was taken in, and he assumed that this missing O was used to form water. Later both Dulong and Depretz, working with water-calorimeters, found a similar defi- ciency in the return of O. In their work, also, there were many sources of error. On the best calculation from the figures of Dulong, the CO2 accounted for 90.6 per cent, of the heat, and from those of Depretz for 92.3 per cent. The general conclusion drawn was, however, that for the most part the oxidations of the body, as expressed by the CO2, accounted for the heat produced. Further calorimetric observations have been made by Senator, Klebs, Sopalski, and others. Senator reached the follow- ing conclusion from the study of dogs : 1. No constant re- lation exists between the CO2 excretion and the heat pro- duction. 2. During fasting less heat is produced and less CO2 expired. 3. In digestion the CO2 and the heat pro- duction increase-the latter in the greater proportion. The average heat production in the daytime for one kilo, of adult dog is 2,530 Ca. per hour. Most of the calorimet- ric experiments on man are open to serious objections, and the estimations of the quantity of heat produced per Total 50.3 ca. 50.3 " Total amount to be deducted 1330.3 ca. 1.330 " Physiological value '. / 4,424 " 597 Heat. Heat. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. kilo, per hour vary from 1,040 to 2,040 Ca. Partial cal- orimetry, introduced by Leyden, gives fair results. As may be seen, no complete numerical proof of the relation between metabolism and heat production has yet been presented ; nevertheless the conclusion is justified, that for the most part the oxidations of the body will account for it. Relation of Heat Production to Mechanical Work.-A question which at once arises is, how far the metabolisms of the body can express themselves in work as well as in heat. In other words, is less heat produced when work is done ? Although there is every reason for believing that the law of conservation does hold in the animal body, it has not yet been demonstrated. Hirns' experi- ments, which were taken to prove this point, are full of errors. He found that at rest he consumed 30 grammes of O in an hour, and produced 155,000 Ca. ; when in the same time he did 27,450 kilogrammetres of work, he used 132 grammes of O, and gave out only 251,000 Ca. The heat equivalent, as is plain, was in the second case much less for a gramme of O than in the first. This was the result required by the theory, but owing to inaccu- racies in the work these results cannot be considered as a demonstration. The fraction of energy which appears as mechanical work is large in animals as compared with other machines. According to Danilewsky, it is 0.22 of the whole. Food.-As has been shown by various experiments, an ample food-supply is accompanied with the development of a full quantity of heat, while in fasting the amount of heat is less, and in the last days of starvation much less than the average. Senator's experiments on dogs always show an increase in heat production after a meal. Action of Cold and Heat.-Pfluger and Colasanti found in guinea-pigs kept in the cold a simultaneous in- crease in the gaseous exchange, indicating increased heat production. Velten found a decrease. Senator concludes that cold in itself causes a decrease in the heat produc- tion. Edwards found that birds in the winter-time became sooner asphyxiated in a closed vessel, and also raised the temperature of water in which they were placed higher than they did in the summer, both of which reactions he looked on as indicating increased heat production. It has been pointed out that it makes a fundamental difference whether the animal exposed to the cold air is itself cooled or not, for in the case of the former event it becomes poikilothermous, and its metabolisms rise and fall with the temperature. Calorimetry thus far gives no satisfac- tory answer to the question how changes of temperature act on men, yet it is plain, from what we know of those living at the equator and within the arctic circle, that vast differences of heat production must exist, and of such a nature that it is greater in cold than in warm re- gions. Voluntary increase in the depth and frequency of the breathing, by which the quantity of the CO2 may be three or four times increased, does not, according to Liebermeister, increase the temperature. This indicates that the CO2 production and discharge do not always take place pari passu, and the increase in CO2 is to be re- garded as mainly due to increased ventilation. Section of the vagi and ordinary dyspnoea are both accompanied by a decrease in heat production. Heat Elimination.-Animal heat is lost by radia- tion, evaporation, and conduction-the first and second, as a rule, being the most important. For poikilother- mous animals the means of elimination are not so perfect as for homoiothermous. The regulation of the loss by the animal itself is, for the most part, through variations in the circulation, or by the secretion of moisture on the surface of the skin. In the higher vertebrates the posi- tion of the limbs with reference to the trunk can to a large extent determine the loss .by radiation. The reg- ulation of temperature by the respiration is apparently of very little importance. The subcutaneous layer of fat found in the vertebrates controls elimination to a very great degree, as can be demonstrated. This protection is found specially developed in the cetacea, where its pur- pose is plain. In the human foetus the loss of heat is by conduction to surrounding tissues almost as warm as it- self. At birth the elimination is suddenly increased, and, the power of production being at first imperfect, the tem- perature naturally falls. The effect of cold ingesta as a means of eliminating heat is very slight, as has previously been pointed out. According to Rosenthal, about six per cent, of the body heat is used for warming the in- gesta, nine per cent, is lost by the lungs, and the remain- ing eighty-five per cent, is eliminated by radiation and evaporation from the skin. This differs slightly from similar calculations by Helmholtz and others, but they all agree in attributing to the skin the most important part in heat elimination. There are no observations on the relative proportions of the heat lost by radiation and that lost by evaporation. Indeed, in the case of a phe- nomenon necessarily so variable, general statements would have little value. The loss of heat in man takes place at such a rate that he has no feeling of discomfort in quiet water at 30° C. (86° F.), and in running water at a little higher point; naked in a room at 20° to 25° C. (68° to 77° F.), and clothed in a room from 16° to 20° C. (60.8° to 68° F.). Heat Regulation.-The prime question here is, does heat production vary with different conditions, or are the variations in heat elimination alone sufficient to explain the constant temperature of the homoiothermous animals ? In this connection the size of the individual is important, for the greater the bulk the less in proportion is the heat- radiating surface to the heat-generating parts, and hence, the larger the animal the less the amount of heat which it proportionally must produce in order to maintain its proper temperature. As bearing on this question, it has been pointed out that the aquatic mammalia, especially those living in cold latitudes, are of large size, and the young are born enveloped in great masses of subcutane- ous fat. Klug has found that with a temperature differ- ence of 9° C. (16.2° F.) 0.8° of the heat was held back by the panniculus adiposus. When it is considered that the temperature of the air beneath the clothes is from 24° to 30° C. (75.2° to 86° F.) (Pettenkofer), it is plain that for man the usual temperature differences are quite small. Evaporation.-One of the chief means of regulating temperature is by evaporation from the skin, and perhaps the lungs. The value of this factor depends again on the saturation of the air with moisture. In poikilothermous vertebrates which are subjected to high temperatures, the skin secretion is of the utmost importance in enabling them to support it for a time. It is found that animals covered with hair, and without sweat-glands in their hairy parts, are but little affected by the saturation of the air. This is an indication that the loss of heat from the lungs is trifling. Rosenthal gives the following for some of the lower animals: temperature of medium, 11° to 32° C. (51.8° to 89.6° F.); proper temperature of animal maintained to temperature of medium, 32° to 36° C. (89.6° to 98.6° F.); a slight rise to 41° to 42° C. (105.8° to 107.6° F.) occurs in the proper temperature. If the medium rises much above 36° C. (98.6° F.) the proper temperature increases to 44° to 45° C. (111.2° to 113° F.), and death occurs, probably from failure of the central nerve-cells. In this case the blood is found venous, showing that in spite of the rapidly increased respiration there was a deficiency of O. In this connection it may be added that the apparently small cooling effect of increased respiration leads Rosen- thal to conclude that its teleological significance must be elsewhere sought. Circulation.-The circulation is to be looked on as the great equalizer of the body temperature, as well as a prime factor in heat regulation. If the skin capillaries be expanded the blood is exposed at the surface, and hence tends to lose heat; if, on the other hand, they are con- stricted, the tendency is to diminish heat loss. This deli- cate regulator expands and contracts under the stimulus of external changes, thus controlling the temperature of the skin. Tomsa has further shown that the fibres of the skin are so arranged that the contraction of the skin muscles, which is brought about by cold, causes a decrease in the thick- ness of the integument, which at the same time tends to press the blood out of it. 598 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heat. Heat. Regulation by Clothes.-An adult man accustomed to wear clothes is far more sensitive to cold than the hairy mammals, and in excessive temperatures he acts like a poikilothermous vertebrate. According to Stapf, at 30° C. (86° F.), the air being saturated, the proper temperature rises to almost 40° C. (104° F.), so that 30° C. (87° F.) is about the highest point at which, under the above condi- tions, the approximately normal temperature can be main- tained. According to Senator and Winternitz, exposure of the naked body to air at 12° to 15° C. (53.6° to 59° F.), or washing with water at 9° to 10° C. (48.2° to 50° F.), causes a sinking of the temperature of skin, axilla, and rectum. A slight rise in the axilla, but not in the rec- tum, precedes the sinking. Up to chilling the decrease is small. Regulation 'by Heat Production.-The case of exposure to unusual temperatures for a few hours, as in a calori- meter, and for years, as when living in an extreme cli- mate, must be sharply distinguished. In the latter case there is no doubt that decrease of external temperature and increase of heat production go together, and that the reverse is also true. For the former case there are Sena- tor's observations on dogs, which show by direct measure- ment a decrease in heat production coincident with a de- crease in the external temperature. Too much reliance is, however, not to be placed on these results. Lieber- meister argued from the rise of temperature in the axilla an increase of heat production on the sudden application of cold. This is really due to a change in heat elimina- tion. Indirect Evidence.-For the influence of temperature on heat production, there is offered a mass of indirect evidence by Pfliiger and his pupils. Pfliiger has stated the general results of these investigations as follows: 1. In the hairy animals whose central nervous system has been eliminated without disturbance of the circulation, the energy of the metabolisms, when measured by the quan- tity of the O absorbed and CO2 eliminated, rises and falls with the temperature of the animal as taken in the rec- tum. 2. In animals with the central nervous system in- tact, there is combined with this tendency an opposing influence, which makes the metabolisms so much the more energetic the more the surrounding medium is cooled. When the proper temperature of the animal sinks very low (30° to 20° C., 86° to 68° F.), or rises very high (39.8° to 42° C., 103.6° to 107.6° F.), the influence first mentioned is again predominant. Results more or less concordant with the above have been obtained by other investigators. In conclusion, it may be stated that although there is little doubt that heat regulation is af- fected by changes in heat production as well as in heat elimination, nevertheless the experimental demonstration of this point is still incomplete. Influence of the Nervous System.-When Claude Ber- nard cut the sympathetic nerve on one side of a rabbit's neck, he found that the blood on the same side flowed more quickly, and that the temperature of the ear rose above that on the opposite side. When Bernard liga- tured the vein and then sectioned the nerve on the same side, a rise of temperature in the corresponding ear fol- lowed the section. When the head of a horse was envel- oped in cotton-wool, and the sympathetic cut on one side, the temperature of the blood in the jugular vein on that side was found above that of the carotid artery. From these and similar experiments, Bernard concluded that the increased generation of heat in the region supplied by the sympathetic was the cause of the increased rapid- ity of the blood-flow-the usual way of interpreting the phenomena being, of course, the reverse of this. Ber- nard, however, viewed the sympathetic as holding the metabolisms of the ear in check, and its section as the re- moval of an inhibition. He therefore designated it as " frigorific." Bernard's experiments are, however, by no means conclusive. Stimulation of a Sensory Nerve. - This question has been most carefully worked out by Heidenhain. The temperature was measured in the heart or one of the main vascular trunks. Electrical stimulation of a sensory nerve was found to cause a fall in temperature when the me- dulla oblongata was connected with the cord. When it was separated from the latter the fall did not occur. Stimulation of the medulla itself, either directly or by stopping the respiration, was followed by a more marked fall than stimulation of a sensory nerve. Almost no change occurred, however, when the medulla was sepa- rated from the cord. This fall from direct stimulation depends on a disturbance of the circulation, and must be distinguished from the action of a sensory nerve. Heidenhain, considering that a slowing of the circula- tion is accompanied by an accumulation of heat, and vice versa, shows that under the influence of the stimulation of a sensory nerve the circulation is more rapid, and thus concludes that the decrease in internal temperature de- pends on an increased loss at the surface. But, in gen- eral, accelerated circulation may be considered as increas- ing the heat production, so that the internal loss is in- dicative of an elimination over and above the increased heat production. The decrease of temperature is found most marked in the vena cava below the hepatic veins, as might be expected, for here the blood arrives after the greatest exposure without having been warmed by pass- ing through any important viscus. Direct Vaso-motor Action.-The direct action of vaso- motor nerves on peripheral parts has been studied both by section and stimulation. In all cases the variations in the blood-supply amply explain the variations in tem- perature. It is well known that a rise of temperature takes place on stimulating contracting muscles and se- creting glands, even though there be no circulation through them; but here we have active metabolisms to account for the rise. The question, then, is whether, where the nerves are neither motor nor secretory, and where the metabolisms are not evident, the section or stimulation of the nerve affects the heat production inde- pendently of the blood-supply. To demonstrate this, it must either be shown that the temperature of the part rises on stimulation, when there is no blood in it, or that the blood in the vein is really warmer than that in the artery. This, as mentioned, Bernard attempted to show, but his experiments are open to objections which render them indecisive. There is no d priori reason why the metabolism of all parts should not be under nervous con- trol, quite independent of the circulation, but such a re- lation has not yet been demonstrated. Influence of the Central Nervous System.-The idea has been advanced that somewhere in the central nervous system there was a centre or centres which controlled the production of heat by acting in an inhibitory manner. The classic experiment was that of Brodie, who found that a decapitated animal in which artificial respiration was kept up cooled even more rapidly than the control animal in which there was no respiration at all. Brodie correctly explained this more rapid loss of heat by the cooling of the blood at the surface, but nevertheless con- cluded that respiration could not be the cause of heat production, and that after the removal of the brain the latter ceased. This idea was taken up and investigated in many ways, with more or less contradictory results. Spinal Cord.-Closely connected with the preceding are the effects of section of the cord. In contradiction to his former views, Brodie later found in injuries to the cord in man a consequent rise of temperature. This looked as if any centre which might be called in to ex- plain the phenomena must be considered as a heat-mod- erating centre and not as a heat-generating one, which was the conclusion from the decapitation studies. The results on this point, as to how far section of the spinal cord affects heat production, are so discordant as to be at present irreconcilable. In total injury to the cervical cord Fischer saw the temperature rise to 42.9° O'. (107.4' F.). In two other cases, with complete preservation of the anterior columns, a continuous sinking to 34° C. (93.2° F.) and 30.2° C. (86.3° F.) was recorded. In sec- tion of the cervical cord completely there was, in rabbits, an immediate rise of 0.5° to 1.7° C. (0.9° to 3° F.). In- jury, with the preservation of the anterior columns, re- sulted in a fall of 0.5° to 3° C. (0.9° to 5.4° F.). Section 599 Heat. Heat. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the dorsal or lumbar cord was never followed by a rise of temperature. Fischer concludes that in the an- terior columns of the cord there is a heat-moderating centre, the stimulation of which causes a fall in temper- ature, its paralysis a rise. Naumyn and Quincke, as the result of a number of experiments, conclude that there is in the cord a series of fibres which moderate heat pro- duction, but place their centre in the brain. Rosenthal, though he has often repeated the experiments of Naumyn and Quincke, has been unable to find any grounds for assuming the existence of heat-moderating fibres, and suggested that the rise in temperature observed was due to traumatic fever. The recent experiments of Bokai14 support the view of Rosenthal, for he does not find any rise after section of the cord, and the fall observed de- creases as the section is made lower and lower down. The clinical observation of a rise of temperature in in- juries of the cord he attributes to acute myelitis and other complications which do not occur in his experi- ments. It is noticed by Rosenthal and others that the higher the section the greater is the tendency of the ani- mal to cool to the temperature of the medium. This is most readily explained by the fact that the higher section causes a more extensive dilatation in the parts cut off, and also interferes with the metabolisms in the muscles thus affected. It is evident that at present no final statements can be made on this point. On the Heat Centres in the Brain.-Tscheschichin did not observe a rise of temperature after section of the cord. When, however, the section was made between the pons and medulla, a marked rise was observed, and he inferred from this a moderating centre in the brain. Bruck and Gunther, under Heidenhain's direction, found a rise of temperature in only a part of their experiments. They also found that the rise more commonly followed slight injury between the pons and medulla than com- plete section. Since, however, the temperature was higher both in the rectum and on the surface of the skin, there must have been an increase in heat production. It does not, however, accord well with Tscheschichin's idea that slight wounding should be more effective than com- plete section. Electrical stimulation between the pons and medulla was effective, but obscured by clonic cramps. Schreiber found that, when the animal was properly pro- tected against loss, a rise of temperature occurred after injury to the pons in all its parts-the pedunculi cerebri, the cerebrum, and the cerebellum. These experiments were carried on at quite a high temperature. The rise was at most 4.3° C. (7.7° F.) at a room temperature of 26.2° C. (80.1° F.), and was accompanied with cramps and respiratory and circulatory disturbances. The study of this question by Wood is important, for he not only took temperatures, but measured calorimetrically the heat given off. He found section of the cord above the splanch- nics to cause an increased elimination and decreased pro- duction, and section above the medulla to be followed by an increase in both production and elimination. This Wood considers as due to a moderating heat centre situ- ated above the section. Christiani15 points out that as the parts of the cerebrum anterior to the corpora quadrigem- ina can be removed with little or no disturbance of tem- perature, but as the removal of the co-ordinating centre in the corpora quadrigemina does cause a great disturbance, that heat regulation probably takes place in that locality; and that the results of Arohnson and Sachs,16 who obtained a rise in body temperature in dogs, rabbits, and guinea- pigs on puncturing the brain in a circumscribed spot on the base, at the juncture of the sagittal and coronal fis- sures, the injury being near the striate body, arc to be explained by their thus indirectly stimulating this centre. Ott17 has reached results apparently similar. Eulenberg and Landois reported a centre in the cortex of dogs, the stimulation of which caused a rise in temperature ; their results have met with much opposition as well as sup- port. Recently Randnitz16 has raised against them the objection that the variations found were within the nor- mal variation for the parts tested (paws). He states that the temperature difference between the two sides may be normally 14° C. (25.2° F.). Bokai's 14 experiments extend over this point, and he has made an elaborate series of observations on rabbits. He concludes that in this animal there are in the occipi- tal part of the cortex centres which so influence the me- dullary vaso-motor centre as to produce vaso-constriction when stimulated. Analogous vaso-dilator centres are also found in the cortex ; he always found both, but could not make out the dilator centres for the posterior half of the body. From these observations, says Rosenthal, an influence of the brain on the general and local tempera- tures of the body is plainly indicated, in so far as they are caused by vaso-motor changes, but it must first be shown that the increased heat production observed by Wood, for instance, could not be due to circulatory changes before such a result can be taken to indicate the existence of a heat centre. , The most important recent literature is : Die Physiologic der Thierischen Warme. J. Rosenthal : In Hermann's Handbuch der Physiologic, 1882, Bd. iv., Th. 2. S. 289-456. Of this the above article is largely an abstract. Landois' Lehrbuch der Physiologie des Menschen, 1885, 4te Auflg. Tor the Embryo, Preyer. Specielie Physiologie des Embryo, 1885, gives a complete bibliography. Henry Herbert Donaldson. References. Below, special reference is made only to some papers not cited in the above-mentioned works. 1 Kidder. J. H.: Smithsonian Miscellaneous Collection, vol. xix., p. 306. Washington, 1880. 2 Richet, C.: Rev. Scient., Paris, 1884, t. xxxiv., pp. 298-310. 3 De Miklonho-Maclay : Proc. Linnman Soc. N. S. Wales, vol. ix„ pp. 425, 1204. Also Nature, London, April 30, 1885, p. 600. 4 Lancet, London, 1878. 6Mauvel: Tribune Med., Paris, 1884. No. xvi., pp. 447-449(a resume). 6 Bonnal: Comp. Rend. Acad. d. Sci., Paris, 1880, t. xci., pp. 798- 800. 7 Maly, R.: Arch. f. d. ges. Physiol., Bonn, 1880, Bd. xxxii., S. Ill- 125. 8 Coleman and McKendrick: Jour. Anat, and Phsyiol., vol. xix., pt. iv., 1885. 9Pictet and Yung: Comp. Rend. Acad. d. Sci., Paris, 1884, t. xcviii., pp. 747-749. 10 Lancet, London, 1878-79. and 1881. 11 V. Rechenberg: Jour. f. Prak. Chemie., Bd. 22, S. 1, 244. 12 Danilewsky : Centrbl. f. Med., Wiesen, 1881, S. 465, 486. 13Rubner: Zeitsch. f. Biol., Bd. xix., H. 2, 3. 14 Bokai: Pest. Med. and Chir. Presse, Budapest, 1882, Bd. xviii., S. 150-151, 232-234 (an abstract). 16 Christiani: Arch. f. Anat, and Physiol., 1885, Heft. v. and vi.. Physiol. Abthl. 18 Arohnson and Sachs: Arch. f. d. ges. Physiol., B. xxxvii., 1885. 17 Ott: Philadelphia Med. News, xlvii., 1885. >8Randnitz: Arch. f. Anat, and Physiol., Heft iii. and iv., 1885, Physiol. Abthl. HEAT-STROKE. The term heat-stroke has latterly come into use as a substitute for sunstroke (insolation), since it has been generally recognized that a stroke is due to heat of any sort, the sun merely being more directly charged with producing the ill effect than any other calorific agent. A heat-stroke is not uncommonly caused by the high temperature of the atmosphere indirectly heated by the sun, yet it may be due to artificial heat of any kind. In considering, however, the effect of heat in its several varieties, we should recognize that the condition of the individual has much to do with the attack, whether the heat be solar or artificial. And first, the fact of motion or rest is extremely important, the most deadly effects being observed when the body is at rest; for it has been attested by actual experiment, that a moderate amount of atmospheric heat, which could easily have been borne by a person in motion, has become fatal when the body was quiet. It is reported by Bauer that a boy falling asleep in the sun, while the mercury stood at 88° F. in the shade, soon became unconscious; and, though efforts were made to resuscitate him, they were unavailing, and he died in a few hours. These observations of the sun's power on a motion- less body have been confirmed by similar ones, when animals, such as dogs, were confined where they could not move, and were then subjected to a moderate heat. It has been shown, in such instances, that they could not resist a solar heat of 90° F., but died after a few hours' exposure to it. On the other hand, dogs not so 600 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heat. Heat. confined, and exposed to the same heat, have not experi- enced any dangerous symptoms. It has been objected, however, that dogs will frequently be seen lying asleep in the hot blazing sun. The explanation of this apparent contradiction is simple. Animals rarely experience the heat of the sun as individuals do, but when the heat becomes excessive they either remove entirely to some shadier spot, or else merely change their position and so avert the danger. Experiment and observation show that when the body is superheated the walls of the blood- vessels, and especially the veins, are paralyzed, and the blood-current in consequence is slow. This slowing of the blood soon affects the heart, which becomes embar- rassed in its action, and stops if the superheating of the body becomes general. The animal or individual then dies of heart paralysis or heart failure, or it may be that death takes place in the lungs, which become engorged with blood so that suffocation ensues. The cause of death is then carbonization of the blood, or, in other words, carbonic-acid poisoning. But the cause of death may be from the brain, through pressure upon the nerves that govern respiration. Before death the bodily tem- perature usually rises to some abnormal height, such as 109° to 113° F. The number of persons that fall victims to this form of heat-stroke from the direct force of the sun's rays appears to be smaller than we should at first suppose, and is insig- nificant as compared to the number that are affected by the other forms of heat. Usually, a person feels the in- tense heat in time to escape it in some way, or at any rate alters his position so that the heat is received by some part of the body that has been previously cool, so that the bodily heat is in a measure equalized in its distribu- tion over the body. This form of heat-stroke is observed to occur in intoxicated persons, or after intense bodily fatigue, when persons have fallen or thrown themselves down regardless of consequences. In either case, if they remain motionless, the full force of the sun centres itself upon some part of the body. If the head be the part most exposed, congestion of the brain may follow, or even active inflammation, leading directly to the fatal re- sult in that way. Persons who have had light attacks of this kind will experience for days and weeks a feeling of heat in one particular spot on the head, usually at the vertex ; and it will commonly be found that this one spot will remain sensitive to heat for a long time after appar- ent recovery, and in subsequent years will exhibit a sen- sible increase in surface temperature after exposure to the hot sun. So much for the effect of the sun in directly producing a shock. That a similar effect may be produced by arti- ficial heat, the following story will indicate : A girl fourteen years of age, suffering from rheumatic ankylosis of the knee-joint, was induced by a peddler to submit to his treatment. She was then placed by him in bed, wrapped in a sheepskin taken from a sheep just killed, and packed about with loaves of bread fresh from the bakery. She became unsconscious after a short while, and died in three hours. The cause of death was, in all probability, the great heat to which the body had been subjected while in a fixed attitude. It has been found that when bread is taken from the oven, the centre of the loaf may reach a temperature of 185° F., and that it retains a high degree of heat for a long time, so that after two hours it may stand at 113° F. Miners, foundrymen, and stokers on steamers, have occasionally met death under somewhat similar circum- stances, when they have been caught in an unusually high temperature, and firmly held where the heat was intense. And yet in this second form of stroke it is not essential that the degree of heat be as excessive as in the form now to be considered, which is the stroke par ex- cellence of the tropics. So common is it there that it may almost be said to prevail as an epidemic. Boudin tells of an instance where one hundred men were struck in a single night while lying in their berths, and Morehead and Geddes have described similar occurrences. The atmospheric temperature at night in these instances is sometimes hotter than during the day. Staples tells of such a case, where for twelve days, in June and July of 1867, a hot wind blew, raising the mercury to 98° and even 102° F. in-doors; and Barclay has described a degree of heat in 1859 that was even more intense. In the larger military barracks the figure 118° F. was reached, in the smaller ones 125° F., and at night it did not fall below 105° F. The hurried and heavy breathing of the men attracted the attention of their comrades, who found them insensible when they attempted to arouse them. A similar occur- rence is not uncommon on steamers that ply in south- ern waters. According to German official returns made to the government, the atmospheric temperature taken on the imperial steamer Hertha, while in Chinese waters, showed that 103° F. was reached in the engine-room, and 138° F. in the boiler-room, when the external air was only 82° F. Other official returns from German war vessels in the Red Sea have shown that the temperature sometimes reached 148° F. in the ship's kitchen, and 153° F. in the boiler-room. The effects of very high degrees of heat upon persons who are exposed to them are somewhat remarkable. In the stokers of the steamer Vineta, the following observa- tions were made: Three men were employed, for four hours at a time, in a temperature ranging from 100° to 104° F. Their bodily temperature rose on an average to about 100° F. After the lapse of from forty-tive minutes to an hour it fell to 99° F., but for two hours did not return to the normal, 98.4° F. A temperature of 103° F. has also been observed under similar conditions in stokers. Still, the heat of the atmosphere or of the sun will not alone account for all the symptoms in such cases. The body also generates heat rapidly during muscular exer- tion. In one of the reported cases mention is made of a runner who had made fifteen kilos, (about nine and three- quarter miles) in an hour during rainy weather, and who was found to have generated a bodily temperature of 103° F. His clothes were wringing wet, his respiration 33, and his pulse 120. Fortunately the ill effects of such a superheated condition are obviated to a large extent by the evaporation of the perspiration from the skin, and by the radiation of heat from the body, for the larger por- tion of the heat received into the body is thrown off again. But these factors in the reduction of heat do not operate well if the atmosphere be damp. In such cases the sweat stands upon the skin, and there is a feeling of oppression even with a very moderate elevation of the bodily temperature. This fact serves as an explanation why on a hot, damp day the effects of the heat are more felt and are more dangerous than on a hot, clear day. If one calculates that the amount of perspiration given off from the body amounts often to several pounds per hour, and if we realize that the evaporation of this secretion is the very readiest means of cooling down the body, we may appreciate what effect may be produced upon a heated system by having the perspiration entirely arrested. Of course, there are a number of conditions that will favor the production of a stroke. A febrile state, by in- creasing the temperature of the body, will necessarily ren- der the subject more liable to be affected. Habitual in- temperance is a strongly predisposing cause, statistics showing that drinkers are more prone to an attack than the temperate. Bad ventilation and crowded quarters are important accessory factors, while, vice versa, a gentle breeze or a current of pure air, even though its tempera- ture be as high as the prevailing general temperature, tends to avert the danger. Vegetations and running streams have also a cooling influence. Acclimatization is also an important element in this matter, for the ma- jority of those attacked in any country are foreigners, wherever there is a foreign population of proportionate extent. Still, those that have become acclimated do not always obtain immunity, for the natives of India, though raised in the most oppressive of climates, are occasionally victims. Under all these ordinary conditions of solar or artificial heat, it will be observed that the bodily temperature did not exceed 103° F. If under such circumstances it should reach 104° F.; and remain there any length of time, we 601 Heat. Hellebore. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. should be extremely anxious, for fear that the blood would become carbonized, the heart paralyzed, or both. If the temperature reach 107° F. there is little chance of recovery, though it did reach 110.5° F. in a patient at Bellevue Hospital, New York, who recovered ; and it is said that 111.5° F. was recorded a number of times, and by different instruments, in a patient at the Presbyterian Hospital, in this city. Recovery also took place. It is common to suppose that a stroke is sudden and without warning, but such is rarely the case; on the con- trary, there are usually some antecedent symptoms. Often there is more or less uneasiness; the individual is de- pressed and irritable, and there may be headache and in- tolerance of light. The skin is apt to be dry and hard, the pulse full and rapid ; in other words, the person is feverish. Sometimes the mind is distracted, and some- times the vision is affected, so that he mistakes colors or imagines that everything has one uniform tint, which may be red or purple. This phenomenon was noted in sixty cases observed by Dr. Swift in this city. All of these symptoms, however, arc of less account than those I shall now mention, viz., excessive elevation of the bodily temperature, together with symptoms that denote impli- cation of the brain and spinal cord, viz., convulsions or paralysis, delirium, and perhaps unconsciousness. The great rigidity of the muscles which has been observed after death has led to the suspicion that death was caused by a coagulation of the muscular substance, which takes place, as experiment has shown, under high degrees of heat; but it is probable that this coagulation is not to be regarded as the cause of death, because at a much less degree of bodily heat than is necessary to coagulate the muscular substance death will ensue. And this brings us to the pathological conditions that have been noted. In the young girl whose case is given by Speck, and who died after being packed about with the hot loaves, it was noted that decomposition had rapidly set in, the vessels and cavities on the day after death be- ing tilled with gas, though the weather was cool. The blood, also, was black and thick. The morbid appearances may be classed as follows: While the left ventricle and arteries are apt to be empty, the right ventricle is more or less filled, as are the veins, with dark and imperfectly coagulated blood. The large veins of the pia and dura are usually distended, not so the smaller vessels of the dura and brain. Sometimes the ventricles contain an excess of fluid, and sometimes the consistence of the brain is soft. Subserous haemorrhages are frequent, as when the blood has been profoundly al- tered. All the organs and the muscular tissue have been seen to undergo a parenchymatous change. These several phenomena are perfectly intelligible, if we realize that the stroke affects the various parts of the nervous system, such as the convexity, base, or spinal cord. They do not, of course, all occur in the same in- dividual at the same time. Treatment.-Since the first and principal danger con- sists in the superheated condition of the body, which, on the one hand, leads to carbonization of the blood, and, on the other, to paralysis of the heart, through the im- plication of the nervous system, the first act on the part of the physician should be in the direction of reducing the bodily temperature. Many ways for accomplishing this object will suggest themselves. First remove the patient to a cool, airy spot, where you may have room to carry out subsequent plans. Since the circulation has been partly arrested, and this alone is important to have rectified, the surface of the body should be gently rubbed and the extremities moved a little, so as to stimu- late the paralyzed vessels. To accomplish this object the clothes should be removed, and a light sheet or cover of some sort thrown over the body. Next, various ways of reducing the temperature will suggest themselves. One of the best is to immerse the person partially in a bath ; or, better still, to extend him on the floor, or on a rubber blanket if one be at hand, and then sprinkle with water ; or place him at once on a water-bed if such be at hand ; then, after removing the external coverings, sprinkle with water from an ordinary watering-pot that has a good rose. It is not necessary to use ice-water, but merely the ordinary cold water as it is drawn from the faucet. Shaving the hair is usually unnecessary, and consumes much valuable time. If the head is very hot and the feet are very cold, hot bottles or heat in any form may be applied to the feet, and cold cloths or ice compresses to the head. An equalization of the cir- culation should be aimed at. In country places the pa- tient may be taken to the nearest pump or well, and if the temperature obstinately refuses to fall, and the sur- face of the skin is hot and dry, ice-water may be used. It will be observed that, though the temperature can be reduced to the normal, after the first application of cold it will again rise to its former height, or certainly to an ab- normal extent. The renewed cold bath or sponging will, however, again reduce the temperature, and ultimately it will remain at the normal, or even fall below it. Ice-bags to the spine are of great advantage in many cases ; when the temperature has been reduced, it may be necessary to give alcohol or diffusible stimulants. The former may be given hypodermatically, in drachm doses every ten min- utes, if it be necessary to produce a reaction. It is prob- able that bleeding is occasionally of use. Louis XV., of France, was bled nine times for a sunstroke and recovered. In a well-known case, that of Dr. Mitchell, of Philadel- phia, the doctor insisted upon being bled by his father, also a physician. He lost from twenty-five to thirty ounces of blood, and recovered rapidly. There is a mild form of stroke known as sun-fever. It may be experienced by walking in the sun on any hot day. A little enforced quiet, a cool application to the head, per- haps a stimulating drink, rapidly effect a cure. It should be remembered by all those who have had a stroke that they will be peculiarly sensitive for some years. In a small number of cases, where the patient recovers from the immediate effect of the attack, there is no permanent recovery, but the nervous system remains in a debilitated condition. The disease, however, is very fatal, fully one- half dying in a few hours after the stroke. Thomas E. Satterthwaite. HEAT, THERAPEUT'CS OF. Under this heading it is intended only to deal with the therapeutics of heat in a general way. The special action and uses of the differ- ent forms of baths will be found described under their several headings. Heat applied in various ways has the following general actions : 1. It is a marked cardiac stimulant. 2. It is a powerful diaphoretic. 3. It is a hypnotic. 4. It is a local sedative. 1. As a Cardiac Stimulant.-The application of heat to the body is a very powerful and quickly acting stimulant to the heart. This action is made use of in cases of narcotic and other forms of poisoning, where the tendency to death is from cardiac failure. It is well known that the great majority of deaths from chloroform are brought about through heart failure, and not through respiratory depression, as is often alleged. There is no more efficient means of stimulating the heart that is about arrested, or has already come to a standstill during chloro- form narcosis, than the application to the cardiac region of cloths wrung out of boiling water. Numerous cases are on record of the great benefit of this simple proced- ure. In addition to the directly irritating influence on the skin, we have the marked dilatation of the peripheral arterioles, which relieves the heart. In the latter particu- lar the influence is similar to that of nitrite of amyl, a drug which has been proved time and again to have a marked effect in stimulating the heart depressed by chloroform. Death from the different forms of narcotic poisoning is brought about not only by the direct depressing influ- ence of these different agents on the heart, but also by the great loss of heat that takes place. Lauder Brunton has shown that as regards chloral this is especially the case. He is of the opinion that the direct loss of heat is the principal factor in bringing about the fatal event. 602 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heat. Hellebore. Brunton, as well as Stricker, has demonstrated the re- markable influence heat has in antagonizing the lethal action of chloral, when given to the lower animals. In the treatment of chloral-poisoning in the human subject it is well to remember this action of heat. 2. As a Diaphoretic.-One of the most pronounced effects of heat, especially when used in the form of the warm or vapor bath, is the production of diaphoresis, and in these forms this agent is made very extensive use of in certain diseases. In certain complications of Bright's disease we have no more efficient agents. It is a common practice, but one that should be strongly condemned, to order a patient af- fected with Bright's disease to take a warm or a vapor bath, irrespective of his general condition. The fact should never be lost sight of, that the repeated use of either form of bath under consideration greatly weakens the patient, and in this way directly leads to anaemia and consequent increase of the dropsy, if this is already present. It is not an uncommon observation to find a patient with Bright's disease show' first signs of dropsy after the use of a few warm or vapor baths. From this it follows that a patient with Bright's disease should not be ordered warm baths unless dropsy or uraemia is already present. In uraemia the use of either form of bath is of undoubted service in many cases, the cerebral symptoms often quickly dis- appearing after free action of the skin. It is not by any means certain that the entire benefit is due to the dia- phoresis produced, for it has not been proved to what, if any, extent nitrogenous waste can be eliminated by the skin. There is no doubt but that urea, in cases of Bright's disease, is eliminated even in very considerable quanti- ties. We have only to instance the classical case of Bar- tels, where crystals of urea covered the face and gave a frosted appearance to the beard. We make use of the diaphoretic action of heat to allay the pain and irritability present in cases of local and general inflammatory dis- turbances. This action is especially beneficial in the in- flammatory disorders of childhood. The calming and soothing effect of an occasional warm bath in the acute bronchial catarrh of children is a matter of every-day ob- servation. If the child is not too weak, a bath night and morning will not only directly relieve the distressed breathing, but will also bring about a calm and refresh- ing sleep. The influence in relieving the catarrhal state of the bronchial mucous membrane is probably correctly attributed to the dilatation of the peripheral arterioles ; in this way the inflamed parts receive less blood, and con- sequently the inflammation, with its attendant swelling, subsides. 3. As a Hypnotic.-The hypnotic action of heat, ap- plied either generally, in the form of a warm bath, or locally, as a foot-bath, is well known, and can be made use of in the treatment of both acute and chronic sleep- lessness. 4. As a Local Sedative.-In a large number of the local pelvic inflammations of both sexes the employment of hot hip-baths has a most marked influence in relieving the distressing symptoms which are so frequently present in these cases. In the different forms of urethritis in the male the use of heat in this form, twice daily, is of the utmost benefit, not only in relieving the patient from the distressing un- easiness always present, but also in directly acting on the diseased mucous membrane, and tending to bring about a resolution of the inflammatory process. It is especially in cases of acute catarrh of the posterior urethra and bladder that the beneficial action of heat in the form of a hip-bath is valuable. Acute inflammation of the prostate is at- tended by very acute and severe symptoms. Of all acute inflammatory affections of the genito-urinary organs in the male it is the most distressing, and one of the most useful means we have for relieving it is the employment of frequently repeated hot hip-baths. Not only is there a general, but also a local, soothing effect from their use. Heat thus applied allays the pain, the incessant desire to urinate, and the straining efforts that follow the empty- ing of the bladder. It is difficult to satisfactorily explain how heat acts in relieving the pain of a renal or biliary colic. It undoubtedly relaxes the spasmodic element in these cases, but whether this is effected through the sooth- ing influence exerted on the skin, or by the weakening effect.of the bath, it is difficult to determine. There is no better known fact, however, in connection with the therapeutics of heat, than the marked influence of the warm bath in relieving the different forms of colic. In many forms of skin diseases the diaphoretic and sooth- ing effect of the warm bath is invaluable. It is especially beneficial in the acute stages of severe cases of eczema and psoriasis, and also in prurigo, urticaria, and ichthyo- sis. The water may be made still more soothing by the addition of bran or potato-starch to it. In those terribly severe cases of acute general pem- phigus the immersion of the patient for days in a gen- eral warm bath is the most effective method we have of rendering the acute sufferings of the patient tolerable. Helm, who first introduced this method of treatment into practice, reports a number of successful cases treated in this way. The baths are so constructed that the patient can both sleep and eat in them without being disturbed. James Steuart. HELICOTREMA. The name given by Breschet (" Re- cherches Anatomiques et Physiologiques sur 1'Organe de 1'Ouie et sur 1'Audition dans 1'Homme et les Animaux Vertebres," Paris, 1836) to the opening of communica- tion between the scala vestibuli and the scala tympani in the cupola of the cochleal portion of the ear. This open- ing is said to have been first accurately described by Cas- sebohm, toward the latter part of the first half of the Fig. 1626.-Transverse Section of the Cochlea, showing the Location of the Helicotrema. X circa 12 diam. (After Breschet.) eighteenth century. The accompanying cut, which is an exact copy (somewhat reduced in size) of that represented on Plate VIII. of Breschet's beautiful work, shows the precise location of the helicotrema. A black bristle is represented as passing from the scala tympani below, through the opening in question, into the scala vestibuli above. (See also " Untersuchungen uber die Lamina Spiralis Membranacea," von Dr. Otto Deiters, Bonn, 1860.) A. H. B. HELLEBORE, AMERICAN(Veratrumtiride, U. S. Ph.; Veratri Viridi Radix, Br. Ph.). This is not a true hel- lebore (see next article), but Veratrum album, var. tiride Baker (V. viride Art.); Order, Liliacece, a large, con- spicuous swamp herb, having a simple, upright, leafy stem, from fifty to one hundred and fifty centimetres high (2 to 5 feet), and numerous large coarsely plaited leaves. It arises from a rhizome from five to ten centi- metres long and from three to six across at the crown, of obconical shape and fleshy consistency, covered with thick, long rootlets below and scaly leaf-bases above. The stem is straight and simple, bearing the many alter- nate leaves in three rows, and terminating in a large, 603 Hellebore. Hemeralopia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. spicate panicle. Leaves oval, or broadly oval, pointed, sessile, clasping at the base, from fifteen to forty centi- metres long. Flowers monceciously polygamous, regu- lar, one or two centimetres across, spreading. Perianth of six narrow, pointed segments; stamens six ; anthers extrorse, opening transversely across the top ; carpels three; fruit of three many-seeded follicles. The whole plant is slightly pubescent, and of a bright, light-green color, flowers and all. It grows abundantly in marshes and along brook-sides in the cooler parts of North Amer- ica-the Northern United States, Canada, and Alaska. Varieties apparently identical with it are found in Alpine districts in Europe and in Eastern Asia. The type of the species, V. album, replaces it in Europe and Asia generally. The poisonous properties of this plant are said to have been known to the aborigines, by some tribes of whom it was used as a sort of ordeal to test their strength and vigor. " He whose stomach made the most vigorous re- sistance, or soonest recovered from its effects, was con- sidered the stoutest of the party and entitled to command the rest" (Bigelow, "Med. Bot.," quoting Josselyn). It was also one of the numerous things used by the early settlers to poison seed-corn for protection against birds ; it is still occasionally so used. In the early part of this century it was employed as a substitute for V. album in gout, rheumatism, etc., in the treatment of which that substance was then popular, and also as a parasiticide, for which purpose both have been superseded by vera- trine and other things. Its modern use as a cardiac de- pressant is of the last half-century only. The rhizome, which is the part used, is collected in the autumn and generally split longitudinally to facili- tate drying, but it may be variously cut or left whole ; the rootlets, to the length of ten or fifteen centimetres, are left attached, and dry in a skein around its lower end. The officinal description is as follows: "Rhizome up- right, obconical, simple or divided ; externally blackish- gray, internally grayish-white ; two to three inches (5 to 8 ctm.) long, one and one-half (4 to 5 ctm.) thick, with numerous shrivelled, light yellowish-brown rootlets at- tached, which are four to six inches (10 to 15 ctm.) long, and about one-twelfth of an inch (2 mm.) thick. In- odorous, but strongly sternutatory when powdered ; taste bitterish and very acrid." Composition.-The numerous analyses of the Euro- pean and American Veratrums have so far only resulted in confusion as to their exact constituents, which have proved to be rather numerous, closely related, easily changed, and only with the greatest difficulty isolated. A considerable amount of resin, itself perhaps not alto- gether inert, adheres with great tenacity to the alkaloids. Referring the reader to Husemann's " Pflanzenstoffe " and similar extensive works for the history of its chemis- try, only the composition as given by two recent investiga- tors, Messrs. Wright and Luff , will be considered here. These gentlemen examined, a few years ago, several of the Veratrums, and the nearly related Sabadilla, with a great deal of care and exactness. According to their re- sults, V. viride contained about one-third of one per cent, of a bitter alkaloid, jervine; a much smaller quantity of pseudo-jervine ; traces of a third alkaloid, rubijervine, and possibly cevadine. If the veratrine of Sabadilla occurs at all in the plant under consideration, it must be in minute and unimportant quantity. The viridine and veratroidine of Bullock are now supposed to have been impure conditions of jervine and rubijervine respec- tively. None of the separate alkaloids of Veratrum vi- ride are prepared on a commercial scale. Action and Use.-The action has been studied with care by several Americans, especially by Dr. H. C. Wood, from whose "Therapeutics" this paragraph is largely condensed. His experiments were made with jervine and Bullock's "veratroidine." The symptoms of poisoning with the former in animals are sluggishness, muscular weakness, and tremblings, followed shortly after by violent convulsions and great prostration. Sensation is affected only very late, and consciousness almost not at all. There is no purging or vomiting, but always profuse salivation. Death from cessation of respiration. Jervine is an intense cardiac sedative, acting both directly upon the muscle of the heart or its local ganglia, and indirectly through the gen- eral vaso-motor system. It reduces the force of the heart- beats and the arterial pressure to a very great degree. The rapidity of the heart is also diminished while the ani- mal is quiet, but even slight exertion raises it to rapid and incoherent action. There is also in jervia-poisoning a marked reduction of spinal reflex. It is not locally irritating. The other alkaloid, " veratroidine," resembles jervine in its general action, but is a local irritant like veratrine and produces generally vomiting and diarrhoea, which the other does not. It stimulates the pneumo- gastric, and for a while increases the arterial pressure. The crude drug has naturally the combined action of its two alkaloids, and within its medical limits produces in man weakening and infrequency of the pulse, lassitude, and increase of salivary and cutaneous secretions, lower- ing of temperature, and sometimes vomiting. None of these effects should be pressed beyond a moderate de- gree. Its utility is limited by conditions requiring these modifications-that is, quick, hard-bounding pulse, fe- brile excitement, high temperature, and dry skin-con- ditions found only in the early stages of acute febrile dis- eases in robust or plethoric patients-in the beginning of pneumonia, pleurisy, rheumatism, etc.; in the hyper- trophic stage of cardiac disease it may be needed, but not often; in typhoid, septic, and other adynamic febrile con- ditions it should never be given, nor as an emetic. In overdoses the vomiting, purging, and prostration are best combated by opium and stimulants, with a strictly enforced recumbent position. Administration.-The dose of the substance itself is about a decigram (gr. jss.), repeated rather frequently and in increasing doses until the pulse is affected. Dur- ing the administration the patient should be carefully watched. Once an hour is a good interval for the first few doses. The following good preparations are offici- nal : The fluid extract (Extractum Veratri Viridis Flu- idum, U. 8. Ph.), strength 4, and a tincture (Tinctura Veratri Viridis, U. S. Ph.), strength |. Allied Plants.- Veratrum album is rather more pu- bescent, with broader leaves, shorter pedicelled and whiter flow'crs, and a few other minor differences, but really very near the one above described. It is common in several varieties in Europe and Asia. It is the White Hellebore (Hellebore blanc. Codex Med.; Rhizoma Veratri, Ph. G.), and has long been in medical use abroad. It is more irritant and poisonous than V. viride, vomiting and diarrhoea being more prominent than after the latter. It has often occasioned death, with symptoms of extreme collapse after the gastric and abdominal symptoms. Its constituents, according to the observers quoted above, are pseudo-jervine, jervine, rubijervine, and veratralbine, the latter in large quantity; its total of alkaloids is considera- bly larger than that of V viride. It is used for the same purposes as the latter, but is less desirable as the vera- tralbine is an intense gastro-irritant poison. Sabadilla, the seeds of a neighboring genus, will be described under Veratrine. For the order, see Squill. Allied Drugs.-Aconite, Tartar-emetic, Hydrocyanic Acid, etc. American Hellebore is, on the w hole, the saf- est of them all for the purposes common to them. IF. P. Bolles. HELLEBORE, BLACK {Hellebore noir. Codex Med.; Christmas Rose), Hdleborus niger Linn.; Order Ranuncu- lacem. This interesting plant, remarkable for unfolding its handsome flowers in midwinter or the very earliest spring, is a native of most countries in the central and southern portions of Europe. It is also cultivated in England, where it is not indigenous, and in the United States, for the sake of its flowers. It is a perennial herb, with a thick and fleshy, branched, and plainly articulated rhizome, from which numerous stout fibrous roots are given off; a cluster of palmately divided leaves, and large, regular, mostly solitary flowers, borne on bracted, ter- minal scapes. Calix petaloid, four or five centimetres across, of five, white or pink, finally greenish sepals. 604 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hellebore. Hemeralopia. Petals (staminodes ?) about twice as many, consisting of short, small, stalked, trumpet-shaped green tubes; sta- mens numerous, ovaries from five to eight, free and dis- tinct, ripening into several-seeded pods. Hellebore, as a name, probably applied to some species of Helleborus (H. orientalis Schroff), figures as a cure for "madness" in ancient mythology. Hellebore has also been used as a drastic and derivative in more recent times, but is now obsolete for these purposes. Since the discov- ery of its active principles, one of them has been used a little (mostly experimentally) for its cardiac action, and its effect upon the nervous system. Composition.-The principal constituents are two glu- cosides, helleborin and helleborein, of which the proportion is but a minute fraction of one per cent. Although pre- pared by one or two chemists, they can hardly be said to be articles of commerce, and the demand for them is ex- ceedingly small. Fixed oil and acrid resin are among the less characteristic substances. Both helleborin and helleborein are cardiac and nervous poisons of great in- tensity, the latter the more powerful of the two. It is, locally, irritant to the mucous membranes, and in its dis- tant action it slows the heart like digitalis.- Dose-of Hellebore from half a gram to one gram or more. Allied Plants.-The genus contains about a dozen European or Asiatic species, all probably poisonous, some (H. viridis) more so than the one under notice. For the order, see Aconite. Allied Drugs.-See Digitalis. IF. P. Bolles. into the sunlight.12 The condition is, therefore, essen- tially one of dulled perceptive power (torpor retina), ■which may, in certain cases, be conjoined with some de- gree of retinal irritation. This view is, moreover, in ac- cord with the seemingly well-attested fact that the same combination of causes may give rise to hemeralopia in certain persons, and to more or less distinctly marked nyctalopic symptoms in others.13 Hemeralopia is an almost constant symptom in certain diseases of the retina, notably in retinal degeneration with stellate deposits of pigment (retinitis pigmentosa), in syph- ilitic retinitis, and in incipient detachment of the retina ; and it is then associated with particular types of limita- tion of the visual field, characteristic of the special retinal disease, and very often also with marked falling off in the acuteness of vision in full daylight (see Retina, Diseases of). Rarely it is congenital, and it is then an early symp- tom of pigmented retina, or perhaps of retinal degenera- tion in which the usually characteristic pigmentation may be wanting.14 Idiopathic hemeralopia has been oftenest observed as an acute epidemic affection attacking large numbers of persons living under nearly identical conditions. De Sauvages mentions such an epidemic as having broken out among the soldiers in several garrison towns border- ing on one of the smaller rivers in the south of France, not far from Montpellier.15 Other extensive epidemics have been observed, occurring almost always in large bodies of men crowded together under unfavorable hygi- enic conditions, and exceptionally exposed to the direct influence of strong sunlight. Thus soldiers in garrison, going habitually from crowded, and often very dark, quarters in casemates to drill for hours together on con- fined and unsheltered parade-grounds, seamen and ma- rines on tropical stations, prisoners employed in stone- breaking or other out-door work in courtyards enclosed by high whitewashed walls, and children in great public orphan-houses, have been especially subject to these visi- tations, while the officers, whose duties ordinarily involve much less exposure, and who are also much better nour- ished and lodged, also the inhabitants of garrison towns, have generally escaped. Hemeralopia has also been de- scribed as endemic in certain localities in the East- and West-Indies, in Brazil, on rice-plantations in China, in several provinces of France, in the countries bordering on the Mediterranean, in Podolia toward the end of win- ter, and also in midsummer among the harvesters of both sexes ;16 also in the Russian provinces bordering on the Baltic, at the period of the very strict Lenten fasts of the Greek Church.1,1 An outbreak of hemeralopia, associated with cases described as nyctalopia, is mentioned by Car- ron du Villards as having occurred in the Piedmontese army while encamped at a high elevation on the Mt. Cenis and Little St. Bernard passes.18 From very early times both hemeralopia and nyctalo- pia have been attributed to " redundancy of humors in the system." Celsus repeats in connection with night-blind- ness19 the observation made by Hippocrates regarding nyctalopia, that it does not occur in women whose men- ses are regular.20 De Sauvages lays stress on the exposure incident to guard-mounting by day and night in a humid and nebulous atmosphere.21 Demours particularly men- tions exposure to the night air.22 Hemeralopia is called moon-blindness by sailors, and is attributed by them to a morbific influence emanating from that planet, and espe- cially affecting such persons as commit the imprudence of sleeping on deck. In Brazil it has been described as endemic among the negroes ;23 it has also been said to especially affect persons with darkly pigmented eyes,24 an observation which was made by Aristotle in connec- tion with nyctalopia.25 Stellwag observed numerous cases of night-blindness occurring in an asylum in Vienna, but almost exclusively in two pavilions which were exposed to the light on three sides,26 and he cites this instance in support of the opinion that sleeping with the face turned toward the window may be an exciting cause of the affec- tion. On shipboard it is often associated with scurvy, and the same connection was observed in the war in the Crimea.21 In certain epidemics pregnant women have HEMERALOPIA and N YCT ALOPIA, respectively night- blindness (day-vision) and day-blindness (night-vision), from npepa, day, wE, night, respectively, and eye, are names used by the older medical writers in opposite senses, to the confusion of the entire literature of the subject. Following Hippocrates, Aristotle, and Galen, although in opposition to the usage of the later Greek authors,1 nyctalopia is a condition in which vision is com- paratively good at night, or in a very feeble light, but is defective in strong daylight; and, conversely, hemera- lopia (used, in contradistinction to nyctalopia, in a single passage in Galen2) is a condition in which vision is acute by daylight, but falls off disproportionately at night or in the dark. If certain recorded observations are to be ac- cepted as trustworthy, it would seem necessary to admit that hemeralopia may occur under two types, the one marked by a quasi-diurnal fluctuation in the perceptive power of the retina, the other directly dependent on changes in illumination. Thus, it has been stated that the acuteness of vision increases from early dawn to the middle of the day, and diminishes as the sun declines to- ward evening,3 falling to its minimum as twilight deepens into night, or, according to some writers, not until mid- night ;4 that the blindness is less marked in the early dawn than in twilight,5 and that in aggravated cases the flame of a candle, the stars, and even the moon are either totally obscured or are seen as through a thick smoke or fog (Nachtnebel).6 As a rule, however, luminous bodies are seen distinctly, while objects at a little distance from the lamp appear enveloped in deep gloom, and the light of the full moon is often insufficient to enable the affected person to see his way.7 By concentrating the light of a powerful lamp upon the book, the hemeralope may be able to read large print; in other cases reading by arti- ficial light is impossible.8 That the falling off in vision at night is closely related to the defective illumination is proved by the fact that it occurs in the daytime on enter- ing a dark room, although wflth some persons, as it would seem, in a lesser degree than at night.8 Recent experi- mental tests of the vision of hemeralopes, by low grades of illumination, have shown that it begins to fail under nearly the same conditions as with normal-seeing persons, but that on further diminishing the light the falling off in vision, as measured by the size of the test-objects which can be discerned, is much more rapid.10 The hemera- lope requires also a relatively long time to reach his max- imum of visual acuteness on going from full daylight into a darkened room,11 and, on the other hand, some hemera- lopes suffer from dazzling of the eyes on first going out 605 Hemeralopia. Hemianopsia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. been especially affected.28 As a rule, whether in epidem- ics of night-blindness or in the conditions prevailing in localities in which it has been observed as endemic at cer- tain seasons of the year, also in most of the sporadic cases which have been reported, two principal factors may be distinguished, namely, impaired nutrition and long-con- tinued exposure to strong sunlight, often intensified by reflection from large bodies of water, snow, or sand; and it appears most rational to regard the former as a predis- posing, and the latter as the chief exciting, cause of the affection. Simulation has doubtless often played a part in swelling the number of supposed cases in outbreaks which have occurred in garrisons, on ships, in work- houses, etc., and this probability must be considered in judging of some of the remarkably prompt cures which have followed very different plans of treatment. Of the objective signs of hemeralopia, that upon which the most stress has been laid by military and naval sur- geons is the considerable dilatation of the pupils, which is generally most conspicuous at night; also the slug- gish response of the pupils to changes of illumination. Dryness of the scleral conjunctiva with formation of scaly patches, a dulled appearance of the corneal epithelium, even xerosis of the cornea, also conjunctival hyperaemia with lachrymation and photophobia, a staring expression of the eyes with the eyelids widely separated, have all been noticed, especially in endemic hemeralopia ; but so far as organic changes have been remarked, they would seem to be connected rather with the concomitant disturbances of nutrition than directly with the affection of vision.29 The duration of the affection in different cases, or as stated by different observers, has been variously reported as limited to a single day or to a few days, or as extend- ing to several weeks or months. As a rule, recovery speedily follows any change which works an ameliora- tion of the two conditions of impaired nutrition and undue exposure to strong light. Relapses are apt to oc- cur on renewed exposure to conditions similar to those which have given rise to the first attack.30 The treatment of night-blindness, as also of day-blind- ness-in both of which conditions the name nyctalopia has been used with little or no discrimination-was, until well into the present century, chiefly depletive and de- rivative. Bleeding from the arm and from the angle of the eye,31 cupping, purgation32 by elaterium,33 scam- mony,34 etc. ; the administration of emetics,35 diuretics, and diaphoretics ;36 the application of blisters and other counter-irritants behind the ears37 or to the back of the neck ; errhines and masticatories ;38 baths, frictions, ex- ercise, and gargles;39 in extreme cases trepanning the skull;40 various applications to the conjunctiva, espe- cially of an ointment made from the juices exuding from roasting liver; also steaming the eyes with the vapor of water in which liver is boiling, to which is added the recommendation to eat the liver;41 these are the thera- peutic measures recommended by the earlier and later Greek and Roman authors, by the Arabian writers on medicine, and by their followers down to quite recent times. Seclusion from bright sunlight and amelioration of diet must have contributed incidentally to the cure, but upon these points little or no stress was laid. In modern times a short confinement to a more or less per- fectly darkened ropm,42 attention to any concomitant pathological conditions, improvement of the nutrition, and, above all, the removal of the patient from the sphere of operation of the combined causes of the affection, have taken the place of the heroic or fanciful plans of treatment formerly in vogue. Nyctalopia, in the sense of seeing exceptionally clearly in comparative darkness, is said to have been observed in the case of prisoners confined for a considerable period in dark dungeons ;43 and such persons are said also to suffer from dazzling of the sight for a longer or shorter time after being set at liberty, or, in some instances, to have continued permanently day-blind.44 Physiological or pathological variations in the size and in the dilatability of the pupils may be relatively favorable to night-seeing or to day-seeing, according as the pupils are habitually larger or smaller than normal. In ametropia-whether myopia, hypermetropia. or astigmatism (see these titles)- also in emmetropia with loss of accommodative power (see Accommodation and Refraction, Physiology ; do. Pathology), the requisite conditions for distinct vision are generally best in a strong light, owing to the contrac- tion of the pupils and the consequent partial suppression of disturbing circles of confusion on the retina ; and this may be also the case in turbidity of the vitreous and in diffused clouding of the cornea or crystalline lens, in which conditions the penetrating power of moderately strong light may be required for tolerable vision. On the other hand, in cases of circumscribed central opacity of the cornea or crystalline lens, vision may be comparatively good when the pupils are widely dilated, as at night, and very bad when they are strongly contracted, as in bright sunlight. Darkly pigmented eyes, as a rule, best fulfil the conditions for clear and undazzled vision in strong sunlight, whereas the sight of persons with light blue eyes, and notably of albinos, is apt to be best at night. Retinal irritation following prolonged exposure to direct or reflected sunlight (snow-blindness), and especially re- flex irritability of the retina dependent on irritation of the terminal ramifications of the fifth nerve in the cornea and iris, are marked by excessive and often painful con- traction of the pupils under the influence of strong light, with consequent inability to use the eyes in the daytime (photophobia). It is a curious fact that the complex of symptoms described under the name of nyctalopia (day- blindness) attracted the attention of medical authors sev- eral centuries before the recognition of hemeralopia (night-blindness), and it is still more remarkable that the carlier teachings regarding the etiology and treatment, and even the name, of the former came later to be applied to the latter affection. Excluding cases of photophobia and of central opacity of the cornea or crystalline lens, the conditions to which the name nyctalopia is in any degree applicable are reduced to certain retinal and optic-nerve affections attended with irritability, and the few imper- fectly reported instances of day-blindness following long confinement in the dark. In the former class of cases the ophthalmoscope now affords the means of making a cor- rect diagnosis ; of the pathology of the latter cases noth- ing is definitely known. A few brief notices exist of day- blindness of an endemic or epidemic type,45 but no recent instance of the kind has been reported. John Green. 1 Aetius, Paulus .Egineta, et al. This later use of vvicTaAuuria in the sense of night-blindness has been justified by interpolating a privative, or aAads, blind, in the formation of the word. 3 Galen ; Eiaa-yaiy^, 16. 3 Stellwag: Die Ophthalmologic vom naturwissenschaftlichen Stand- punkte. Buch iv., § 193. Freiburg im Breisgau, 1853. 4 Vid. Himly: Die Krankheiten und Missbildungen des menschlichen Anges, Band ii., S. 451. Berlin, 1813. 6 Vid. Stellwag: Op. cit., iv., § 197. 6 Ibid., iv., § 193. 7 Vid. Leber: Graefe-Saemiseh, Handbuch der gesammten Augenheil- kunde, Band v., cap. viii., § 380. Leipzig, 1877. 8 Ibid. cf. Demours: Traite des Maladies des Yeux, t. i., p. 424. Faris, 1818. 9 Stellwag: Op. cit., iv., § 197. 10 Fiirster: L'eber Hemeralopie, etc. C. Reymond : Giorn. d'Oft. ital., xii.; ibid., xx.; Ann. di Oft., ii. (cited from Leber, loc. cit.). 11 Forster: Ibid. 13 Leber: Loc. cit. 13 Carron du Villards: Guide pratique pour 1'Etude et 1c Traitement des Maladies des Yeux, t. ii. Paris, 1838. 14 Leber: Op. cit., § 89. 15 De Sauvages: Nosologia Methodica, Cl. vi., ord. i., iii., i. Amste- lodami, 1768. 16 Vid. Himly: Op. cit., ii., 8. 453. 17 Blessig, vid. Leber: Op. cit., § 384-385. 18 Carron du Villards: Op. cit., t. ii. 19 Celsus: De Medicina. vi., vi., 38. 30 Hippocrates: HpoppTjTiKoi', B'. 31 De Sauvages: Loc. cit. 33 Demours: Op. cit., i., p. 425. 33 Vid. Leber: Op. cit., § 385. 34 Dubois (cited from Schmidt-Rimpler in Eulenburg's Real-Encyclo- padie der gesammten Heilkunde. B. vi., art. Hemeralopie). 35 Aristotle : Hep! yeveatos, E., Ed. Bekker, p. 170, 16. Bero- lini, 1831. ' 36 Stellwag: Op. cit., iv., § 198. 37 Vid. Ophthalmic Hospital Reports, ii., pp. 35-43, London, July, 1859. 38 Vid. Mackenzie: A Practical Treatise on the Diseases of the Eye, xxiv.. xii. Fourth edition, London, 1854. 39 Ibid. cf. Leber : Op. cit., § 386. 30 Vid. Himly: Op. cit., ii., S. 452. 31 Paulus Algineta. iii., xxii. 33 De Sauvages: Loc. cit. 33 Hippocratic Treatise, Hepi 34 Paulus JEgineta ; Loc. cit. 35 Demours : Op. cit., p. 430. 36 De Sauvages : Loc. cit. 37 Ibid. 38 Paulus ^Egineta : Loc. cit. 39 Celsus: Loc. cit. 40 Hippocratic Treatise. Hept audios. 41 Ibid. Celsus: Loc. cit. Paulus JEgineta : Loc. cit., et al. Said to be even now a popular remedy in some parts of Italy. 43 Netter (cited from Leber, op. cit., § 386). 43 Buffon, vid. Himly: Op. cit., ii., S. 449, note. 44 Vid. Larrey : Memoires de Chirurgie Militaire et Campagnes. Also, Galen's account of the captives of Dionysius. 45 Vid. Mackenzie : Op. cit., xxiv., xiii. 606 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hemeralopia. Hemianopsia, HEMIANOPSIA is a condition of blindness limited to one-half of the visual field. Hemiopia is used as a syno- nym incorrectly, as it signifies vision (not blindness) in one-half of the visual field. This condi- tion may be present in either the outer (temporal) or inner (nasal) half of the field of vision, and may affect one eye alone or both eyes. If both eyes are af- fected like-named halves of both may be involved-e.y., the left half of both eyes, in which case the condition is called homonymous hemianopsia; or unlike- named halves of both eyes may be in- volved-e.g., the left half of the left eye and the right half of the right eye, in which case the condition is known as heteronymous hemianopsia. By means of Forster's perimeter the visual field of each eye has been deter- mined (Fig. 1627). It is found to have an irregular outline, and to be divided into a large outer and a small inner portion by a line drawn vertically through the point of fixation. This point corre- sponds with the macula lutea, and lies on the outer side of the entrance of the optic nerve. The two inner fields really overlap one another, so that the actual outline of the entire visual field of both eyes is that represented in Fig. 1628. It becomes evident from this figure that the loss of one nasal half of the visual field is not appreciated by anyone unless the unaffected eye is closed. This fact is of importance, as it is evident that a nasal hemianopsia is a symptom which may not be noticed by a patient, and hence must be looked for by the phy- sician. The unequal size of the two portions of each visual field is so marked that in an homonymous hemianopsia the patient usually ascribes the blindness wholly to a defect in the eye whose larger portion is affected, and a careful medical examination is necessary to es- tablish the existence of a bilateral affec- tion. To determine a patient's visual field, each eye is to be tested separately. The patient holds a card before one eye and looks the examiner in the eye with the other. Any object, preferably a white one, is then moved about in the visual field of the eye which is uncovered, and the power and extent of indirect vision is thus determined. If hemianopsia ex- ists the patient will be unable to see the object when it is within the field of vision which is defective, or when it is carried beyond the vertical line passing through the fixation point toward the defective side. More accurate measure- ments may be made by means of a peri- meter, but the method described is suf- ficient to establish the existence of blind- ness in one-half of the visual field. lu no case of hemianopsia is direct vision at the fixation point affected. Since the lens of the eye reverses the image of the object seen upon the retina, each half of the visual field corresponds to the opposite half of the retinal expan- sion. A hemianopsia therefore indicates a suspension of function in the half of the retina opposite to the defective visual field. Such a functional derangement of one-half of the retina is rendered possible by the origin, course, and distribution of the nerve-fibres in the optic nerves, as seen in Fig. 1629. Each optic nerve is seen to pass from the eyeball back to the optic chiasm, and there to divide into two parts. One of these turns outward and joins the optic tract of the same side. The other crosses the Fig. 1627.-Visual Field of Both Eyes, taken separately. The vertical lines represent the portion of the visual fields affected in left hemianopsia; the horizontal lines, in right hemianopsia. median line in the chiasm, decussating with its . fellow from the opposite optic nerve, and joins the optic tract of the opposite side. The anatomical separation of the fibres from one optic 607 Hemianopsia. Hemideamns, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nerve renders it possible for a lesion situated in the chiasm, or in the optic tract, to affect a portion of the fibres com- ing from one eye, and consequently a part of the retina ; while a lesion affecting the optic nerve itself involves necessarily the entire extent of the retina, producing amau- rosis, not hemianopsia. It is found that the portion of the retina lying to the outer side of the fixation point is joined with the fibres of the optic nerve which pass directly into the optic tract of the same side ; while the inner portion of the retina sends its fibres across the median line in the decussation (Fig. 1629). It has been already shown that the nasal portion of the retinal ex- pansion, corresponding to the temporal half of the visual field, is larger than the other portion. The number of fibres in the optic nerve which decussate is greater than the number which do not cross the median line. The ratio of non-decussating to decussating fibres in the optic nerve, in any animal, is directly proportionate to the extent of the visual field common to both eyes. Bilateral hemianopsia is far more common that uni- lateral. It may be of several varieties. Bilateral nasal hemianopsia implies a destruction of the direct optic fibres on both sides, the decussating fibres being unaf- fected. Such a case has been observed by Knapp, in which a tumor surrounded the chiasm, pressing upon its sides, but not affecting its centre. Bilateral temporal hemianopsia is a rare condition, and is only produced by a lesion which divides the chiasm through its antero- posterior diameter without affecting its lateral halves, thus destroying both decussating strands. It has been observed in a few cases of tumor of the hypophysis. Bilateral homonymous hemianopsia is a not uncom- mon condition, and may be produced by many causes, and by lesions situated in many various parts. This will be better understood after the course of the optic tracts has been followed to their terminations in the visual area of the cerebral cortex (Fig. 1629), since a lesion at any point in this course will produce the symptom named. Each optic tract, after leaving the chiasm, passes around the crus cerebri, lying directly upon the fibres which pass through the foot of the crus (pes pedunculi), and ends on the level of the tegmentum of the crus in the external geniculate body, in the pulvinar of the optic thalamus (».«., the eminence forming its posterior surface), and in the corpora quadrigemina anteriora, which latter it reaches by the brachium conjunctivum. The last-named fibres of the optic tract have probably nothing to do with con- scious vision, and may therefore be ex- cluded from consideration in studying hemianopsia. They form the sensory part of a reflex arc, whose motor part is made up of the motor nerves to the eye- balls. The functions of this reflex mech- anism arc to direct the motion of the eyeballs, and to regulate the process of accommodation and the size of the pupil. The primary visual centres are, therefore, the external geniculate body and optic thalamus. The fibres of the optic tract end in the cells of these ganglia, and from these cells new fibres arise which collect in a large tract and issue from the poste- rior external angle of the optic thalamus into the posterior third of the internal capsule. This visual tract turns upward and backward in the internal capsule, radiates into the centrum semiovale of the occipital lobe, and, passing around the outer border of the posterior horn of the lateral ventricle, terminates in the convolutions of the oc- cipital cortex, including the cuneus. At no point in this course is any decussation found. The only decussation of fibres between the eye and the cortex is in the optic chiasm.1 Bilateral homonymous hemianopsia may be caused by a destructive lesion lying anywhere in the course of these fibres between the optic chiasm and the occipital cortex, or by a lesion in the cortex which destroys the perceptive centres in which the fibres end. 'Wherever the lesion, the character of the symptom will be the same. From the accompanying symptoms, it is in some cases possible to locate the lesion causing the hemianopsia. Thus, if the optic tract is involved as it curves around the crus cere- bri, the same lesion which causes the hemianopsia will be likely to affect the motor tract in its passage through the pes, or to involve the third nerve in its exit from the pes. In this case hemianopsia and hemiplegia of one side, with oculo-motor paralysis of the other side, will be combined. Or, if the termination of the optic tract in the geniculate body and thalamus is involved, the lesion, unless ex- tremely limited, will affect the sensory tract from the opposite side of the body in its passage through the teg- mentum of the crus, or in the posterior portion of the internal capsule; and in this case hemianaesthesia and hemiataxia will be associated with hemianopsia. Or, if the visual tract in its passage through the internal cap- Thus in the horse, or the rabbit, in whom there is no part of the visual field which is common to both eyes, the de- cussation of the optic fibres is total. In dogs, cats, mon- keys, and man, in whom, to a less or greater degree, the eyes are directed in parallel lines, the decussation is par- tial. In a rabbit or horse hemianopsia is impossible. In the other animals named it is observed. Unilateral hemianopsia is produced by lesions affect- ing the optic chiasm only. If the lesion lies on the outer side of the chiasm it produces nasal hemianopsia on the side of the lesion. Thus a tumor pressing upon point N in Fig. 1629 would produce blindness in the temporal half of the left retina, and hence nasal hemianopsia in the left visual field. If the tumor lies in front of or behind the chiasm, or presses upon it from above or below in such a manner as to involve the decussating strand of fibres either before or after they have crossed to the opposite side, it will cause a temporal hemianopsia (T in Fig. 1629). As it is impossible to determine whether the fibres are affected before or after decussation, no state- ment as to the side upon which the lesion lies can be made. Fig. 1628.-Outline of the Entire Visual Field of Both Eyes. 608 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hemianopsia. Hemidesmus. sule is involved by disease in the basal ganglia or in the capsule, the proximity of both sensory and motor tracts in the capsule will render a combination of hemianopsia, hemianaesthesia, and hemiplegia quite probable. This is the seat of the lesion, and this is the combination of symptoms most frequently observed (see vol. i., Fig. 518). Lesions in the centrum ovale involving the optic radi- ation may not produce any other symptom than that un- der discussion. If it is the left hemisphere, however, in which the disease is present, a condition of word-blind- lobe, since destruction of a portion of the convexity has produced the same result as destruction of its median sur face? Nor is it possible to project upon the cortex the retinal expansion, as has been attempted by Munk, since lesions in all parts of the occipital convolutions produce the same effect. Lesions in the angular gyrus may produce hemianop- sia, and it is well known that Ferrier has located in this convolution the visual centres. It is probable that such lesions have caused the symptom by affecting the visual tract as it passes beneath this gyrus in the centrum ovale. There is no reliable evi- dence that a unilateral lesion in the cor- tex can produce blindness of one eye alone. Hemianopsia is, therefore, a local symp- tom of brain disease of great value in de- termining the situation of a lesion, when considered in connection with other symp- toms. The symptom alone affords little evidence of the nature of the disease pro- ducing it, since it may be caused by any of the various forms of brain lesion (see Brain). It has been observed in cases of basilar menin- gitis, in tumors of the occipital lobe and basal ganglia, in haemorrhage and softening involving the internal cap- sule, and in embolism of the terminal branches of the posterior cerebral artery, and of the trunk and posterior branch of the middle cerebral artery, as well as in other rarer conditions. The diagnosis of the symptom may be made by an ex- amination such as has been described. The prognosis and treatment of it will depend entirely upon the nature of the disease producing it. JL Allen Starr. 1 Von Monakow: Arch. f. Psychiatric, xiv., 698-750; xvi., 151-200. Wernicke: Lehrbuch der Gehirnkrankheiten, Bd. i., s. 79-84. 2 Compare cases of Haab with those of Fritsch and Westphal cited by Starr : Visual Area of the Brain. American Journal of the Medi- cal Sciences, January, 1884; and these with Seguin's case, Journal of Mental and Nervous Disease, January, 1886. Full bibliographies are to be found in these articles. HEMIDESMUS{Hemidesmi radix, Br. Ph.). "The dried, root of Hemidesmus indicus R. Br. Order, Asclepiadaceee. A twining Indian shrub with slender, straggling stems, opposite ovate or lanceolate leaves, small axillary clusters of minute, regular flowers, and a fruit of two long and narrow divaricate pods ; seeds plumed as in milk-weeds. The root is long and slender, and slightly branched. The description in the British Pharmacopoeia, into which it is introduced apparently out of compliment to the In- dian physicians, is as follows : "In cylin- drical, more or less twisted, longitudinally furrowed pieces, six inches or more in length; covered by a thin, yellowish- brown or corky layer, which is easily sep- arated from the other portions of the bark, the latter being frequently cracked in an annular manner. Odor fragrant, resem- bling that of melilot or Tonquin bean ; taste sweetish, and very slightly acrid." A syrup, made from one ounce of Hemi- desmus to ten and one-half ounces of menstruum, is also official in England. The medicinal properties of hemides- mus are said to be those of sarsaparilla, in the stead of which it is used in British India ; in Europe or in this country it is rarely used. Its composition has not been fairly studied, but it is safe to say that nothing physiologically very peculiar or active is contained in it. An odorous princi- ple has been partially examined. The syrup in which it is prepared, like that of sarsaparilla, is scarcely more than a flavoring vehicle. Allied Plants.-The order, Asclepidacece, is a large and generally tropical one, but not especially interesting from an economic point of view. Several genera contain Fig. 1629.-Diagram to Show the Course of the Visual Impulses from the Eyes to the Brain. I., I., Infundibulum; C. Jf., corpora mammillaria; III., exit of third nerve; 8. N., substantia nigra of crus ; L., lemniscus of tegmentum ; I. G., internal geniculate body ; R. N., red nucleus of tegmentum ; N, lesion in chiasm causing unilateral nasal hemianopsia; T. lesion in chiasm causing unilateral temporal hemianopsia; II, lesion in chiasm causing bilateral temporal hemianopsia. The shading indicates the fibres, lesions of which at any place between the optic chiasm and the right occipital lobe will produce bilateral homonymous left hemianopsia. The portions of the visual field affected by such lesion are also shaded. The eyes are sup- posed to be directed in parallel lines and not to converge to a point. ness (see Aphasia) is not infrequently associated with it ; and in all the cases of word-blindness hitherto reported hemianopsia has been found. This is probably due to the destruction of association fibres between the occipital and temporal lobes which lie side by side with the visual tract. Lesions in the cortex of the occipital lobe produce no other symptom than hemianopsia. It is impossible to limit the visual area of the brain to any one part of the 609 Heinidesmus. Hemlock. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. caoutchouc, and from a few species it is collected for commerce. Some of the milk- or silk-weeds have been used as sources of fibre for textile purposes. One or two are cultivated for ornament, and a number have been used as unimportant drugs (Asclepias tuberosa, Tyloph- ora asthmatica), etc. Allied Drugs.-See Sarsaparilla. IF. P. Bolles. cult. In walking a dragging of the toes on the paralyzed side is often observed. In cases of permanent hemiplegia, especially if the paralysis be considerable, contracture of the paralyzed muscles usually occurs at a later period, a condition termed late rigidity. In a well-marked case we will find the arm drawn toward the chest, the forearm flexed on the arm and pronated, and the fingers flexed ; in the infe- rior extremity all the joints extended, and the foot in the position of talipes equino-varus. The rigidity is usually greater in the upper than in the lower extremity. In rare cases we find extension of the joints of the arm instead of flexion, or flexion in the lower extremity instead of extension. Sometimes the muscles of the face are also affected ; then the naso-labial fold becomes deeper, and the angle of the mouth elevated on the affected side. In extreme cases the rigidity is more or less constant; but in many cases it is much less marked than in the instance above described, and it is then increased by voluntary efforts to move the parts, or by emotional excitement, while it is diminished or absent during sleep. In some cases the rigidity improves very much with time, so that it is only observable during acts requiring special skill. Hemiplegics often succeed in walking with the aid of a cane, even though the leg be completely paralyzed, especially if the limb be at the same time rigidly ex- tended. In this case the pelvis and hip of the paralyzed side are elevated by the contraction of the abductor mus- cles of the thigh on the sound side, and the foot is then propelled forward by the action of the inward rotators of the healthy limb, the toes usually scraping the floor dur- ing the forward movement. The body now rests partly upon the foot of the paralyzed limb, partly on the cane held in the hand of the sound side, the centre of gravity being between them while the healthy limb is being brought forward. In connection with late rigidity there is found an in- crease of the deep, or tendon, reflexes. The patellar ten- don-reflex is exaggerated, the foot-clonus can be elicited, ■which is almost never present in health, and tendon-re- flexes can be elicited in the upper extremity, where they can rarely be found in the normal subject. Similar con- tractions of muscles can often be produced by striking the periosteum-periosteal reflexes. Hemiplegia is most frequently caused by a lesion of, or in the neighborhood of, the corpus striatum, on the side opposite to the seat of paralysis. If the paralysis be per- manent, it is because the internal capsule has been dam- aged, while the late rigidity is attendant on subsequent degeneration of the pyramidal tracts. Hemiplegia, produced by lesions of other parts of the motor tracts, has, in some instances, special manifesta- tions. Lesions in the motor area of the cortex, the an- terior and posterior central convolutions, more frequently produce a monoplegia-paralysis of one limb, or of the face-than hemiplegia, but the latter may occur if the lesion be sufficiently extensive. Such lesions are often attended by convulsive movements, especially if the lesion be a neoplasm. In such instances there occur usually periodic attacks of clonic spasms in one extremity or one side of the face ; in the hand, if the lesion chiefly affect its centre, etc. These spasms are at first quite limited, and not accompanied by loss of consciousness. But in succeeding attacks the convulsions are likely to extend to other parts of the body. They first travel over one side of the body. If the convulsion also seizes the other side, loss of consciousness is likely to supervene. There is often in such cases some blunting of the sensibility cor- responding to the amount of paralysis, indicating that the cortical centres for motion have also direct relationship with the sensory functions. But such cases do not al- ways give a like clinical picture. In a case recently seen by the writer, where there was a large tumor on the con- vexity, implicating chiefly the leg-centre, there was pare- sis of the opposite arm and leg, but no appreciable im- pairment of sensation, and there had never been any convulsive movement. Hemiplegia from lesion of the crus cerebri is often at- tended by paralysis of the third nerve on the side of the HEMIPLEGIA (¥//j.iavs, "the half," and ■KXr)<r(ru, "I strike Paralysis of one side of the body. Hemiplegia is usually the result of a cerebral hemor- rhage or embolism. It sometimes occurs suddenly with- out other marked symptoms, but commonly it is ushered in by an apoplectic attack and on the return of con- sciousness it is observed that one side of the body is para- lyzed, the paralysis being often profound in the begin- ning, and disappearing to a greater or less extent at a later period. Hemiplegia is much more rarely produced by a tumor. It then, generally, comes on slowly, the paralysis gradu- ally increasing as the neoplasm encroaches more and more upon the motor tracts, though the tumor may be complicated by the occurrence of a haemorrhage and a sudden hemiplegia. A gradual hemiplegia may also be produced by an ab- scess, or chronic softening of the brain-substance. Other conditions or symptoms presented will, in such case, as- sist us to diagnose the nature of the lesion. In all of these instances, whether the paralysis occur suddenly or gradually, it is the result of a lesion of the cortico-muscular tract-that is, of the nerve-fibres which convey voluntary impulses from the cortical motor cen- tres to the muscles, or of a lesion of the centres them- selves. But there are other instances in which the pa- ralysis is caused by no palpable lesion. To these the term hysterical hemiplegia is applied. The paralytic manifestations vary greatly. Shortly after an apoplectic attack, if it be severe, most of the muscles on one side of the body are paralyzed. The arm and leg are entirely powerless. The muscles supplied by the lower branches of the seventh nerve, those of the cheek and mouth, are completely paralyzed. That side of the face is expressionless, and the mouth is drawn to- ward the other side. But the muscles supplied by the upper branches of the seventh nerve-the orbicularis pal- pebrarum, occipito frontalis, and corrugator supercilii-are only slightly affected. The tongue, when protruded, de- flects toward the paralyzed side. The muscles of the chest and abdomen of the paralyzed side are slightly af- fected, and there is usually, at an early period, some im- pairment of the cutaneous sensibility on the paralyzed side. On the other hand, some muscles almost invariably escape injury. These are the muscles supplied by the third, fourth, fifth, and sixth nerves-those of the eye- balls and of mastication-and the muscles concerned in swallowing and vocalization. The articulation of words is usually somewhat indistinct for a short period, or there is a loss of speech-aphasia. The high degree of paralysis just described is of short duration. The paralysis of the muscles of the trunk, of the tongue, and the indistinctness of articulation usually disappear at an early period. The facial paralysis also diminishes; sometimes disappears altogether. The pa- ralysis of the arm is usually most profound and slowest to improve. The hemiplegia of a later period is, as a rule, only to be found in the face and extremities, though sometimes the tongue continues, when protruded, to deflect toward the paralyzed side. If the facial paralysis be slight, it will be observed that the naso-labial fold is less marked than on the sound side, that the upper lip is less arched and the angle of the mouth droops somewhat on the affected side. A slight paralysis becomes more marked when the muscles are actively exercised, as in smiling, exposing the teeth, etc. In the extremities the movements of the hand are usually more impaired than those of the elbow or shoulder, and those of the foot more than of the leg. The extensors of the fingers are weaker than the flexors, while the skilful movements of the fingers are most diffi- 610 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hemidesmus. Hemlock. lesion. There is paralysis of the face and extremities on one side, and of the muscles of the eye on the other side. Lesions of the pons Varolii frequently cause what has been termed alternate hemiplegia, that is, paralysis of the apn and leg on one side, and of the face on the other, the extremities being affected on the side opposite to the face, on the same side as the lesion. The reason for this is the following: The central prolongation of the seventh nerve, like that of all other motor nerves, passes from one side of the brain to the other, the site of crossing being, in case of the seventh, in the pons. Lesions, then, in the latter locality may affect only the peripheral parts of the nerve-the nerve-trunk itself, or its nucleus-and the facial paralysis be on the side of the lesion. The fa- cial paralysis in such cases differs from that with ordi- nary hemiplegia, in that it has the stamp of peripheral paralysis. The paralysis is likely to be complete, all parts supplied by the nerve being equally affected, the eyelids and forehead as much as the lips and cheek. There will also be found changes in the electrical reac- tions, the so-called reaction of degeneration. The elec- trical reactions of the nerve and faradic contractility of the muscles are lost, while the galvanic contractility of the muscles may be heightened, but follows different laws from the normal. Such changes in the electrical reaction are never found in central paralysis, only in the paralysis of a peripheral type. If the degree of paralysis be great, some atrophy of the facial muscles may also take place. Hemiplegia from lesions of the medulla oblongata is likely to be attended by paralysis of other cranial nerves, while the seventh nerve escapes. There is likely to be a considerable paralysis of the tongue, indistinctness of ar- ticulation, and paralysis of the vocal cords from the in- volvement of the hypoglossal and pneumogastric nerves. The writer has under his observation at present a case of unusual interest, in which there is probably a lesion of the medulla and pons of traumatic origin. The injury was caused by an iron rod penetrating the right submaxillary space, and passing upward four inches in the direction of the foramen magnum. Immediately after the injury there was complete paralysis of the right arm and leg, of the cheeks, lips, tongue, and vocal cords. The patient was unable to swallow or to make any vocal sound. The upper part of the face was unaffected. He could move the eyes freely, open and close the lids, and was entirely conscious. There was also loss of sensation on the left side of the face. The condition of the patient rapidly improved, but there remain permanently a right-sided, paralysis, considerable difficulty in articulation, and anaes- thesia of the left side of the face. Lesions of one-half of the spinal cord produce hemi- plegia quite peculiar in its manifestations. There is motor paralysis of the parts below the seat of lesion, the loss of power being on the side of the lesion, while there is at the same time hyperaesthesia in the paralyzed parts and anaesthesia on the opposite side. Brown-Sequard has produced the same array of symptoms in animals by a section of the right or left half of the spinal cord. Some cases of hemiplegia of infancy, which are either congenital or acquired early in life, deserve special men- tion. The lesion in the acquired hemiplegia is usually haemorrhage or encephalitis, involving chiefly the cortex of the convexity ; in the congenital cases a parencephalic defect, that is, the absence or lack of development of a part of a hemisphere, the defect being occupied by a cyst- like space. The hemiplegia is usually attended by con- tractures of the paralyzed muscles, and by a considera- ble arrest of development. The leg and arm are smaller in circumference and shorter than those on the sound side, and the face is also frequently smaller than on the paralyzed side. There are sometimes choreic movements of the paralyzed limbs. Great impairment of intellect, even complete idiocy, are frequently found, and epileptic convulsions become established in many cases. In hysterical hemiplegia the paralysis is usually not complete, the face is not affected, and the leg is more completely paralyzed than the arm, while in hemiplegia of organic origin the arm is commonly the most affected. In almost all cases the paralysis is accompanied by loss of sensation on the affected side. The latter is often com- plete. If it be only partial, the sense of pain and tempera- ture is affected to a greater extent than that of touch or contact. Even though the loss of sensation be complete, it is often unknown to the patient, and only revealed by the objective examination of the physician. It generally affects the left side. It sometimes comes on slowly and insidiously, but more frequently occurs suddenly after an hysterical attack. Its duration is variable; it may continue but a short time, and in the meantime vary in its intensity, or it may continue unchanged for years. The paralysis is often accompanied by contractures of the muscles, and in some instances the patellar tendon- reflexes seem to be exaggerated. Both the contractures and the paralysis sometimes disappear suddenly from the effect of some emotional shock, even though the condi- tion has existed for years. One must often be cautious in making a diagnosis of hysterical hemiplegia. The mere symptoms as above given would not be sufficient. Very recently the writer saw a case of hemiplegia where the muscles of the face were not affected, the arm was less affected than the leg, and the motor symptoms were much less pronounced than the sensory, there being com- complete hemianaesthesia. So this was the exact picture, as above given, of hysterical hemiplegia. But it occurred in a man of sixty, without any nervous history, and there was evident degeneration of the blood-vessels. There is, doubtless, a lesion involving especially the posterior part of the internal capsule. Perhaps the motor filaments to the lower extremity in the internal capsule lie posteriorly to those for the upper extremity, and in this way the greater paralysis of the leg is to be accounted for. The diagnosis, then, must be based upon something more than the mere paralytic manifestations : upon the age of the pa- tient, upon the presence of other hysterical symptoms, and the manner of coming and going of the paralysis. Yet it must be remembered that the mere presence of ordi- nary hysterical symptoms does not preclude the possibil- ity of organic disease. In some extreme cases, made especially well known by the classical descriptions of Char- cot, the diagnosis cannot be doubted. In these there is, in addition to hemiplegia and hemianaesthesia of both general sensibility and the special senses, localized ten- derness over the ovarian region, pressure over which may bring on or abort an hysterical paroxysm. In these cases, too, the phenomena of transfer can often be produced. The application of metals or other agents to the surface cause a disappearance of the paralysis and other symptoms from the one side of the body, and their appearance on the other, though the transfer is of only short duration, the symptoms again disappearing from the second side and reappearing where they were originally. Philip Zenner. HEMLOCK (Conium, U. S. Ph., fruit; Conii Fructus, Br. Ph.; Conii Folia, Br. Ph.; Herba Conii, Ph. G.; Cigue officinale, Codex Med., leaves and fruit). This classical poison, Conium maculatum Linn., Order, Urnbel- liferw, is a stout, erect, biennial herb a metre or more (three to six feet) in height, with a long, simple or forked, rather fleshy, yellowish-white root two centimetres or so in diameter, and a smooth, branching, striated or fur- rowed, purple-spotted, dark-green, hollow, slightly glau- cous stem. The spots are small and rather numerous ; the pith-cavity is closed at the joints of the stem. Leaves numerous, those of the root and lower part of the stem very large, smooth, dark-green, of triangular outline and long-petioled. They are twice pinnate, with rather dis- tant pinnae and small lanciolate-pinnatifid and sharp- toothed divisions; those of the upper part of the stem and branches are smaller and simpler, short-petioled or even sessile, sometimes clustered. Umbels small, numer- ous, once compound, with few involucral bracts, and only three or four involucels to each " umbellule," generally on its outer side. Flowers small, white; those on the outer side of each umbellule larger and more perfect than those on the in- ner. Calyx teeth abortive; corolla of five petals with 611 Hemlock. Hemp. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. blunt incurved tips ; stamens five ; ovary of two united carpels. Fruit broadly ovate, pointed, slightly flattened laterally, ridges prominent, thick and wavy ; vittae ab- sent or rudimentary. Odor disagreeable; taste bitter and nauseous. Hemlock is a common old-world plant occurring in the temperate portions of Europe, Asia, and even Africa. It is also rather common in many places, as an introduced weed, in the United States. It affects rich and moist waste places, especially swamps and brook-sides and damp and shady gardens. It is easily told from most harmless UmbellifercB by its spotted stem, dark leaves, treating with potash is a rough way of estimating its value. The leaves are especially unstable (their general description is given above); their odor, when fresh and green, is strong and disagreeable, and developed still more so by the potash ; when dry they often have no strength or value. The fruits (like those of the other umbellifers generally called seeds) are alone officinal in the United States, the dried leaves having proved to be generally worthless in this country. They are thus de- scribed in the Pharmacopoeia : "About one-eighth of an inch (three millimetres) long ; broadly ovate ; laterally compressed ; gray-green ; often divided into the two meri- carps, each with live crenate ribs, without oil-tubes, and containing a seed which is grooved on the face ; odor and taste slight." The odor may be developed, as in the case of the leaves, by trituration with a solution of potash. They hold their strength comparatively well, and yield, on the whole, more uniform preparations than even the fresh leaves. Composition.-Conium contains but very little essen- tial oil compared with the aromatic members of the order, and that little is neither pleasant nor useful. Its most important constituents are two or three closely related alkaloids. The most important of these in quantity and activity is conine, which in the plant exists combined with one of the common vegetable acids, probably malic, to the extent of about two parts per mille in the fruit. The leaves contain much less. It is a strongly basic, color- less, oily liquid, of penetrating odor, exactly like that of the urine and nests of mice, and a sharp, burning, tobacco- like taste. It is volatile at ordinary temperatures, and boils at 160° to 180° C. In vacuum it can be redistilled without change, but in the air a portion is decomposed. It becomes thicker and yellow upon prolonged exposure, and, finally, resinous looking. Specific gravity, 0.88. Chemical composition, C8Hi7N. It is freely soluble in alcohol, chloroform, the essential oils, etc., but only to the extent of one per cent, in water. It, on the other hand, dissolves from twenty to thirty per cent, of cold water, which may be separated by heating. It unites with acids forming neutral salts, which are often crystal- lizable. There are several ways of preparing it, involv- ing, generally, liberating it from combination by an al- kali, distilling, and purifying. One is as follows: The green fruits or fresh juice is treated with a solution of caustic potash and distilled. The distillate contains the conine along with water, oil, ammonia, etc. This is neu- tralized by sulphuric acid, the oil poured off, and the remainder evaporated to a syrupy consistence ; this is treated to a mixture of ether and alcohol, which elimi- nates the sulphate of ammonia, and dissolves only the salt of conine. This solution is then evaporated, and the re- maining conine sulphate decomposed by potash and the conine carefully distilled off and freed from water by chloride of calcium. Complete purification is difficult to accomplish. The second alkaloid, conhydrine, is solid, and concretes in the head and tube of the retort in pearly, iridescent, white, foliaceous crystals. It has a faint, comne-like odor, melts at a lower and boils at a higher temperature than conine, and, like camphor, volatilizes without change below its melting point. The proportion of conhydrine in conium is much less than that of conine. Methyl conine is usually present in commercial conine, and is probably a constituent of the drug itself. Conhydrine can be converted into conine by abstracting the elements of water with phosphoric anhydride. The conine of the market is also apt to contain some conhydrine dissolved in it, which can be separated by freezing. The physical properties of conine and con- hydrine are very nearly those of an essential oil and its camphor. Action and Use.-The action of conium may be re- garded as entirely that of conine ; conhydrine and methyl conine, besides their smaller proportion, are physiologi- cally only conine reduced ; the oil and other constituents (vegetable acids, etc.) amount to nothing. It is said that conine itself is a local irritant, on account of its property of coagulating albumen, but this action is certainly not prominent, and does not appear among the symptoms of Fig. 1630.-Conium Maculatum. short, thick, disagreeable-smelling fruits, and the absence of oil-bearing vittse in the latter. History.-Conium is notorious as an ingredient of the state poison of the ancient Greeks, by which the philos- opher Socrates met his death. It is mentioned by several Greek writers of about the same time, and by numerous Latin ones since-by these often under the name Cicuta. It was used as a medicine by English and Scotch phy- sicians several hundred years ago, but its employment under modern ideas of medicine dates from the time of Stoercke, about seventy-five years since. The use of the term Cicuta as the name of the Hemlock by Latin authors has created some confusion, which was not diminished by Linnaeus when he gave the latter name to a related and almost equally poisonous plant. (See Allied Plants.) All parts of Hemlock are active, and have been em- ployed in medicine, but the leaves (herb) and fruit are the official portions. Both should be gathered when fully developed, but while still green, and, if not used at once, carefully and quickly dried without heat. As the active principles are volatile, the drug deteriorates rapidly, and should be considered inferior if more than one season old. The intensity of odor developed by moistening it and 612 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hemlock. Hemp. either accidental or physiological poisoning. Conium is a very active drug, poisoning all classes of animals, with few exceptions, and in the same general way, that is, by paralyzing the motor nerves from the extremities upward, and finally the action of the heart. In birds and the lower animals cerebral convulsions occasionally super- vene, and may become a prominent symptom; in man and most warm-blooded animals they are less common. Lan- guor, weakness beginning in the legs or hind extremities, then appearing in the arms and extending to the body, are noticed in nearly all. The classical case of the death of Socrates, as given in the Phsedo, describes its action well, as also does the following from " Taylor's Medical Jurisprudence : " "A man ate a large quantity of hem- lock-plant by mistake for parsley. In from fifteen to twenty minutes there was loss of power in the lower ex- tremities, but he apparently suffered no pain. In walk- ing he staggered as if he was drunk ; at length his limbs refused to support him, and he fell. On being raised, his legs dragged after him, and when his arms were lifted they fell like inert masses and remained immova- ble. There was perfect paralysis of the upper and lowTer extremities within two hours after he had taken the poison. There was a loss of the power of swallowing and a partial paralysis of sensation, but no convulsions, only slight occasional motions of the left leg ; the pupils were fixed. Three hours after eating the hemlock the respiratory movements had ceased." Death took place by gradual asphyxia a quarter of an hour later. The in- tellect was clear till near the end. The sensory nerves appear to be also affected, but only as a late symptom. The spinal cord resists its action still longer, and the brain, at least the hemispheres, almost to the end. The pupils are dilated. The heart is but little affected. The quantity of conium or conine required to produce death is not very definitely known, on account of the va- riability both of preparations of the plant and of the com- mercial alkaloid. Several cases of death in this country have occurred from doses of one preparation theoretically the same as had proved innocuous with another. In the famous case of Louisa Berger, death followed rapidly after ten or fifteen drops of the alkaloid. In another, oc- curring in New York, three hundred and twenty drops of the fluid extract, taken in divided doses over a period of six or seven hours, produced the same result. The use of conine as a medicine is of very restricted range. Its employment in scrofulous conditions, in rheumatism, cancer, inflammation of the lungs, and various other af- fections, may be considered obsolete. As an antispas- modic, it has both physiological and clinical evidence in its favor. In whooping-cough, hysterical excitement, and " nervousness," it is often of value. In the wild rav- ing of acute mania or the exacerbations of chronic insanity large slightly paralyzing doses are often of great service. But that it is not free from danger in such quantities the experience of a St. Louis asylum has shown. Administration.-Conium should not be given in sub- stance, as when ground into powder its activity must soon diminish. The leaves have been found so useless in this country when dried, in which condition only they were used, that they have been entirely discontinued. The fresh leaves and the juice expressed from them are better, but far from satisfactory. They are in use in England and on the Continent; the solid extracts are almost neces- sarily spoiled by the heat used in making them. The fully grown but not quite ripe fruits, as required by our Pharmacopoeia, are the most uniform and permanent of all parts of the conium plant, and should be used exclu- sively for the Galenical preparations. The following are officinal: The Abstract (Abstractum Conii, U. S. Ph.), strength f; the Extract (Extractum Conii Alcoholicum, U. S. Ph.); the Fluid Extract (Extractum Conii Fluid- urn, U. S. Ph.), strength { ; and the Tincture (Tinctura Conii, U. S. Ph.), strength Of these, the two last are theoretically perfect, especially if the fluid extract is made by the process of repercolation without the use of heat. The dose of this extract may be stated at half a gram (0.5 Gm. = 1H_vij.), to be increased until its physio- logical effects are noticed. Conine itself and a hydro- bromate are in the market, and occasionally prescribed. Dose, one or two milligrams (0.001-2 = gr. -fa to aU). Allied Plants.-Several interesting and poisonous Umbellifers are nearly related to Conium. Cicuta macu- lata Linn., of our swamps, is one of the most dangerous. It resembles Conium very closely, and its large, fleshy roots have been eaten in a number of cases with fatal ef- fect. It is supposed to contain conine. Cicuta virosa Linn., of Europe, is also a well-known poison, although exceedingly variable in its activity, and in some places said to be even harmless ; it contains a convulsive poison, cicutoxin. (Enanthe crocata Linn., also of Europe, has caused many fatal cases, and other species of (Enanthe are also dangerous. For the rest of the order, see Anise. Allied Drugs.-Curare, Physostigma, Lobelia, Gel- seminum, Tobacco. W. P. Bolles. HEMP, CANADIAN (Apocynum, U. S. Ph.). A peren- nial herb with a very long, branching, horizontal root, upright branching stems, a tough, hemp-like bark (from which it gets its name), and small greenish flowers in close cymes. All parts contain a bitter, milky juice. It is common along river-banks and in pastures generally in the United States and parts of British America. The dried root, which is the officinal portion, is "long, cylin- drical, somewhat branched, one-fourth to one-third of an inch (six to eight millimetres) thick, pale brown, lon- gitudinally wrinkled, and transversely fissured ; brittle ; fracture short, white; the bark rather thick, the wood porous, spongy, with delicate medullary rays, and a thin pith; inodorous; taste bitter, disagreeable." Apocynum promotes excretion in various directions. It is emetic and cathartic, also diaphoretic, and perhaps diuretic. With such distributed action, and a constantly present doubt in which direction it will prove most ener- getic, it is to be questioned whether it is often the best choice that can be made for depleting a patient, or even reducing a " dropsy." Among other things a supposed active principle has been found in it, and called apocynin, a "digitalis-like heart-poison," and a glucoside, apocy- nein. Its general action depends, however, probably on a variety of ' ' extractive " ingredients. Administration.-From one to two grams (1 to 2 Gm. = gr. xv. ad xxx.)are a full emetic-purgative dose. It may be given in substance or in decoction. Allied Plants.-A closely related species, A. Andro- scemifolium Linn., also growing in the pastures and hill- sides of this country, with more straggling stems and larger flowers, was formerly officinal. Its properties are similar to those of A. cannabinum, but milder. The order is a generally tropical one, of medium size, and generally deleterious qualities ; a milky juice is generally present, and some species are important sources of caoutchouc. Alstonia constricta and A. scholaris are occasionally used in medicine. The oleander and periwinkles are common garden-flowers. Allied Drugs. -Ipecacuanha, Stillingia, etc. . W. P. Bolles. HEMP, INDIAN (Cannabis Indica, U. S. Ph., Br. Ph.; Herba Cannabis Indices, Ph. G.; Chanute, Codex Med.; Ganga, ' ' Guaza "). The hemp-plant, Cannabis sativa Linn.; Order, Vrticacece, is a large, very variable annual herb with an upright, slender, usually branching stem from one to three metres high (three to ten feet), long-petioled, grace- ful, palmately divided leaves, and small, clustered dioe- cious flowers. The bark of the stems and branches has an exceedingly tough liber, which, treated like flax, is the source of the hemp used in ropes, matting, and coarse fab- rics. The leaves are opposite (or alternate above), stipu late, and consist of from five to seven (excepting near the top of the stem, where they are simpler) linear-lanceolate, pointed, sharply serrate leaflets. Flowers in axillary clusters ; the staminate in lax, spreading or drooping pan- icles, consist of five sepals and as many opposite, large- anthered stamens; the pistillate in small, erect spikes, each flower in the axil of an upright, pointed bract, consist of a single one-seeded, two-styled carpel envel- oped in a broad, spathe-like, one-leaved perianth. Fruit 613 Hemp. Heredity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (the hemp-seed of commerce), a roundish-pointed ache- nium containing a single pendulous, oily seed. All parts of the plant are either pubescent, scabrous, or glandular to a degree vary- ing according to the part, the vari- ety, and especial- ly the climate in which it grows. Hemp is a native of central and tem- perate Asia. It is also cultivated there and in so many other places that its exact hab- itat, as well as type-form, is diffi- cult to define. It is now cultivated and more or less naturalized in China, India, Rus- sia, Southern Eu- rope, Africa, and the United States. That which grows in hot countries (India, China) con- tains the largest proportion of intoxicating resin ; that of temperate ones (Russia, Italy) the best fibre. In cool localities it produces almost no resin. The numerous botanical varieties are not "well separated from each other. Like other plants, it grows larger and ranker in the tropics. Hemp was cultivated by the Chinese for its bark at least five hundred years before Christ, and its narcotic properties were known not long after. Herodotus speaks of garments made of it as being almost indistinguishable from linen. Its employment as an exhilarating narcotic among the Arabians dates from before the Middle Ages. Its introduction into modern medical practice is due to the efforts of Dr. O'Shaughnessy in the first half of the present century (Fliickiger). Description.-Hemp, as a narcotic, is known in Asiatic commerce in several forms : 1, the dried tops of pistillate flowering plants ("gunjah"); 2, the leaves ("bhang"), which are used for smoking; and, 3, the resin itself (" churrus "), collected in a rude way by brushing through the plants with leathern garments on, tow'hich it adheres, and then scraping it off. This is also used in smoking. Hashish is an Arabian preparation from the resin. The first is the form imported for medicine. It is in pieces generally about five centimetres (2 inches) long, but sometimes ten or twenty, branching, com- pressed together, brittle, consisting of the upper re- duced leaflets (one to three to each leaf), and the spikes of pistillate flowers de- scribed above, or the more or less developed fruit. The parts are all more or less agglutinated together with the resin. Color dusky-green or brown ; taste slight; odor peculiar; " narcotic." The tops of hemp grown in Kentucky and other parts of America are also officinal under the name of Cannabis Americana, U. S. Ph. The description is that of the plant ; it is never so resinous as that from India, and is but little employed. (See Ward's " Therapeutics.") Composition.-About one-third of one per cent, of es- sential oil gives hemp its odor, but not its medical value. This is due to the composite resin, cannabin, or one of its not yet well-determined parts, possibly to a thick oily alkaloid-like substance, " cannabinin," obtained by Sie- bold and Bradbury from the resin. A doubtful chemical "cannabin tannate " is offered as a convenient form for the active principle of hemp. Action and Use.-The action of hemp is primarily upon the intellectual centres, producing disorders of sense and thought; reveries, hallucinations, distorted notions of time and space, and of intensity of noises and other impressions upon the senses, lapses of consciousness, par- tial paralysis of both sensation and motion, and some- times coma, catalepsy, and convulsions ; dual conscious- ness is a rather frequent symptom ; so, also, is sleep. It is used to a great extent in Asia as a gentle intoxicant, generally smoked, either by itself or mixed with opium. For this purpose it is prepared in several ways, and mixed or flavored to suit the taste of the buyers ; the crude resin, cheken, is the source of most of these prepa- rations. Hashish is the name of the form in which it is used by the Arabs. The above symptoms, while not very plainly indicating its use in medicine, are, never- theless, the guide to it. The mental exhilaration and indifference to external impressions and the moderate paralysis tend to divert the lunatic from the usual train of his thoughts, or diminish the suffering of neu- ralgia or migraine, or overcome the convulsions of tetanus and the paroxysms of whooping-cough. As a hypnotic it has some value, but does not compare with chloral or paraldehyde ; as a reducer of spasm it is often quite effi- cient, but generally less so than the above or even the bromides. It may often be used with advantage com- bined with the above as an adjuvant. Administration.-Hemp is of exceedingly variable quality, from an absolutely inactive to a very energetic substance. Climate, elevation of ground, and variety of the plant affect it greatly ; and, finally, age and exposure may have altered that which reaches us. Certainly the ef- fects of hemp here, although sometimes very striking, do not generally equal those said to be obtained from it when it grows in India. The dose of hemp-tops to start with is from one to three decigrams, and it is to be in- creased until its physiological effects appear. The Phar- macopoeia offers an Extract (Extractum Cannabis Indices, U. 8. Ph.) five or six times as strong as the crude drug, and a Fluid Extract (Extractum Cannabis Indices Fluidum) strength f. The Tincture (Tinctura Cannabis Indices) is one-fifth as strong as the tops themselves. Allied Plants.-There is but one species of Canna- bis. Humulus, the Hop, is in the order and yields a some- what similar product (Lupulin). The order in its widest sense is a large one, and contains several pretty distinct groups. The greatest diversity of size and appearance exists among its species. Elms, Breadfruits, Mulberries, Figs, and Nettles are representative types. Allied Drugs.-Hops, Lupulin, Opium, Hyoscya- mus, Belladonna, etc., the bromides, chloral, and, more remotely the anaesthetics and Lactucarium. IE P. Bolles. Fig. 1631.-The Hemp Plant-Pistillate Inflo- rescence. (Baillon. HENBANE {Hyoscyamus, U. S. Ph.; Hyoscyami Folia, Br. Ph.; Herba Hyoscyami, Ph. G.; Jusquiame noir, Co- dex Med., leaf and seed), Hyoscyamus Niger Linn. ; Or- der, Solanacees. A coarse-leaved, viscid, disagreeably smelling annual or biennial herb, 'with a large, fleshy, simple root and an upright, branched, leafy, and very hairy stem. The root leaves are large (twenty or thirty centimetres-six to twelve inches), long, ovate, or tri- angular ovate, very coarsely and deeply sinuate-den- tate. Stem leaves narrower and simpler, the upper ses- sile, all raggedly toothed or pinnatifid. All the leaves are thin and soft, and lose much in drying ; midribs broad and prominent; surfaces rough or hairy. The pubescence of all parts of the plant is more or less glandular and sticky. Inflorescence, a scorpioid raceme involuted at the top and unfolding as the numerous, two- rowed, leafy bracted flowers open. Flowers crowded, sessile, single in the axils of the bracts, rather large (two Fig. 1632.-Staminate Inflorescence. (Baillon.) 614 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hemp. Heredity. to three centimetres across) and slightly irregular. Calyx persistent, vase-shaped, with an ovoid or globular tube, enclosing, but not adherent to, the ovary, and a conically spreading five-toothed limb. Corolla yellow, with pur- ple veinings, bell-shaped, limb five-cleft, the lower lobes slightly larger than the others. Stamens five, adherent to the corolla. Ovary two-celled. Fruit an ovoid, many- seeded pyxis, with a conspicuous lid, falling off at ma- turity by a transverse fissure. Embryo coiled. Henbane is a native of Europe and grows in an annual, and a more prized biennial, form. Its area extends from the south to as far north as the British Isles, and eastward into Russia and Central and Western Asia. As an introduced weed and occasionally cultivated, it grows in the United States and other parts of America, As might be expected, so conspicuous and poisonous a plant early attracted the attention of man, and it is no- Composition. - The principal active constituent of Henbane is a peculiar, very poisonous alkaloid of the Atropine group, hyoscyamine, discovered by Geiger and Hesse in 1833, and separated and purified since by many other chemists by almost as many methods. The per- centage of hyoscyamine is very small (0.164 per cent, from fresh leaves) and variable; its complete purification has proved very difficult. When pure it crystallizes in tufts of minute, white, shiny needles of no smell, but a bitter and disagreeable taste. With special care it can be sublimed and recovered unchanged. It is permanent in the air, and but little soluble in water; in alcohol, ether, chloroform, etc., freely so. Impure hyoscyamine, on the other hand, is unpleasantly odorous, hygroscopic, and easily soluble in water. It saturates acids and forms with them neutral crystal- line salts, of which one, the sulphate, is officinal. A second alkaloid, hyoscine, is also present in small quan- tity, a colorless, semi-liquid mass, which also forms crys- tallizable salts with acids. It is present in amorphous com- mercial hyoscyamine, from which it is usually prepared. The leaves, like those of other Solanacece, contain a large amount of nitrate of potassium ; the acid, with which the alkaloids are united, is stated to be malic. The seeds of henbane contain, besides the alkaloids just mentioned, a large amount of fixed oil. Action and Use.-The general action of Henbane is the same as that of Belladonna (vol. i.), for which it may be considered to be a duplicate : staggering, delirium, dilatation of pupils, and dryness of throat. Erythema and coma are rarer symptoms. Of the separate alka- loids hyoscyamine is the most like atropine, and occasions slight increase of the pulse-rate and respiration, dryness of throat, hoarseness, dilatation of the pupils,* disordered vision, dizziness, headache, etc.; in small doses it is mod- erately hypnotic ; hyoscine is said to be " stronger" than the former, which it in general resembles, but it is as yet scarcely sufficiently investigated. Hyoscyamus may be used for any of the purposes for which Belladonna and Stramonium are employed, but it is less often employed about the eye, and more often as a hypnotic and anti-spasmodic than the former. For over- coming restlessness, "nervousness," and producing sleep in insane cases, it has been a good deal employed, both alone and in combination with the bromides, and with opium. In asthma, whooping-cough, and the sweats of phthisis, it is valuable-for epilepsy probably but little so. But the introduction into use of amyl nitrite, chloral, paraldehyde, narceine, and several other remedies for these affections, has made hyoscyamine less necessary than it was formerly thought to be. Of the alkaloids, salts of both are to be had in the market. Administration.-Hyoscyamus may be given in pow- der, dose, two or three decigrams (0.2 to 0.3 grm. = gr. iij. ad v.), but there are numerous preparations : The Ab- stract (Abstractum Hyoscyami, U. S. Ph.), is a new one, representing twice its weight of the powder, dose, 0.1 to 0.15. The Alcoholic Extract {Extractum Hyoscyami Al- coholicum) is more generally used, but is more uncertain in its strength : dose, six to twelve centigrams (0.06 to 0.12 grm. = gr. j. adij.). The Fluid Extract {Extractum Hyoscyami Fluidum), strength, f, and the Tincture {Tinc- tura Hyoscyami), strength, -fa, are the best preparations. The Sulphate of Hyoscyamine {Hyoscyamines Sulphas, U. S. Ph.) may be given in doses from 0.001 grm. (gr. fa), until its action is evident; the dose of the Hydriodide of Hyoscine is said to be 0.0005 grm. (gr. T|u). Allied Plants, Allied Drugs.-See Belladonna. IK P. Bolles. Fig. 1633.-Henbane, riant and Fruit (about one-half natural size)- Seed Enlarged. (Bailion.) ticed by writers of the greatest antiquity among the Greeks and Romans. In Northern Europe, also, it is spoken of as a medicine by writers of the Middle Ages. The name Hyoscyamus is from the Greek and means hog's bean. The leaves, which are generally used, although the seeds are no doubt better and more uniform, resemble in their lightness and brittleness when dry others in the family (Belladonna, Stramonium, Tobacco). They should be gathered when the plant is in Hower, and correspond to the description above given of their size and shape. The officinal description is as follows : " Ovate, or ovate- oblong, sometimes ten inches (twenty-three centimetres) long, and four inches (ten centimetres) broad; sinuate- toothed, the teeth large, oblong, or triangular; grayish- green, glandular-hairy ; midrib prominent; odor heavy, narcotic ; taste bitter and somewhat acrid." HEREDITY (Hares, an heir). In its widest sense, he- redity would signify that biological law by which indi- viduals transmit to their posterity all the traits that char- acterize the species to which they belong, and in this sense it would be indispensable to permanence of species. It would include instinct, which is the innate intelligence * The dilatation is said to come on and disappear more quickly than that of atropine, and to be greater in one axis than the other, so that the di- lated pupil is oval (Nothnagel). 615 Heredity. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. derived from the experience of progenitors, and also all the characteristics of complexion, feature, and mental traits which distinguish races, nations, and families of mankind. Practically, however, the definition is restricted to transmission of such physical and mental traits as serve to distinguish a few from the main body of their asso- ciates. These traits were originally accidental variations from the prevailing type, but it is not meant that the de- viations occur without efficient cause-only that the cause is unknown or obscure. They differ from monstrosity, which physically is an arrest of development of certain organs or parts, and is not transmissible ; though inher- ited moral depravity is sometimes loosely characterized as monstrous. It was observed by Prichard that variations from the normal type, commencing after birth, are far less liable to be transmitted than congenital variations. Satisfac- tory explanation of this fact is not easy. In either case they consist, not in the appearance of new features or traits, but in the augmentation or diminution of the same from the normal standard. Inasmuch as the doctrine of evolution is now gener- ally accepted by the scientific world, it will be found convenient to discuss heredity in terms of this doctrine, which will imply that deviations from the normal type are due to influences of environment, whether they be discerned or not. It is evident that continuance of such conditions will greatly aid in perpetuating the diver- gence, and even in magnifying it to the extent of form- ing a new species. On the other hand, the prevailing law which governs the species exerts an influence in re- storing the equilibrium in succeeding generations, so that decided exaggeration of particular traits usually disap- pears in two or three generations. Mating with an indi- vidual possessing the given trait to an average degree, ■would reduce the exaggeration one-half in the next gen- eration, while deficiency in the mate would give still fur- ther reduction. Contrariwise, the possession of the same exaggerated traits by the mate often results in augmented deviation from the normal type. The researches of De Candolle into the history of the sciences, and of scientific men, indicate that heredity plays a very important part, but that the distinctive traits are oftener transmitted by fathers than by mothers, par- ticularly the higher intellectual faculties. It is difficult to distinguish the prenatal transmission of characteristics from the influences of parental precept and example. Both are commonly included in the estimate put upon heredity, and this accounts for the greater credit to in- heritance in mental faculties than in morbid predisposi- tions. It is especially illustrated in the extraordinary contribution of sons of clergymen to the ranks of men eminent in intellectual attainments. Much credit is due to the personal attention paid by clergymen to the educa- tion of their sons. Here it is proper to note the serious cost to the intellectual advancement of communities min- istered to by a celibate clergy, and deprived of about one five-hundredth part of the whole influence of heredity, which should be estimated at a much higher value to correspond to the superior importance of the traits pos- sessed but made unproductive for transmission. Advantage is taken of this law by breeders of domestic animals, to improve and preserve the purity of choice breeds for excellent and valuable qualities, such as speed, endurance, strength, and docility in horses ; size, ease of fattening, dairy qualities, and good temper in horned cat- tle ; early maturity in swine ; quality of wool and of flesh in sheep, etc. By careful selection and mating of animals possessing particular characteristics, new breeds are produced, and by continued matching these are made permanent. A remarkable example of this was the ancon or otter breed of sheep, which originated by the variation of a single individual in Massachusetts, in the year 1791. By selection and mating, a variety was produced with long bodies, and legs so short that they were unable to leap over fences like other sheep. The subsequent intro- duction of merino sheep, which have finer wool and a tractable disposition, led to neglect of the ancon breed, and it has become extinct. The principle of heredity, as here used, must have been recognized in ancient times, and undoubtedly gave rise to such family names among the Romans as the Na- sones, the Labeones, the Buccones, the Capitones, etc. In the present age the Bourbon nose and the Hapsburg upper lip are well-known family characteristics. A great variety of traits, physical and mental, are of every-day ob- servance as existing in unusual degree in certain families, or in most of their members. Such are superior or in- ferior stature, corpulence or leanness, extraordinary mus- cular strength, loquacity, precocity in mental or bodily development or tardiness in the same, left-handedness, grace in movement or oddities of gesture. Innate apti- tude for mathematics, natural science, music and other line arts, and for the mechanical arts, is often observed to run through several generations. While some fami- lies are characterized for such virtues as business integ- rity, truthfulness, temperance, and frugality, others are equally marked for dishonesty, mendacity, drunkenness, and prodigality. Bad spelling, as well as lewdness, are occasional family traits, more noticeable than their oppo- sites. A marked physiognomy and proneness for com- mercial pursuits have been Hebrew characteristics from time immemorial. Survival of traces of useless organs in animal forms is due to heredity, and the tenacity with which both sexes of the higher species preserve, in rudimentary form, the organs of the opposite sex is an extraordinary example of this principle, Redundancy and deficiency of particular organs run through successive generations, appearing in a varying proportion of individuals. Sexidigitism and excessive growth of hair on the one hand, and on the other deficiency of teeth, light growth and early loss of hair characterize certain families. Scars of peculiar shape, and dark-colored moles appear through several generations in more or less of the members, and always upon the same parts of the body. The writer knows a family in which a peculiar scar under the chin belongs to the mother's side, while certain descendants of the same father and a different mother present such abnormalities as deficiency of teeth, and a webbed condition of fingers and toes. The father had a large mole on the back and has transmitted this mark to children of both mothers. Longevity and shortness of life are family traits, both of which have an important bearing on prognosis in sickness ; and death at or near a certain age has been observed as a family characteristic, without resulting from any particu- lar disease. Vicious and criminal propensities recur in some fami- lies, as a rule with some exceptions, and in varying de- grees of depravity. A low standard of morality and in- telligence together is usually, but not invariably, found to exist. A most remarkable example of this form of heredity has been traced through six generations by Dr. Dugdale, in the descendants of a depraved woman named Margaret Jukes. Of seven hundred and nine individuals, the great majority consisted of murderers, thieves, pros- titutes, and idiots. The transcendant superiority of in- tellectual traits which constitutes genius, is quite apt to carry with it want of mental balance and sterility. Per- manent changes in race or family, whether bodily or mental, must be within moderate limits at one step. Atavism may be defined as interrupted heredity, the interval sometimes being through so many generations as not to be recognized as a recurrence of preexisting traits. Thus it would account for physical abnormalities and remarkable traits in particular individuals of ordi- nary families. Thus a solitary genius occasionally dashes out from obscurity, a prodigy and a puzzle. Atavism may also be regarded as a weak or vanishing form of he- redity. To medical practitioners the subject of hereditary dis- eases is one of peculiar interest. Of these the most marked are goitre and cretinism, leprosy, gout, scrofula, tuberculosis, cancer, rheumatism, scaly cutaneous affec- tions, and the neuroses-epilepsy, insanity, chorea, hys- teria, and asthma. Heredity is less frequent, but un- doubtedly operative, in organic disease of the heart, diabetes, emphysema of the lungs, haemophilia, and lithi- 616 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Heredity. Hernia. asis. To these should be added color-blindness, whose rule of transmission is curious. Females are about one twenty-fifth as liable to this affection as males, but the color-blind transmit their peculiarity to their grandsons through their daughters, who have normal color-percep- tion as well as the sons. So this defect recurs in alternate generations in the female line, the females rarely being affected. Gout and haemophilia also appertain chiefly to the male sex. Of the above, leprosy, gout, and cancer are never con- genital, and sometimes absent until old age. Strictly, the predisposition, not the disease itself, is hereditary, and the subject may die of some acute disease before heredity has had time to declare itself. The neuroses are so cor- related that anyone may succeed another by inheritance, but the correlation belongs less to asthma than to the others. Another common inheritance in certain families is un- usual severity or mildness in the course of contagious diseases, and unusual degrees of susceptibility to the same. Scarlet fever, diphtheria, and whooping-cough are fearful scourges in some families, while others escape entirely or have light attacks. There is no reasonable doubt that the transmission of hereditary diseases could be effectually prevented in the human race, as surely as valuable traits are preserved by breeders of domestic animals, and the stock is gradually improved, provided the mating of human pairs were equally under wise control. Marriages of near relatives are prohibited, for the purpose of preventing the redoub- ling of family defects. This step in the right direction might be supplemented by granting divorce to those who have married into families tainted with particular dis- eases, such as leprosy, insanity, cretinism, gout, scrofula, tuberculosis, and syphilis, unless the privilege of claiming separation on such ground were expressly renounced be- fore marriage. Existence of these morbid tendencies is studiously concealed in most families, and irreparable wrong is often inflicted by unions which never would have been consummated, had the victim been forewarned. Even with the best foresight and care which can be exer- cised with propriety, betrayal and wrong are liable to oc- cur. The disgrace which would attend public trial and conviction in such cases would soon serve as a stern warning, and obviate the necessity of frequent resort to legal proceedings. In case of failure to make out a case, the disgrace would fall upon the prosecuting party with such severity as to discourage frivolous suits of this na- ture. Much good might doubtless be effected by better in- formation of the public upon the consequences of ill-as- sorted unions. With respect to such as might not give ground for legal redress, people ought to be informed that no intermarriage should take place between families in which the same morbid heredity exists. This should be taught, not only as a principle of physiology, but of morals. Already it is recognized as one of binding force among intelligent and honorable people, but the lesson should be more widely inculcated. The family physician could be of great service in such cases and ought to be consulted, but the fortune-teller is generally preferred. The principles of personal and public hygiene are now fairly taught in the public schools of many States of the Union, but that branch which relates to the welfare of posterity is still neglected, and might be supplied by a judicious chapter on prevention of hereditary diseases. For those of adult years, particularly those contemplating matrimony, a suitable monograph would be extremely serviceable. Unfortunately, this delicate subject has so far been treated ad nauseam by the predatory branch of the medical profession, and neglected by those best qual- ified to instruct. 8. 8. Herrick. as the result of atony or injury, occur at any part of the abdominal wall. Some portion of the contents of the ab- domen is slowly extruded and a hernia is formed. The varieties of hernia have received their names either from the viscus which is extruded, the region or point at which it occurs, or from the developmental imperfections which give to the herniated viscus particular relations to the testicle and the tunica vaginalis. Males are more liable to hernia than females. This is, no doubt, due in part to the larger size and more patu- lous condition of the inguinal canal, as also to the greater activity, and more violent and oft-repeated muscular ef- forts demanded by their vocations. A hernia dependent on a congenital defect is likely to occur before the age of thirty-five. When the processes of nutrition are impaired, as by age or sickness, and waste exceeds repair, or when for any reason the tonicity of the tissues is diminished, a new factor comes into play to favor the development of a hernia. Hence the feebleness of old age is a predisposing cause. Developmental imperfec- tions are often well marked and find expression, possibly, in the long and lax peritoneal attachment of the viscera ; but more frequently and positively in the patulous condi- tion of the natural openings, and the thinness of the walls at certain weak spots. Individuals show great differences in the firmness and resisting powers of the tissues. In one they are lax and loose, with tendinous and muscular fibres widely separated and loosely bound together, while in another these tissues are close, compact, and strong. Occupations demanding violent and sudden efforts, or the stooping or reaching postures, act as exciting causes. The symptoms of a rupture vary with its volume, the viscus protruded, and its condition, as also with the condi- tion of the tissues enveloping it. The first indication is often found in a sense of weakness of the part, accompanied by a fulness or swelling. Sudden or violent muscular effort, as in the act of coughing, gives an impulse at the site of the protrusion. The swelling is most conspicuous in the erect posture and on exertion, but diminishes or dis- appears when the recumbent position is assumed. The tissues which envelop a hernial sac, the sac itself, and the protruded viscus, vary in structure and react dif- ferently under the changing conditions to which a hernial tumor is subjected. A clear conception of the importance of the changes occurring in these different tissues may be best obtained by considering the anatomy of the tissues which form a hernial tumor, and the changes occurring during its development, and then noting the effect of strangulation. The hernial sac, always formed of a pouch of the peritoneum, is composed of a body, a neck, and a mouth. The mouth is the short funnel-shaped opening which communicates with the general peritoneal cavity. The neck is between the mouth and the body of the sac, and is the constricted portion which is usually found at the opening in the abdominal wall through which the hernia escapes. The body of the sac may be large or small. The yielding and stretching of the peritoneal pouch is gradual. In its growth it borrows from the abdominal cavity, and although the peritoneum is delicate and pli- able, there must be some puckering or pleating of its wall at the neck of the sac. The folding of this membrane thickens it, and by the adhesion of these folds to each other and by the induration of the connective tissue about the neck, there is gradually formed a thickened ring of tissue, that is usually adherent to the adjacent structures which originally determine the situation and the tight- ness of the stricture. This ring formed by the neck of the sac is not always attached to the abdominal wall, and may be drawn out into the hernial tumor, thus establish- ing a constriction in its body ; or, if pushed into the cavity, it may still hold the hernial tumor separate from the gen- eral cavity of the abdomen and maintain strangulation. The tissue forming this thickened band is in part elastic, and no doubt influences the constriction which determines strangulation. This thickening may be so marked as to close the open- ing, till the ring, and cure the hernia, or it may be that the hardened tissue of the ring is pushed onward by the HERNIA. Conjecturally derived from iovos, and used in its present sense by Latin writers of the time of Celsus. An abdominal hernia is the protrusion of a viscus from the confines of its natural cavity. This protrusion occurs most frequently at the inguinal canal, the femoral ring, or at the umbilicus ; but it may, from unusual weakness, 617 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. impulse of the viscera, and if entirely closed, the empty sac may overlie a second one and its contents. Various complications in the relation of the hernia to its envelop- ing tissues may occur, for this isolated sac may be dis- tended with serum and form a distinct tumor. Since these changes are the result of long-contiuued protrusion of the sac, it should be stated that if the hernia and its sac be returned to the cavity soon after development, the folding of the peritoneum at the neck will disappear as soon as it is returned to the cavity, and released from the rigid opening in the abdominal wall. The contents of the hernial sac are usually small intes- tine and omentum, though the colon, the stomach, and the bladder have been found in it. If intestine only is protruded, it is called an enterocele-if omentum, epiplo- cele-if both, an entero-epiplocele-if bladder, cystocele -if stomach, gastrocele, etc. There are many variations in a hernial tumor dependent upon changes in the enveloping tissues, which are pro- duced by inflammatory or hypertrophic processes induced by long-continued distention. The skiu is at first thinned and the subcutaneous fat absorbed, so that the vessels become more distinct. These tissues may, however, become thickened and hardened in an old hernia, and in one case of labial hernia which came under my observation, there developed an immense fibroma. The other tissues are apt to become thickened and adherent, so as to lose their laminated structure, but occasionally in inguinal hernia the laminae remain distinct and seem to multiply. In rare instances a local circum- scribed collection of fluid forms in these tissues. The anatomy of a hernia depends upon the viscus pro- truded, the sac, the enveloping tissues, and the relations of the point through which it escapes to the tissues of the abdominal wall. Acquired Oblique Inguinal Hernia is the most frequent hernia, and is a typical one. It involves not only the tissues of the groin above Poupart's ligament, but also the scrotum and its contents. The skin of the scrotum is continuous with that of the hypogas- tric region, but differs ma- terially from it in character and in its connection with the subjacent structures. It is corrugated and dark, closely attached to the dar- tos, but loosely connected with the deeper parts by connective tissue which is destitute of fat. This dar- toid tissue and its subja- cent fascia are continuous with the superficial fascia of the pubic region. The superficial layer of this fas- cia is continuous with that of the abdomen and the thigh, but the deeper layer of the superficial fascia is remarkable for its close, firm connection with Poupart's ligament, and its continuity with the fascia of the scro- tum and of the perineum. This close connection separates the inguinal from the femoral region, and helps to guide the oblique inguinal hernia into the scrotum. Remove the skin and the superficial fascia from the aponeurosis of the external oblique and the fascia lata. The fibrous line, forming the fold of the groin, becomes visible. Above it are situated the parts involved in in- guinal hernia, below those connected with the crural form. This ligament (Fig. 1634) is formed by the lower border of the aponeurosis of the external oblique, and ex- tends from the anterior superior spiue of the ilium to the spine of the os pubis, thus forming the crural arch. It is firm and strong and finds attachment to the pubic spine, and is a part of the anterior and inferior wall of the in- guinal canal. This band of fibres blends with and helps to form the inferior pillar of the external abdominal ring. The fibres of this portion of the aponeurosis of the exter- nal oblique which form Poupart's ligament and the exter- nal pillar diverge at the pubic spine, the upper fibres pass- ing in front of the spine, the middle ones to the spine, while the inferior ones, curving downward and backward to be inserted into the ileo-pectineal line, form Gimbernat's liga- ment (the arched fibres between No. 2 and 3). The inter- nal, or superior, pillar is also formed by a band of fibres of this aponeurosis that passes to the crest and the anterior surface of the os pubis. This external abdominal ring is the point of exit of all forms of inguinal hernia, hence the spine of the os pubis forms an important surgical landmark, being below and to the outer side of these protrusions. If this aponeurosis is now so reflected from above as to show its continuation with Poupart's ligament and its attachment to the os pubis, the triangular outline of this ring will be perceptible, and the inter-columnar fibres which form the upper boundary of the ring become distinct, and are seen to be continuous with the inter- columnar fascia which envelops the cord and testicle. Examining now the parts thus exposed, we find the spermatic cord resting on Poupart's ligament, and behind the internal surface of the aponeurosis of the external oblique when it is in position. The lower bundle of the muscular fibres of the internal oblique and transversalis, which, passing in front of and above the upper or first part of the spermatic cord, dips downward and inward to form the conjoined tendon of the internal oblique and the transversalis, is seen to arise from the outer half of Poupart's ligament. This con- joined tendon is behind the lower part of the inguinal canal and the external abdominal ring, and finds inser- tion into the pubic crest and the ileo-pectineal line. Con- tinuous with the lower border of the internal oblique and transversalis is the cremasteric fascia, composed of the muscular fibres and a connecting fascia which envelop the spermatic cord, and extend to the testicle. Deeply placed behind the muscular wall, and in the transversalis fascia, is situated the internal abdominal ring (No. 5). This ring forms the upper end of the inguinal canal, wdiich, passing obliquely through the muscular wall of the abdomen, gives exit to all forms of oblique inguinal hernia. The internal abdominal ring is situated two centimetres above Poupart's ligament, midway between the spine of the os pubis and the anterior superior spine of the ilium. The inguinal canal begins at the internal and terminates at the external abdominal ring. It is about four centimetres in length. This canal is occupied by the vas deferens, the blood-vessels, the lymphatics, the nerves, and the loose areolar tissue which, uniting at the internal abdominal ring, form the spermatic cord. The testicle, originally developed in the lumbar region, is invested by a fold of the peritoneum, the mesorchium, which descends with it as it slowly makes its way to the scrotum, and ultimately forms the tunica vaginalis. This peritoneal envelope, which is at first part of the peritoneal sac, is at birth usually separated from it by the adhesion of the walls of the tubular process which connects the tunica vaginalis with the general peritoneal cavity. The testicle, as it passes through the abdominal wall, carries before it into the scrotum investing laminae de- rived from the tissues of the wall. The vas deferens and the fibrous bands formed by the atrophied tissue of this tubular process of the peritoneum, together with the ves- sels, nerves, and lymphatics of the cord, are invested by the infuudibuliform process of the transversalis fascia, then by the cremasteric fascia, and as they emerge at the external ring, by the intercolumnar fascia, the superficial fascia, and the skin. These tissues invest the cord, and a hernia escaping through the inguinal canal is enveloped by them, while the cord is usually placed behind the hernia. The tissues are easily separated when normal, but in old hernias they become thickened, adherent one to the other, and may be so changed as to lose their lami- nated character. The deep epigastric artery (No. 6, Fig. 1634) takes its ori- gin from the external iliac, and passes behind, but across the course of the inguinal canal. It is situated in the trans- versalis fascia, and ascends obliquely upward and inward Fig. 1634.-Relation of the Parts in- volved in Inguinal Hernia. (After Luther Holden.) 618 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. toward the umbilicus. This artery runs to the inside of the internal abdominal ring, hence all hernias which es- cape through this ring are to the outside and in front of the internal epigastric artery. If the funicular portion of the vaginal process of the peritoneum which is attached to and invests the testicle is not obliterated by the adhe- sion of its walls, an open channel of communication re- mains between the peritoneal cavity and the tunica va- ginalis. Irregularities in the closure of this canal, and the relation to it of the protruded viscus, determine the other forms of oblique inguinal hernia. If it remain open, the intestine may enter this tubular canal and fill the tunica vaginalis. The intestine and the testicle are then separated from each other only by their proper peritoneal coats, and the hernia is without a sepa- rate sac, but occupies the cavity of the tunica vaginalis (see Fig. 1635, after Bryant). This is the condition in congenital inguinal hernia. Con- genital inguinal hernia is not of so gradual a development as the ac- quired, for since the sac is already formed the force which produces it may at once fill the tunica vaginalis. It is most frequent in infants. As the child develops there is a strong tendency toward perfection, and the channel, even when imperfectly closed at birth, may become obliter- ated as adolescence is attained. Yet it is not an unusual case to find an oblique inguinal hernia suddenly and fully developed in an adult-the funicular process of the tu- nica vaginalis having remained patent, but without the development of a hernia. These cases are more dangerous than those in which the development has been gradual, for the opening at the neck of the congenital sac is apt to be small and firm, and strangulation is often established on the first escape of the hernia into the vaginal process of the peritoneum. There is in some of these cases a thin membranous adhesion of the funicular portion of the vaginal process, which gives way and results in the im- mediate development of a hernia. The closure of this canal may begin at any point be- tween the internal abdominal ring and the testicle. If it begins at a point near the testicle while the canal remains patent above, the intestine entering and distending this canal forms a hernia into the funicular portion of the vaginal process of the peritoneum, as described by Bir- kett (see Fig. 1636, after Bryant). This varies in its de- velopment from the congenital her- nia, for it is separated from the testicle and is not in the tunica vagi- nalis. It has the funicular portion of the tunica vaginalis as its proper sac, and it differs from the acquired hernia because its sac is adherent to the cord and to the wall of the tuni- ca vaginalis. If the adhesions of the walls of this tubular process begin at the internal abdominal ring and the canal remains open below, or, if a hy- drocele of the cord is established, either one of two conditions may ex- ist after the development of a hernia. The hernia, hav- ing a separate sac, may push its way down the inguinal canal, invaginating the funicular process (see Fig. 1637, from Eulenberg's " Real-Encyclopadie "), so that the proper hernial sac is enveloped by the doubled peritoneal fold formed by this portion of the tunica vaginalis, thus forming the encysted hernia of Sir A. Cooper or the in- fantile hernia of Hey. Again, the inguinal hernia may pass to one side of this arm of the tunica vaginalis. The congenital inguinal hernia, whose sac is formed by the vaginal process of the peritoneum, is found in in- fants and young adults. It is suddenly developed, and has a long neck which is in the line of the inguinal canal, and the hernia envelops and surrounds the tes- ticle. The acquired inguinal hernia is one of middle life and old age, it has a separate sac (see Fig. 1638, from Bryant), with its outline distinct from the testicle, and being slowly acquired, the dragging of the tissues draws the internal abdominal ring downward and inward until it is nearly or quite opposite to the external ring, and the neck is thus shortened. An acquired hernia is slowly formed, often requiring months or years to become well devel- oped. Female children may have congenital inguinal hernia, the protrusion occupying the unob- literated canal of Nuck, a tubu- lar process of peritoneum which invests the round ligament. In- guinal hernia develops in the fe- male at all ages, but is not so frequent as in the male. If an oblique hernia enters the inguinal canal, but does not emerge at the external ring, it is said to be incomplete and forms a bubonocele. Direct Inguinal Hernia.- The conjoined tendon of the in- ternal oblique and the transver- salis muscle is inserted into the ileo-pectineal line, and is situ- ated behind the external abdomi- nal ring. It guards a weak point in the abdominal wall outside of the rectus and above Pou- part's ligament. Direct inguinal hernia, pushing its way out through the external ring, carries this tendon with it, or separating its fibres, escapes through the opening thus made. This hernia is less frequent and smaller than the oblique. The hernial mass pushes outward, rather than downward, and inward into the scrotum. Its investing tissues are much the same as those of the indirect. It is not, however, enveloped by the fibres of the cremaster muscle, but has instead the conjoined tendon as a cover- ing. Sometimes the direct hernia enters the inguinal canal just above the external ring to the outer side of the conjoined tendon, and then it has the same investing tis- sues as the oblique form, but maintains its proper rela- tion to the deep epigastric artery. The relation of the neck of this hernia to the deep epigastric is the reverse of what it is in the oblique. It is to the inside of the artery, and, since it is impossible always to determine that a given hernia is direct or indirect, it is not safe to cut either to the right or left in dividing the stricture. Direct hernia is most frequent in strong, muscular men whose tissues have been torn during some violent mus- cular effort. This sudden develop- ment and the unyielding character of the tissue of the conjoined tendon give emphasis to the fact that stran- gulation is apt to occur at once and that it is more dangerous and severe than in the acquired oblique ingui- nal hernia. These two forms of inguinal hernia are quite distinct in their anatomical relations. The one, passing through a natural channel, is outside the internal epigastric ar- tery, the other, to the inside of the artery, forces its way through the wall, carrying before it the conjoined Jen- don. Both forms, however, emerge at the external ab- dominal ring. Every hernia, whether inguinal, femoral, or ventral, is liable to develop characteristics which are so distinct and important as to determine the treatment of the tumor. It is of vastly greater importance to determine whether a hernia is reducible or irreducible, inflamed, obstructed, or strangulated, than it is to know its special form. The surgical treatment of hernia is largely determined by these conditions. The skill of the surgeon is severely tested in dealing with them, and the wisest judgment is often at fault in recognizing the demands of the particu- lar case. Fig. 1635. Fig. 1637. Fig. 1636. Fig. 1638. 619 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Reducible Hernia.-When the contents of a rupture can be returned to the abdominal cavity by taxis, it is said to be reducible. The recumbent posture, with or with- out the elevation of the pelvis, is often sufficient to ac- complish reduction. The traction on the extruded loop produced by gravity, aided by the pull of the longitudi- nal muscular fibres exercised in the peristaltic movements, is an important factor in the efficacy of the position as- suiped, and often brings about the gliding of the smooth serous surfaces of the bowel through the neck of the sac. The influence of such slight traction, if prolonged, is at- tested in many cases where the firmest pressure and the most skilful taxis fail to accomplish the desired result. Karl Nicolaus, in the Gentralblatt fur Chirurgie, No. 51, 1885, insists upon the importance of the semi-prone posi- tion of Sims with pelvis elevated, or of the knee-shoulder position, in thus effecting traction on the herniated intes- tine. The point of exit of the hernia must, of course, be the most elevated part. Nicolaus gives experimental evi- dence and clinical facts to show the efficiency of slight traction, not only in reducing the hernia, but in effecting the reopening of the intestinal canal, and thus empty- ing the protruded coil of its fluid contents and making easy the reduction. The dartoid tissue of the scrotum is frequently much hypertrophied, and when stimulated to contraction by hot or cold applications, no doubt exercises compression on the tumor and aids in its reduction. The hernia is most apt to be reducible when it is intes- tinal, when it has been slow in forming, and has not been allowed to remain long unreduced. Irreducible Hernia.-When the hernia cannot be returned to the abdominal cavity by use of the above means, aided by intelligent taxis, it is said to be irreduci- ble, provided there is no marked obstruction or strangula- tion present. If either of these conditions is manifestly present, its importance gives to the tumor its character- istic as an obstructed or strangulated hernia. A rupture may be rendered irreducible by adhesion of the intestine to the sac, or by atrophy of the hernial mass where it passes through the neck, together.with such hypertrophy of the general mass of the tumor as frequently occurs in omental hernia. The permanent enlargement of the structures forming the tumor is effected by the deposit of fat or by a fibroid or glandular thickening. A hernia may be temporarily irreducible because of distention of the intestine with gas, fluid, or fecal matter, or by the extrusion of an unusual quantity of the abdomi- nal contents. Muscular contraction of the ring or in- flammatory infiltration of the tissues at this site may tem- porarily prevent reduction. These passing conditions may quickly disappear, and the hernia be returned to the cavity, but when present they always induce some con- stitutional uneasiness associated with gastric irritability on the part of the patient. This discomfort or pain is de- pendent upon partial obstruction or the slight strangula- tion that necessarily exists. These are the cases which frequently pass on to the severer strangulations with vom- iting, necessitating herniotomy, or resulting in death. The patient should at once assume the position most favorable to the reduction of the hernia. Warm or cold applica- tions should be made to allay the irritation of the parts, opium administered to relieve pain and control peristal- tic action, and if success is not soon obtained, taxis is demanded before strangulation becomes fully developed. When the hernia is irreducible because of adhesions or hypertrophy, the return may in certain cases be accom- plished by putting the patient to bed, keeping him on low diet, administering laxative enemata, invoking the aid of gravity and employing moderate pressure, possibly elastic, and finally consummating the reduction by the ju- dicious use of strong taxis. Opening of the sac and reduc- tion by direct manipulation are sometimes justifiable, for the presence of omentum or intestine in the neck of the sac renders a truss ineffective, and the discomfort and danger attendant upon such a condition are often great. An irreducible hernia is exposed to sudden and violent strangulations, to contusions, injury, and inflammations. Inflamed Hernia.-An irreducible hernia is apt to become inflamed, for the intestine or omentum is exposed to external violence, the wall of the hernial tumor is put upon the stretch by an unrestrained protrusion, and if a truss is worn it becomes a source of constant irritation to the viscus occupying the sac and its enveloping tissues. An inflamed hernia may simulate all the local symptoms of strangulation. The skin becomes tense and red, the subcutaneous tissues are infiltrated and the sac is dis- tended with serum, while the bowel itself may be suf- ficiently involved in inflammatory action to establish adhesion to the sac, but the severer symptoms of obstruc- tion and strangulation are absent. The bowel may be acutely inflamed but not strangulated, and with no ob- struction except such as follows the loss of tone in an inflamed muscle. This inflammation is generally the result of local injury, but may be dependent upon the ex- tension of inflammatory action from the peritoneal cavity through the medium of intestinal irritation and inflam- mation. This condition is to be corrected by hot or cold applications, by rest, anodynes, low diet and such agents as influence favorably inflammatory processes. Persist- ent gastric irritation, vomiting, and the extreme depres- sion of strangulation are absent in the simple inflamed hernia. The local peritonitis generated in a hernial tu- mor may become general and result in death. Faecal im- paction may be thus established, and give rise to all the evidences of obstruction. Obstructed Hernia.-Where this condition is present without strangulation it is usually slowly developed. Constipation is persistent, the abdomen becomes gradually distended, eructations of gas, associated with borboryg- mus, but without any escape of flatus per rectum, attest the severity of the obstruction. Vomiting, which finally be- comes faecal, completes the group of symptoms, and often renders it difficult to separate this condition from that of strangulation. Strangulation.-The strangulation of a hernia is al- ways a source of danger. Every hour that it continues lessens the chances for recovery. Efficient efforts for its relief must be enforced, for delay is dangerous, and when faecal vomiting is present it is culpable. The physician should not for a moment lose sight of these facts, for it is too frequently the case that surgical aid is sought only after irreparable injury has been inflicted upon the tissues and when death is already imminent. Strangulation is established when the return flow of blood is impeded and the onward current of the intestinal fluids is obstructed in the coil of the extruded intestine. Stran- gulation is very uniformly the result of the mechanical forces which exert their influence in effecting the pro- trusion of the bowel, together with the constriction exer- cised upon the neck of the tumor by the rigidity or resiliency of the opening through which it escapes. In- testinal irritation, distention with gas, or general relaxa- tion of the system may predispose to a larger hernial protrusion than is habitual in a given case, but it is the physical relations of the sac, its neck, contents, and sur- roundings, that determine the strangulation. The dis- tention of the sac may increase the tightness of the stricture by pulling on the tissues of the ring. An irri- tated bowel will, by pouring its contents into the efferent or proximal end of the protruded coil, distend the loop, increase the constriction exercised upon the efferent end, and by thus preventing the escape of the fluid, increase the size of the tumor and determine strangulation. Acute obstruction with strangulation, internal or ex- ternal, is established suddenly and evidenced by pain, fixed, central, and paroxysmal, followed or accompanied by vomiting, first stomachic, then faecal. The constipa- tion is obstinate and abdominal distention rapidly su- pervenes, and, as it increases, peristaltic movements may make visible particular coils of the intestinal tract. The urine is scanty and albuminous or suppressed, while col- lapse and death may appear, even before this group of symptoms is complete. If the strangulation becomes marked and remains long unrelieved, the local symptoms are distinct. There is usually, though not necessarily, uneasiness and pain in the tumor, but undue tension and fulness are always present. There is an elastic resiliency, 620 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. not quite fluctuation, which is conveyed to the touch by the distended gut. This may soon give place to distinct fluctuation, as the sac fills with serous fluid. The skin becomes reddened and tense, and the tissues outside the sac infiltrated and inflamed. These local symptoms are at times masked by the marked general distress, and some- times escape the notice of the patient and of the physi- cian. The condition thus indicated tends toward the ulti- mate destruction of the parts. The extruded viscus becomes congested and thickened from venous engorge- ment. The normal elasticity of the intestine is lost, and the flow of fluid and gas into the proximal end makes the tumor more bulky and increases the stricture. The equi- librium once disturbed is more and more difficult to re-establish, and with the lapse of time hastens to the de- struction of the parts strangulated. Where the strangu- lation is partial and progressive, the local uneasiness, dis- comfort, and pain become more and more marked as the hernia and its enveloping membrane take on inflammatory action, and give warning of danger before strangulation is absolute. Strangulation of the bowel, whether internal or external, develops gastric uneasiness and discomfort, followed by nausea, vomiting, and pain. The lower bowel may, under the stimulus of the pain, empty itself, but obstinate constipation is present, though, in isolated instances, accompanied by persistent and straining efforts at stool. With the stercoraceous vomiting collapse is present. The pulse, the obtundity of the nervous system, the shrivelled skin, and cold sweat indicate the violence of the shock, or the extent and severity of the damage to the parts involved. This condition of shock is sometimes fatal, even though little change has occurred in the gut. If the strangula- tion is immediate and absolute, and occurs at the first descent of the hernia, as it does in some recent ruptures, usually small and either femoral or of the congenital in- guinal form, this condition may be rapidly developed and death result in a few hours with total destruction ofc the extruded bowel. When strangulation is thus evident, and severe taxis is not to be thought of, but an operation seems to be immediately demanded, it occasionally hap- pens during collapse, from the complete relaxation of the parts, that the hernia reduces itself before local destruc- tion takes place. The patient may then make a good recovery, but occasionally even after such reduction, the damage to some one or more of the tissues forming the bowel is so great as to lead to general peritonitis and the death of the patient. The changes in the hernial tu- mor will vary with the tightness of the strangulation and the time consumed in the progress of the case. If the death of the bowel has been accomplished, it will in a few hours appear blackened, inelastic, and bloodless, often but slightly, if at all, distended, and, if time has permitted, with an ulcerated line at the site of the stricture. If the stricture has been less decided, the changes in the gut will be very different, although they may be equally de- structive. Congestion of the intestinal wall, evidenced by redness and distention of the bowel, is the first result of the strangulation. Later, the wall becomes thickened and dark, with a layer of lymph covering its serous sur- face. If sphacelus is not pronounced, it may present ul- cerated points on its mucous surface, or there may be ash-gray spots of dead tissue involving the thickness of the bowel. Rupture at the site of the stricture with faecal extravasation, may have occurred. Adhesions will form between the bowel and the sac if the vitality of the parts is not too much depressed, and it is sure to occur about the neck of the tumor if death does not intervene to pre- vent. A clear serous exudation is present when the con- gestion has been slowly developed. This becomes dark and bloody when the congestion is more marked, and if gangrene is present or rupture of the bowel has occurred, it is offensive and feculent in odor. The sac itself may be gangrenous from the disturbance of its circulation. In a case of large congenital inguinal hernia in a fleshy man, where the bowel was sphacelated, I once saw at least half of the sac gangrenous. In a child, twenty-six days old, suffering from a congenital inguinal hernia, I found the testicle gangrenous, although the epididymis was intact and the bowel in sufficiently good condition to be returned to the cavity. The child made good promise of recovery, but died thirteen days after with jaundice and probable peritonitis. The total destruction of the gut is not often attributable solely to the constriction of the hernia, but it must often be in part ascribed to the damage inflicted by ill-advised efforts at reduction. The influence of violent manipulation is quickly expressed in the skin by ecchy- mosis, and in the connective tissue by oedema, while the deeper tissues testify to its evil influence by infiltration and blood-effusion, and in the case of the gut, death is hastened by many hours, and often solely determined, by the violence thus inflicted on a congested and tender in- testine. Serious as are these changes, destroying life as they often do, they are the precursors of the development of a peritonitis which is apt to become general, though at first limited to the hernial sac. This may result either from a continuous extension of inflammation, or from the escape of faecal matter into the abdominal cavity through ulceration of the part of the bowel which was implicated in the hernia. When death does not occur, the strangu- lation being unrelieved except by gangrene cf the gut and the escape of faecal matter, abscess or sloughing of the external parts follows, and an artificial anus is thus established through this accidental opening, by the ad- hesion of the intestine to the neck of the sac. If the hernia is omental, the symptoms of strangulation are not so pronounced, and are more slowly developed, but are of the same character. The ultimate result may be just as destructive if the local peritonitis becomes general. Taxis.-A strangulated hernia is not invariably to be subjected to an immediate effort at reduction. If unusual fulness and tension exist in an old hernia, with pain and abdominal uneasiness, and the mass is not readily reduci- ble, it is better to put the patient at rest in the recumbent position, tyith hips elevated, with the tumor well sus- tained, and to apply a moderate and equable pressure with a water- or sand-bag, or with an elastic bandage. Hot or cold applications should be used, opium administered, and a few hours allowed to elapse before resorting to anaesthe- sia and taxis. This delay is oftener applicable to old and large, than to small and recent, strangulated hernias, and to inguinal rather than to femoral. Such measures will often determine the success of taxis, and enable the surgeon to avoid herniotomy. This delay is not justified when the evidences of strangulation are marked or have been long continued, and it is positively prohibited when emesis has been repeated and persistent. Opium, or some of its derivatives, is an important agent at this time, yet it will mask or mitigate all the symptoms of strangulation, and may lead to fatal delay by the implied security it gives. Judgment and tact are required in making a system- atic effort at reduction by taxis, and careful manipulation is necessary to secure success without injury. The patient should be put in a position favorable to the relaxation of the parts, and in which gravity will favor the return of the herniated bowel. The recumbent position, with elevated pelvis, more or less dependent shoulders, thighs semi-flexed, and possibly rotated slightly inward, are the conditions necessary to a fair trial of relief by taxis. A strangulated hernia is sensitive to manipulation, and the irritability excited by pain is a powerful opponent to reduction. No effort of more than a few minutes is jus- tifiable without anaesthesia, if the anaesthetic can be ob- tained without unreasonable delay. Anaesthesia is uni- formly demanded, since it relaxes the parts, prevents involuntary muscular resistance, and relieves pain. Ir- reparable injury may be inflicted upon the parts by taxis. A hernia that has been long strangulated and in which inflammation was so pronounced as to have softened the parts, or a small hernia in which the stran- gulation is very tight, are exceedingly susceptible to injury, even from the gentlest handling, and only the mildest effort at reduction is permissible. Under such conditions this effort is to be limited (if it be possi- ble to fix an arbitrary time) to three or four minutes. In estimating the necessity for taxis and its value and limitations, the surgeon must bear in mind the fact that 621 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the strangulation is the dangerous element in a hernia ; the tighter it is and the longer it has continued, the more dangerous the case, and the demand upon the surgeon to relieve it is imperative and immediate. The operation is not dangerous, but mitigates every danger in the individ- ual case. It is least dangerous when promptly undertaken before strangulation and taxis have inflicted fatal trauma- tism upon the parts involved. Mr. Birkett, after care- fully studying the question, says (" Holmes' System of Surgery," First American from Second English Edition, page 685): " I may represent the danger which is asso- ciated with violent attempts to reduce the hernia, by stat- ing in a few w'ords that more irreparable damage may be inflicted on the bowel in a few minutes by coarse, impetu- ous, brute force, than the natural means of constriction could produce in several days." Nevertheless, with these precautionary words, I think I may safely say that a vigorous and an earnest effort at taxis is demanded in all hernias where the strangulation is recent, and especially where the hernia is an old and large one. This is particularly true of inguinal hernia, and though not so uniformly applicable to umbilical hernia, meets with more marked limitation in the crural form. These latter do not bear manipulation well. The most impor- tant point to consider in a case of strangulated hernia is the condition of the contents of the hernial sac. Are they in a condition to be returned to the cavity ? If so, then every aid to the success of the effort at taxis must be invoked. It is important to accomplish the result with as little direct manipulation of the tumor as possi- ble. If the strangulation be not violent or long-con- tinued, we may proceed to the direct manipulation of the tumor, as hereafter described, but if either of these two conditions be present, and doubt is entertained concern- ing the ability of the tissue to resist the injury to be in- flicted by taxis applied to the tumor, then we may direct our efforts first to the measures which will exert traction upon the protruded coil, and afterward to the direct manipulation of the tumor itself. The positions of comfort which favor traction have been used before the taxis is applied. These include the recumbent position, with the elevation of the hips, the semi-prone position, with the pelvis raised, and possibly the knee-shoulder position. More powerful traction dur- ing the effort at reduction may be obtained by a more or less complete inversion of the body. This may be ac- complished by elevating the foot of the bed, while hold- ing the patient in position, or by the effective but not elegant proceeding of placing the flexed legs of the pa- tient over the shoulders of an assistant, the patient hang- ing with head down and with his back to that of the assistant. These measures invoke only the traction of gravitation, but by placing the patient on his back, with the hips elevated, the surgeon may exert stronger traction by kneading and manipulating the abdominal walls, thus directly influencing the intestine as it passes to the point of escape from the abdominal cavity, which is usually the point of strangulation. Traction may sometimes be efficiently applied through the rectum. The fingers, and on rare occasions the hand, may be introduced, and trac- tion applied to the lower part of the ileum which rests in the pelvic basin, and possibly to the colon itself. The influence of traction thus obtained is an important factor in determining success. When the tumor itself is subjected to the taxis, care must be exercised to so apply the force used as to obtain the best result from a minimum power. The neck of the sac should be sought by the thumb and index-finger of one hand. Pressure should be made upon the neck to reduce or prevent any marked bulging just outside and below the site of stricture. The free hand now grasps the tumor, and aids the first one in its efforts by a gentle traction on the neck, straightening and diminishing any bends in the neck of the sac. While thus making traction, the hand grasping the tumor makes firm and continuous pressure upon the hernial mass. This will frequently empty the intestine of some of its gaseous and liquid contents, and soon the strangulated viscus may be felt to be moving until it finally slips with a rapid and distinct rush into the abdominal cavity. The relief is instant and perfect. The strangulation is, how- ever, often much more obstinate, and a more prolonged taxis is required. The fingers surrounding the neck of the sac now knead it, or better, milk it, by pressing the neck between the fingers and slowly moving them from the -body of the tumor toward the hernial opening. The motion should be firm and repeated, first upon one, then upon the other side of the neck-pressure upon the tu- mor being meanwhile well sustained. A lateral motion given to the tumor will help'to free the gut at the point of strangulation. Success is announced by a gurgling sound, and the rapid return of the intestine into the ab- domen. The surgeon may feel confident and comfortable when success is thus marked, although he may be dealing with an old hernia which has some portion of its contents irreducible. When, however, the reduction is slowly ac- complished, and there is an absence of the sudden and pal- pable recession of the mass, there will remain in the mind of the surgeon some doubt about the local condition, for a rupture of the bowel is possible, and again the strangulation may be unrelieved, though the tumor has been reduced (see Fig. 1639, from Eulenberg's " Real Encyclo- padie "). If the latter condition obtains, the finger, when carried up the inguinal canal, will meet with a slight resistance from an elastic tumor, which indicates the reduction of sac and intestine en masse, without relief of the stran- gulation. The sac, however, may be ruptured, and the hernia pushed into the transversalis fascia or the subserous cellular tissue. This accident may occur in reduction after operation as well as during taxis. In such a case the hernia must again be pulled outside the cavity, and the constriction in the neck of the sac relieved. If the sac has been ruptured care must be taken to return the bowel through the neck of the sac. The time occupied in an effort at taxis should not at most exceed fifteen minutes, and most likely the surgeon will be rewarded with success or convinced of the futil- ity of the effort in less time. Prolonged taxis, where strangulation is present, is not safe. An irreducible but not a strangulated hernia per- mits more prolonged and forcible efforts at reduction. Herniotomy.-The operations for the cure of an ir- reducible hernia, and those for a radical cure of hernia, may be best considered separately. Strangulation of the bowel, unrelieved by position and taxis, demands herniot- omy. This operation may be completed in certain cases without opening the sac, provided the contents of the her- nial sac are in condition to be returned without direct in- spection. This is the minor operation, and is possible where the constriction is in the tissues of the hernial open- ing and not in the neck of the sac. It is not always possi- ble to determine which operation will best fulfil the indica- tions until the sac is exposed and the neck of the tumor is accessible. Hence, since the peritoneal cavity is endan- gered, the teachings of modern surgery should enforce the most rigid cleanliness in this operation. Everything should be rendered at least aseptic. The skin should, if necessary, be shaved, and the soft parts at the site of the incision, or about the pubes, cleansed by thorough wash- ing, and sponged with a sublimate solution. The hands and the instruments should be clean. Antiseptics, with most practitioners, are essential to the best success, and will vary with the operator. I believe the most satisfac- tory results are obtained by the use of the sublimate solu- tions, The operation, though not ordinarily a dangerous or difficult one, yet presents an ever-varying condition of the parts involved that demands the wisest judgment and a most extensive experience to correctly manage it. Each case presents its own problem. The first incision is made by pinching up with the left hand the skin and superficial tissues in a fold, Fig. 1639. 622 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. transverse to the proposed line of incision. An assistant grasps the fold with one hand to steady it, while the operator, also grasping it, transfixes it at its base with the knife, which has its back turned toward the hernial tu- mor (see Fig. 1640). The tension of the hernial sac pre- vents it from being caught in the fold, and the operator accomplishes with one stroke, without danger, as much as will ordinarily be accomplished in a much more tedi- ous dissection. The line of the incision is, as a rule, in the axis of the tumor, and for an inguinal hernia this is the axis of the canal. In an old scrotal hernia the line of the incision approximates a vertical one. The length should vary with the size of the tumor and the thickness of the superficial tissues, and it is very accurately con- trolled by the size of the fold transfixed. The operator, after making the first incision, must then cautiously and slowly dissect his way down to the hernial sac through tissues not easily distinguished. The director to be used should have a rather blunt point. It may be slipped through and under the looser tissues, but as the firmer and more closely woven fascias are encountered they should be pinched up by the fingers or forceps, lifted from the subjacent tumor and nicked with the knife, which should be held with the flat of the blade parallel to the surface of the tumor. The director is slipped through the opening thus made, and the tissue divided throughout the length of the incision. When the sac is ing band or neck until it yields enough to permit the easy reposition of the hernia. The constriction may be due to the tissues outside of, and immediately in contact with, the neck of the sac, and the strangulation may be relieved by dividing these tis- sues without opening the sac. This operation is less dan- gerous, as it avoids opening of the peritoneal pouch, does not subject the bowel to the direct contact of the fingers, and obviates the possibility of haemorrhage into the peri- toneal cavity from injury to the vessels cut in dividing the constricting tissues. There are some cases which are easily reduced without division of the stricture, after the thick- ened fatty walls of the tumor have been incised, and the hernial mass is subjected to more direct manipulation. This operation, however, prevents inspection of the con- tents of the hernial sac. The principles laid down for the selection of cases to which taxis is applicable will guide us in the selection of the proper operation. Where a surgeon is willing to apply taxis and reduce without operating, he will generally be willing to reduce if possi- ble, without opening the sac, if division of the constrict- ing band makes it easy. The propriety of this procedure is doubtful when the hernial contents are complex in character. A mass of omentum, the presence of the colon or a large fluid exudation, are contra-indications. Long-continued strangulation, great prostration, and the presence of gas in the sac, demand the major operation. The sac opened and the stricture divided, the surgeon must then face the most responsible part of the task. Is the bowel to be returned to the abdominal cavity, or left permanently in the sac on account of adhesions, a circumscribed ulcer, a rupture, or because of its gangrenous condition ? Is the ulcerated spot to be closed by sutures and returned, or shall the gangrenous bowel be further withdrawn and a section excised, and the two ends of the sev- ered bowel brought to- gether, sutured, and re- turned to the cavity ? These are some of the puzzling questions which force themselves on the surgeon. Before considering them in detail, it is better to follow to its completion the steps of an ordinary herniotomy. When the constriction is divided, the intestine is ordi- narily easily returned. If it slips quickly and with a sudden rush away from the fingers, the operation prom- ises success. Little remains to be done to secure recov- ery. The wound should be thoroughly cleansed with a weak sublimate solution, bleeding points controlled, and the tissues carefully adjusted. A small drainage-tube in the lower end of the incision, with its inner end just within the sac, is, I think, a safeguard and of ad- vantage. An antiseptic absorbent dressing should be applied so as to make light but even pressure on the part. Absolute quiet is to be enforced, and if pain is .present, a mild opiate may be administered. A liquid diet is to be enjoined and continued until free and easy move- ments from the bowels tell of restored function and power. Rapid union will occur unless the tissues have been much contused. A pad or truss to prevent protru- sion of the hernia is not often necessary, unless indicated by violent cough, for the vomiting ordinarily soon sub- sides after the reduction of the strangulated gut. If the intestine has been injured by the surgeon's knife, it must be sutured. The suture should include only the perito- neal layer. The needle, armed with catgut or fine anti- septic silk, enters about one centimetre from the edge of the cut, and passing under the peritoneum, emerges through this membrane about three millimetres from the edge, and so traverses the opposite side (Fig. 1641). The object is to oppose the serous surfaces. A single suture Fig.1641. reached a fold should be picked up with the forceps. The fingers catching this fold and moving to and fro will appreciate beneath it the outline of the distended gut. The bowel may be separated from the sac by a serous ef- fusion which escapes when the sac is opened. A distinct wall clearly outlining a cavity free from connective tis- sue gives unmistakable evidence that the cavity of the hernial sac has been opened. The bowel now presents itself with its surface natural in color, or red and con- gested, or, if long strangulated, purple and mottled, with a thick and leathery wall which is coated with a layer of lymph. Sometimes the intestine is covered by omentum. This loose vascular mesh-work, with well- defined vessels traversing its tissue, is occasionally loaded with fat, and may deceive the operator. This omental fold occasionally forms a complete sac for the herniated bowel, but more frequently it lies loosely, upon the coil, and is easily separated from it. The stricture is now to be divided, and the intestine returned to the cavity of the abdomen. The site of the stricture is usually at the neck of the sac. This is found at one of the inguinal rings. It is to be divided by the hernia knife. An ordinary probe- pointed, preferably curved, bistoury may be converted into a hernia knife by wrapping the blade from the heel nearly to the point with gauze. A short cutting edge, of not more than half an inch, is all that is needed. This knife-blade, guided by the finger, should be carried in front of the bowel to the site of the constriction, its edge turned forward, aud firmly pressed against the constrict- Fig. 1640. 623 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. may be all that is needed. The continuous suture is the safer one if a long slit is to be united. If the omentum envelop the intestine, it must be care- fully removed without lacerating its tissues, as it bleeds easily and it is to be returned to a cavity that favors con- tinued oozing from injured vessels. Any portion that is torn should be carefully inspected, and the vessels ligated. The constricting band may be in the omental tissue. If, however, a thickened mass of omentum is present in the sac and it cannot be returned, it should be cut off. This is especially demanded when it has been bruised or has become inflamed during the strangulation, for it is liable to suppurate and maintain an ulcerating wound. The pedicle is to be carefully and securely ligated, either as a whole or in sections. If the pedicle is adherent, it may be left in the neck of the sac, but it is important that the sac be empty in order that subsequent control of the hernia may be effected by a truss. Recent adhesions of the sac and intestine may be safely ruptured, unless the bowel is much softened, but if the adhesions are old and long, they may be cut, and, if necessary, ligated. Close, firm adhesions forbid the reduction of the hernia when thus irritated by strangulation. Such a hernia is danger- ous, and if the bowel could be released by a dissection additional risk might be justified, but this risk is intensi- fied when the parts are irritated and inflamed, and should not now be incurred. Artificial Anus.-If the bowel is found gangrenous, with its wall dark-purple, flaccid, and leathery, shall portion. The constricting band must be divided, if a com- plete loop is involved, and the gangrenous intestinal loop must be freely incised if it has not already broken down. If it is thought best to secure the living margin of the intestine to the ring the proximal end is of most importance, and must be most securely fixed in its posi- tion. The discharges will, of course, be from the upper end of the bowel, and free and perfect drainage is the essential point in thus preparing for an artificial anus. The flow of faecal matter will for a time be entirely through the opening of the sac. The extruded portion of the bowel is thrown off by ulceration, and the open ends of the intestine are slowly retracted as the external opening contracts (see Fig. 1642, from Eulenburg's " Real En- cyclopadie," ed. 1885). A spontaneous closure may occur when only a knuckle or fold of the intestinal canal has been destroyed and the continuity of the channel is intact, except for the open- ing thus made on one side. If such an opening remains, it forms a fistula through which only a small discharge appears. If the fistulous tract is deep, its edges may be freshened and approximated, and a cure thus effected. If, however, an entire loop has been lost, there will be two distinct intestinal openings at the site of the arti- ficial anus, one for the proximal, and one for the distal end of the bowel (Fig. 1643, from Eulenburg). These are separated by a partition-wall formed by the union of the contiguous peritoneal surfaces of the bowel within the cavity. This septum may be destroyed by transfixing Fig. 1642. Fig. 1643. we prepare for an artificial anus or excise the sphace- lated portion, and hope for a restoration of the continu- ity of the intestinal tract ? Cases recover after such excisions, and the condition thus re-established is far preferable to an artificial anus, but, no doubt, increased danger is encountered by an excision. Nature during the time of the strangulation and death of the intestine has been guarding against the dangers of the condition by forming plastic adhesions about the neck of the sac, and the bowel is often firmly adherent to the abdomi- nal wall and the neck of the sac. Thus security to life is sometimes obtained by the conditions which de- termined the local destruction, and the danger is increased if these adhesions are destroyed and a portion of the bowel removed. This condition is established when the strangulation has been slowly developed, and is most fre- quent in old hernias. Cases of strangulation in which the constriction is sharp and suddenly established-as in a large congenital hernia when strangulated on its first ap- pearance in adult life, and in the small hernia which is forced through a narrow and rigid opening, notably the femoral or umbilical-frequently result in a total destruc- tion of the bowel before any change is effected in the con- dition of the intestine at or above the neck. It may escape even the congestion incident to the irritation which pre- cedes inflammation. Adhesions are absent, and the loop is held in the sac only by the distention of its herniated it with a loop of silk tightly tied, or by an elastic ligature, or by the use of a clamp. The continuity of the bowel, if thus re-established, will favor the ultimate closure of the opening. The wound may be enlarged, the coil of the intes- tine loosened from its detachment, and the ends of the 'severed canal freshened and sutured, as first suggested and practised by Dr. R. A. Kinloch, of South Carolina. Repeated operative interference may be required to ac- complish the closure of the opening, and in some cases this cannot be effected. The continued oozing of faecal matter and irritating discharges from such an opening soon begets an irritation of the parts about the artificial anus that is annoying and exceedingly difficult to control. This constant oozing may be partially controlled by pads and pressure, or a receptacle may be adjusted to the open- ing, but all such measures are imperfect, and the condi- tion is in many ways deplorable. Excision of Bowel.-The excision of the bowel, when sphacelated, certainly commends itself most strongly to the surgeon. The number of cases in which complete excision, with union of the divided ends, has been success- fully performed is increasing, and the perfect result, when obtained, is so much to be desired, that there is a strong incentive to accept the increased risk rather than face the disagreeable alternative of an artificial anus. Antiseptic surgery, and the consequent freedom with which the ab- 624 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. dominal cavity is nowr invaded, all lend their influence to help forward this advance, if it can be so called, for its value and rank can only be determined by the results, and it yet remains to be seen whether it is more danger- ous than the fatality which attends the return of an intes- tinal loop of doubtful vitality, or the combined risk in- cident to the establishment and cure of an artificial anus. As yet much must be left to the discretion of the surgeon as influenced by the exigencies of the individual case. After an excision has been determined upon it is of the greatest importance to have the strangulation perfectly relieved before proceeding with other steps in the opera- tion. The bowel, when well freed from constriction, is drawn downward, so as to bring healthy intestine into view and give easy access to the bowel at the point where the incisions are to be made for the resection. The bowel should be emptied of its contents and scissors used to ex- cise the gangrenous part. Great care must be taken in ligating the mesenteric fold so as to prevent haemorrhage. A needle free from cutting edges, and threaded with cat- gut or silk, should be at hand so as to ligate in sections the mesentery, which, unless it is stiffened and thick with fatty deposit, may be divided near the intestinal margin. The portion to be removed should be surrounded by liga- tures, with which the haemorrhage is to be controlled. These loops may then be tightened as the part is severed. If the mesenteric fold is not pliable it will be necessary to remove at least a small V-shaped piece, in order that the divided intestine may be approximated without ten- sion. When a long section of the bowel is to be removed the larger vessel in the mesenteric fold may be sur- rounded with a ligature placed near the spine. Where the mesentery is thick it would, no doubt, be of advan- tage to unite the serous membrane over the severed margin by a continuous catgut suture. The ends of the intes- tine are to be united by the approximation of their serous surfaces. In order to accomplish this it is necessary to in- vert one or both of the free ends. The rectal end may be inverted and the gastric extremity slipped into it, or the two ends so approximated as to turn the cut edge of each extremity into the calibre of the bowel, thus presenting a ridge inside of the intestinal canal. The two ends of the divided intestine should be united as quickly and with as little handling as possible. I have found that the division of the constricted neck of the hernia must be free, to prevent a rapid congestion and discoloration of the intestinal ends. The proximal end, especially, must be watched, as the flow of faecal matter into it will distend and constrict it. The hernia can be returned through an opening that is not sufficiently free to prevent undue constriction and congestion during this operation of uniting the divided ends. Gentle pressure on the neck may prevent the flow of faecal matter, and thus help to avoid engorgement. The united intestine must be easily replaced in the cavity without undue pressure being exercised, for lacerations of the tissues included in the sutured line are likely to occur if roughly handled. The most feasible plan for an easy, rapid, and secure union of the divided extremity is, I believe, to be found will secure the ends in position, and then the continuous suture, including only the serous layer, will rapidly com- plete the approximation. The interrupted suture should be near the end, and the line of the continuous suture is set a little farther back. When the divided ends are secured and approximated, the intestinal loop should be placed just within the cavity, so that if a break in the con- tinuity of the canal occurs the faecal flow may find exit through the hernial opening. The external wound should be approximated and an absorbent antiseptic dressing ap- plied. Crural Hernia escapes through the crural ring under Poupart's ligament, and after following the crural canal, finally forces forward its anterior wall, emerges at the saphenous opening, and rests in the fold of the groin, bending upward over Poupart's ligament, but situated be- tween the superficial fascia and the fascia lata. The deep layer of the superficial fascia is closely ad- herent to the margins of the saphenous opening and to Poupart's ligament. The long saphenous vein is between the two layers of this fascia, but below the neck of the hernia. A group of lymphatic glands is closely held in that portion of the deeper layer that enters into the forma- tion of the cribriform fascia. This deep layer of the superficial fascia-the so-called cribriform fascia-forms a resisting layer to the escape of a crural hernia, and pre- vents its passage upward over the abdominal wall. Underneath the deep layer of the superficial fascia is the fascia lata, divided at its upper margin into the iliac and pubic portions. The iliac portion is attached to the iliac crest and Poupart's ligament, but blends with the pubic portion at the lower margin of the saphenous open- ing, where the pubic portion departs from the plane of the iliac, and takes position behind it, as it continues upward to be attached to the ilio-pectineal line, the body and the horizontal ramus of the pubis. The femoral vessels lie behind the iliac portion and in front of the plane of the outer part of the pubic portion of the fascia lata. The crural ring is formed (see Fig. 1634) by Gimbernat's ligament, Poupart's ligament, the horizontal ramus of the os pubis, and the inner wall of the sheath of the femoral vein. This gives a fibrous bor- der in front and to the inner and outer sides, but a bony one behind. The fibrous portion on the outer side sepa- rates the femoral vein from the crural ring and canal. It is one of three bands which firmly unite Poupart's liga- ment to the pelvis. These bands generally determine the protrusion of a femoral hernia at this one point by pre- venting an increase of the space between the arch and the pelvis. The other fibrous bands are upon either side of the femoral artery. This crural ring is the point where a femoral hernia finds escape from the cavity, and it is continuous with the crural canal, which is a funnel-shaped channel formed by the sheath of the femoral vessels. Its base is at the ring, and its apex about two centimetres below. It is the innermost of the three compartments of the sheath of the vessels. Femoral hernia escaping through this ring carries the peritoneum, a layer of the transversa- lis fascia, and the femoral or crural sheath out through the saphenous opening, where it receives as additional cover- ings the cribriform fascia, the superficial fascia, and the skin. A lymphatic gland lies in the septum crurale, or the layer of the transversalis fascia which is situated at the crural ring. The course of a femoral hernia is a tortuous one, as it first passes downward along the crural sheath, then pushes forward the anterior wall of the crural canal and the cribriform portion of the superficial fascia, and turns upward over. Poupart's ligament. The neck of the her- nia is below the spine of the os pubis, but the body of the tumor, if sufficiently developed, is turned upward (together with a reflected layer of the superficial fascia) over the abdominal muscles. It can, however, always be lifted from this wall by passing the finger under it. The anatomical relations of the obturator artery to the neck of the hernia are important, as it is frequently irregular in its origin and in its course. These variations occasionally bring the artery into contact with the crural ring. In one case in three and a half it arises from the Fig. 1644. in the use of both the interrupted and the continuous sutures. The interrupted sutures should include the en- tire thickness of the wall of the intestine, and be tightly drawn; they may traverse the margins of the cut ends, as represented in Fig. 1644. Three or four of these sutures 625 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. deep epigastric, more rarely it springs from the exter- nal iliac, and when so arising it may receive a branch from the epigastric. If it have either of these irregu- larities of origin, it still usually reaches the obturator foramen by passing downward and backward to the in- side of the femoral vein, but outside of the crural ring. It follows occasionally the margin of Poupart's and Gim- bernat's ligaments, thus surrounding the crural ring and the hernial neck. It is only in the rare instances where it pursues this course that it is a source of danger in fem- oral hernia. The point of strangulation in femoral hernia is at the crural ring. The firm and rigid character of the borders of this ring makes prompt and speedy relief necessary. Successful taxis demands that attention be given to the course followed by the hernia in its escape from the cavity. The body of the hernia rests on Poupart's liga- ment, the external oblique muscle and the os pubis. The tumor is to be lifted from the groin, and while com- pressing the mass with one hand, the fingers of the other may manipulate the neck by following it backward and upward. The tumor passes through the saphenous open- ing into the crural canal, and thence through the ring into the abdominal cavity. The taxis is much more dan- gerous here than in inguinal hernia, and is not permis- sible if emesis has been long continued and the strangu- lation is tight. In operating, the superficial incision, six or eight centimetres long, should be vertical and over the saphenous opening. The long saphenous vein is below the point at which the cribriform fascia is opened to ex- pose the crural sheath. The strangulation is to be re- lieved by dividing the margin of the crural ring with a probe-pointed bistoury, which is carefully passed through the ring on the finger as a guide. The incision must divide the margin of Gimbernat's or Poupart's ligament. The edge of the knife is therefore to be directed forward or inward, as may be deemed best. It is very important not to pass the blunt end of the knife much beyond the constricting band. The cutting edge should never pass beyond the margin of the ligament, and should be firmly and steadily pressed against the ligament until the con- stricting band is divided, for if it is allowed to enter the cavity it may sever the obturator artery. This incision of the ring may occasionally be accomplished without opening the sac, but if doubt exists regarding the condi- tion of the intestine, the sac must be opened and its con- tents exposed. Care should be taken to retain the sac outside while reducing the hernia, lest the strangulation be caused by the neck of the sac itself. Inguinal hernia makes its exit above the pubic spine- crural hernia emerges below it. A crural hernia differs from a psoas abscess in the tension of the sac, the reso- nance of the tumor, and the absence of fluctuation. The tumor presents to the inside instead of to the outside of the femoral vessels, and the general symptoms of an abscess are wanting. A varicose condition of the veins is easily detected by the engorgement which follows pressure made upon the femoral vein. It is more difficult to ex- clude enlarged glands, for when a hernia is inflamed its local signs simulate very perfectly adenitis and peri- adenitis of the glands found in the cribriform fascia. Umbilical hernia is frequently congenital, and in that case a portion of the viscera occupies the unclosed ring, and is covered only by the tissues of the cord. Males and females are alike subject to it ; the acquired form is most common in elderly, fleshy females. The sac of the ac- quired umbilical hernia is a distinct pouch of the perito- neum. The investing tissues of the sac are the internal abdominal fascia and the skin, with its subjacent fascia. The wall of the hernia is thin. The opening is in the linea alba, which is formed by the union in the median line of the aponeuroses of the abdominal muscles. The linea alba is dense and firm, wider above than below, and is the thinnest part of the abdominal wall. The umbili- cal opening is a rigid fibrous ring, circular in outline, and closely connected with one of the lineae transverse. The neck of the hernia is situated at the upper part of the tumor, which varies greatly in outline and size. This hernia is often irreducible, and obstruction of the bowel is of frequent occurrence. The obstruction is generally amenable to rest, enemata, pressure, and mild purgatives. Strangulation will, however, quickly supervene when unusual tension or fulness of the sac is present. It is a dangerous hernia, because of the rigidity of the ring, and it is difficult to relieve without operation, because of the presence of a mass of omentum which often forms the larger part of the hernial tumor. The pliability of the abdominal walls nullifies all efforts to invoke the aid of gravity, and seriously interferes with the success of taxis. Before attempting taxis the tumor should be carefully explored to determine whether the tension of its different parts be uniform, for, in old irreducible hernias, it is fre- quently a new loop just escaped that gives rise to the strangulation, and it is apt to be more tense than other portions of the tumor. This loop, if correctly located, can, by direct effort, frequently be returned, although the greater part of the mass remains irreducible. When herniotomy is demanded the case is of great gravity, for if the intestine and omentum, often irreduci- ble even after operating, are exposed to manipulation, there is danger of inflammatory complications. This in- flammation is dependent not only upon the irritation thus established, but is promoted and made fatal, in many in- stances no doubt, by the imperfect circulation in the her- nial mass. The neck of the sac should be approached from the upper surface, and the operation limited, if possible, to the division of the ring through a small incision in the sac. The upper margin of the ring should be divided. The finger is the best guide for the hernia knife. The strangulation thus relieved, the hernia, or at least that portion which is new and strangulated, may be returned to the cavity without exposure or direct manipulation. The danger is thus materially lessened. Ventral Hernia.-A hernia of the stomach or colon is in rare instances found to protrude at the xiphoid car- tilage, and is described by some authors as epigastric hernia. Ventral hernia most frequently occurs in thelinea alba, between the umbilicus and the pubes. Distention of the abdomen by dropsical effusions, by pregnancy, or by tumors, weakens very materially the wall in this line. The imperfect union of wounds of operation favors such a hernia, but it may appear at any portion of the lateral wall of the abdomen when it has become weakened by the stretching of the parts, by direct violence, or by tear- ing. The symptoms and treatment do not need special con- sideration. Elastic pressure, with suitable pads, will best fulfil the requirements for a truss. Obturator Hernia escapes at the upper and outer part of the thyroid foramen. If any tumor is visible it is below the horizontal ramus of the os pubis, a little to the inner side of the femoral vessels, but behind the pectineus muscle. Deeply seated and difficult of detection, many of the cases on record have only been discovered after death. The obturator nerve is subjected to pressure by the tumor as it passes through the foramen, hence pain in the region of its distribution is a frequent symptom. If the surgeon diagnosticates a hernial tumor at this site, and the evidences of strangulation are distinct, an incision parallel to the line of the femoral artery, and midway between the vessel and the pubic spine will en- able the operator to reach the neck of the tumor. The anatomy of the parts and such dissections as have been made of obturator hernia, indicate that the tumor is slowly formed. Mr. Birkett states that the hernia fre- quently includes only a part of the calibre of the canal of the intestine, but that this portion is frequently elongated and converted into a diverticulum. Gastric uneasiness, local pain, and sensitiveness, to- gether with a diffused pain over the region of the obtu- rator nerve, increased by the movements of the hip-joint, point to the existence of an obturator hernia. The tumor, when too small to be located by external manipulation, may possibly be diagnosticated by exploring the obtura- tor foramen per vaginam or per rectum. 626 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. Perineal Hernia escapes between the anterior fibres of the levator ani, and appears in the perineum as a soft pliable tumor. The fold of peritoneum, dipping down between the prostate and the rectum, or in the female between the vagina and rectum, forms the sac. Pudendal Hernia escapes at the inner side of the as- cending ramus of the ischium, and presents itself in the posterior part of the labium, thus differing distinctly from an inguinal hernia, which, as it becomes labial, dis- tends first the anterior portion of this structure. Cysts occasionally develop in the labia, and the hernia should not be confounded with them. Vaginal Hernia may be formed by the protrusion of the bladder, the rectum, or the large or small intestine pushing downward the wall of the vagina. The vaginal wall needs support or operative treatment to correct the condition. Ischiatic Hernia.-A small obscure tumor, situated under the glutaeus muscle, near the position of the notch, when associated with symptoms of strangulation, would justify exploration. The neck may be either above or below the pyriformis muscle. Strangulation of the bowel at this site may exist without giving local evidence of its presence except on firm, deep pressure. Diaphragmatic Hernia may occur through the di- lated oesophageal opening, but most frequently it is the result of wounds that have penetrated this musculo-mem- branous partition. Trusses.-A truss is a pad fitted to the hernial open- ing or tumor, and attached to a spring or to an elastic band, which holds it in position. It is to be applied to the given case, either to prevent an increase in the size of an irreducible hernia, or to control the descent of the in- testine. When it accomplishes the latter purpose, it may also accomplish the further and higher aim of the cure of the hernia. These are the indications to be fulfilled in the adap- tation of trusses : They should be worn all day, removed at night after reclining, and replaced before arising. The hernia should never be allowed to protrude, as it exposes the patient to unnecessary danger, and removes all prospects for a radical cure by the use of a truss. The shape of the pad should be determined by the outline of the parts, and must vary in size with the hernial opening. It is best to have it overlap the margins of the ring. It should not penetrate it nor act as a wedge in dilating the opening. A flat, concave, or slightly convex pad should be fitted to the ring. Mr. Bryant commends very strongly, for an irreducible hernia, the accurate adjustment of the pad used to the exact shape of the tumor. This is best accomplished by making a plaster cast of the tumor when it is small and favorably conditioned, as after a day's rest. The cast serves as a model in the formation of the pad. The pad adapts itself best to the part when it has a joint at its junction with the spring. The spring should be elastic and not so strong as to be painful. A light, closely-fitting spring which will pre- vent the expulsion of the bowel is sufficient, as inflam- matory action produced by a truss is not desirable, for there are better methods of exciting it if a radical cure is to be sought through its agency. The cure of a hernia by the use of a truss is frequent, but it is to be obtained rather by preventing its descent than by exciting an adhesive inflammation. It is most frequent in the young and growing subject. In fitting a truss the nature of the hernia and the size of the hernial opening should be specially consulted, and in ordering a truss the girth of the body at the umbilicus, as also the circumference of the pelvis one inch below the crest of the ilium, should be given. The direction in which pressure will be most effective, is best determined by an examination in the erect posi- tion. The efficiency of a truss is tested by coughing, jumping, or by assuming the stooping posture. In oblique inguinal hernia the truss should be applied opposite the internal abdominal ring. Radical Cure.-This is the most important task set before the surgeon in connection with hernia, since it is a preventive means, and enables many persons to avoid the dangerous conditions to which a hernia subjects them. There are two chief points to be sought: First, the ob- literation of the sac. This may be accomplished by ex- citing adhesive inflammation of its walls, by division of the neck of the sac, or the extirpation by excision of the sac. The adhesion of the parietal peritoneum to the ab- dominal wall and the firm agglutination of the tissues about the neck to the adjacent parts, add materially to the resistance of the parts, and help to prevent the for- mation of a new sac. Second, the narrowing of the in- guinal canal, so that it encloses snugly the tissues of the cord. This is generally accomplished by the approxima- tion of the borders of the ring after freshening and sutur- ing them. These two objects are most easily attained in the young. There is a disposition to the obliteration of the sac and the solidification of the tissues involved that favors success. This effort of nature will very often suc- ceed without further aid from the surgeon than is implied in the simple retention of the hernia. This retention is usually obtained by means of the truss. Trusses have been supposed to derive their curative influence from the strength of their spring and the consequent inflammation which they excite. No doubt occasional success has been thus obtained, but not often except in children, and it has been at a great expense of suffering. The tissue subjected to the direct pressure is the skin. It is the most sensitive of all the tissues, and when irritated is exceedingly pain- ful, and I do not believe that inflammation and adhesion of the less vascular tissues of the sac, viz., the fibrous structure of the ring and the connective tissue, are ob- tained as a result of pressure without unnecessary and prolonged pain. The truss is most successful where it is effective as a retentive agent, and in the young subject there is a strong tendency to a spontaneous cure by the natural oblitera- tion of the sac and the consolidation of the tissues envel- oping it and forming the boundaries of the hernial open- ing. The truss can be made more effective and the retention of the hernia be often perfectly accomplished without a truss, by causing an inflammatory deposit in the tissues about the neck of the sac and the ring of exit by the injection of irritating fluids. This method of treat- ment is especially applicable to the young, in whom re- tention is sufficient to enable nature to effect a cure. The injection of a few drops of the decoction of oak bark, after Heaton's method, into the cellular tissue outside the neck of the sac at the hernial opening, renders efficient aid in restraining the hernia and exciting to action the tissue which, by consolidation, effects a cure. This is less painful, more speedy, and efficient than the inflammation excited by the pressure of a truss. In adults, and in cases where herniotomy is demanded, the excision of the sac and the approximation of the bor- der of the ring by suture is more efficient. The safety with which, under conditions of strict cleanliness, the pouch of the peritoneum forming the sac can be excised, has, for a time at least, diverted the attention of the sur- geons from the subcutaneous methods of operating. The total removal of the pouch of peritoneum at the hernial opening seems to be a very essential aid in the perma- nency of the cure. It is not necessary to dissect the sac out of the scrotum, though this is frequently done and is desirable, since it more firmly agglutinates the parts to- gether. The division of the neck of the sac, the ligation or the suturing of the proximal end with catgut, and its return to the abdominal cavity, are the important steps in the operation. These alone will frequently result in a cure, especially if the adjacent tissues are sufficiently in- volved to firmly attach the peritoneum to the abdominal wall at the hernial opening. The neck of the sac must be loosened and pulled down, so as to make the division as high as practicable, in order to obliterate the pouch in the peritoneum. The edges of the ring can then be brought together, with or without freshening, and sut- ured with strong catgut or other animal ligature, or with wire. The edges of the wound are then to be approxi- mated after the introduction of a drainage-tube. The 627 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tube should be removed as soon as possible, generally in from twenty-four to forty-eight hours. The whole proceeding should be in every detail thoroughly anti- septic. This operation is applicable to an ordinary herni- otomy and does not materially increase the danger, Tinless the intestine to be returned to the abdomen is in bad con- dition and it is desirable to retain the opening into the hernial sac as a drain from the abdominal cavity. The extent of tissue disturbed by the excision of the sac is often great and adds danger to the operation ; hence a simple division of the sac at its neck is occasionally sub- stituted for it. A congenital hernia, or one complicated by a hydrocele of the cord, makes the operation more tedious, as the vas deferens is more closely connected with the sac, and the dissection for its release is more difficult. In an ordinary herniotomy, where the irritation of the tissues and the inflammatory action are limited to the parts out- side of the ring, it seems rational to conclude that the sep- aration of the abdominal cavity from the external wound by a division of the neck, with subsequent suture of its proximal end, with or without removal of the body of the sac, would give added security to the patient, as it cuts off the danger of infection from the secretions of the inflamed surface. These are the cases that should be subjected to this operation for the radical cure of hernia. Certain other complicated cases, where a truss is not efficient or is in itself a source of danger, or where it fosters other dis- eases, as varicocele, etc., demand the operation. The number of these cases is large, and the permanency of the cure to be thus obtained will soon be tested. The wound made by the operation, when performed with the parts in a good condition, usually heals kindly and quickly. The peritoneal cavity is generally, though not uniformly, exposed, and every care must be exercised to guard against inflammation. The operation is not to be urged upon every patient who has hernia, but I believe that it is more rational and will be of more permanent benefit than those heretofore practised, though relapses have not been infrequent after the operation. The ability to command the healing of the wound with- out inflammation and suppuration is the element which justifies the operation, and yet the absence of inflamma- tory deposit about the ring, and of that firm agglutina- tion of the parts which is encouraged by suppuration, is no doubt accountable for some of the failures. The sub- sequent injection of irritating fluids may be found to give added security against a relapse. This operation of excising the sac, freshening the edges of the hernial opening, and their approximating them by means of sutures, is especially applicable to umbilical hernia. The opening here is more easily and perfectly obliterated than in either the inguinal or the femoral form. H. H Mudd. everywhere, we see in many instances the occurrence of double hernia on the same side. To establish in the centre of the tissue an active but circumscribed inflamma- tion is the difficulty which at once presents itself; and an inflammatory process of such intensity as shall result in the formation of an modular or cicatricial tissue, too or- ganized to be absorbed, too firm to yield, will undoubtedly insure us against the possibility of a relapse. That such has sometimes been obtained will hereafter be seen, but it has often been rather the result of the dangers through which the patient has passed, than the expression of any surety in the surgical provisions offered for his relief. However readily we may sometimes control inflammation elsewhere among the tissues, in this particular situation it can be effected neither with certainty nor with safety. The inguinal canal is but the largest of those interstices formed by the decussating fibres of the abdominal tendons. The external ring is principally formed by the divaricated fibres of the external oblique tendon, while the internal ring results from the splitting of the aponeurotic fibres of the internal oblique; the anterior wall of this canal is but the aponeurosis of the great oblique, its posterior wall that of the transversalis. The most inferior fibres of the internal oblique form a superior boundary, while the inferior is composed of those confluent aponeurotic ele- ments known as Poupart's ligament, or the ligament of Fallopius, with the epigastric artery coursing transversely behind the fascia transversalis in the sub-peritoneal layer, to reach the external margin of the rectus. Let us here add the serous cellular connective tissue which binds these parts together, and, for practical purposes, we have completed the enumeration of those structures upon which we are to operate with the view of exciting adhesive inflammation. Now it is evident, from the physical and vital properties of the structures implicated, that there is but little prob- ability of their exhibiting the amount of irritation re- quired for the production of formative exudates, since, in such tissues, these are rather the consequences of slow and chronic action. With little or no cellular tissue, with fibrous and aponeurotic fasciae, and an interposed serous sac, parts are brought in apposition which are ill-disposed to adhere with firmness, and whatever theory may dispose us to admit, experience has often shown that, most frequently, such adventitious productions as may occur form but feeble bonds of union ; but should, on the other hand, a more violent action be contemplated, in what way shall we restrict this inflammation within provisional limitations ? and how shall we determine in advance the nature of that inflammation which is about to result ? In these preliminary remarks we must not be under- stood as denying any of those successes which have been claimed for ancient and other more recent modes of oper- ating ; we have no disposition to question statements handed in with almost every new suggestion ; but such fortunate results are rare at best, and may sometimes be advanced in behalf of almost any plan of treatment. Ex- ceptions, under almost any mode of procedure, sometimes present themselves, in which adhesions, established we scarcely know how, have subsequently and permanently resisted the impulse of the recurring interstitial hernia long enough to allow the muscular fibres in the vicinity of the rings to recover their tonic contractility, at once restoring the obliquity as also the dimensions of the canal. Even dorsal decubitus has occasionally effected a similar result. An account of some of the ancient methods of cure will now be referred to, and perhaps this brief history will not prove a dry narrative to the student of pathology; for whoever supposes that he must reject the successive oper- ations of an early period, as fashions out of vogue, forms no adequate conception of the kind of inheritance be- queathed us in even the rough tentatives of ignorance transmitted to us traditionally. Many of the so-called specifics of earlier times form a long list of local and general remedies for the cure of her- nia, that are as useless as some are formidable and danger- ous, though they continued to press their claims, as late as 1775, upon the public, obtaining the patronage of many HERNIA, REDUCIBLE, RADICAL CURE OF. Surgi- cal methods for the radical cure of reducible hernia have been almost entirely confined to inguinal hernia. An en- cyclopaedic review of this subject will exhibit a long list of ill-devised procedures, commemorative of the surgical intrepidity of a less enlightened age, and this burdened page of surgical literature shows an earnest labor in this direction from the earliest periods of our science. The entire obliteration of the hernial canal should constitute the only condition of a radical cure, yet this was not even aimed at, and was not, therefore, ever accomplished in the earlier attempts, as will be seen. If the outer ring, or two-thirds of the inguinal canal, be all that is at the time obliterated, we only convert a complete into what is called an interstitial hernia ; the accidental adhesions which we have thus established are soon destroyed, and the hernia returns ; the only possible means of occluding the entire passage must rest upon the production of a sufficient amount of adhesive inflammation on the one hand, and upon the co-arctation of the opposed surfaces and pillars of the rings on the other. Effacing of the hernial sac, even its entire destruction by excision, is no guarantee against the production of another hernial protrusion through the already dilated canal ; for, even where the thickened sac of an incarcerated hernia lias contracted adhesions almost 628 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. of those highest in authority throughout Europe. In 1680, Cambriere, a French ecclesiastic, entertained Louis XIV. with extraordinary promises respecting a plaster and remedy that were to effect a cure without surgical interference. This proved to be a solution of hydrochloric acid in red wine, with one of those " emplastra contra rupturam" well known to Ambroise Pare, Dionis, and others. The famous Littlejohn disclosed his secret cure to George the First for five thousand pounds sterling, and received an annuity besides of five hundred more. This consisted in the application of oil of vitriol and caustics over the inguinal region until a deep ulceration was caused, and when the granulations touched with caustic were healed, a bandage was worn until the cure was completed. An appeal to the authority of Ambroise Pare and his quaint account of his autopsy of the priest, shows that, from a remote period, the disappearance of hernia in the horizontal position, and its maintained reduction by the hand, offered promises of cure and ended sometimes in permanent relief. Even in more recent times we find Ravin, Biagini, and others, recording many permanent cures from position and pressure combined. Here the reader is naturally introduced to the inven- tion of the truss, an instrument that has undoubtedly done more to expunge from the annals of surgery the least scientific of its memorials, than have all the denun- ciations of royalty and vituperations of classic writers. Without discussing the question as to the inventor of the truss, he certainly conferred the greatest benefit upon the sufferer, taught him at once the simplest means of retain- ing, and the possibility of curing, his hernia, and rescued him from the dangerous methods to which he would probably have fallen a victim. The ancients, to render these instruments more effective, introduced irritative substances within the pads in the form of sachets ; these medicated salves, plasters, and fomentations, were of Arabic origin. Sachets were filled with oak-bark mois- tened with red wine, lead, and alcohol; compresses were dipped into decoction of tormentil root, gall-nuts, and calamus boiled in red wine and moistened with spirits of ammonia ; quack remedies called balxama anti-herniosa, of tannin, subcarbonate of lead, spirit of wine, and tincture of cantharides, were used even by Schneider and Schmidt. Only fifty years ago, the French Academy of Medicine was entertained with accounts of applications of medicated sachets, said to have cured many cases of hernia, by MM. Duplat and Lafonde, and a Committee Report of the American Medical Association states that Dr. George O. Pond, of Griggsville, has seen a large per- centage of cures from pressure with Stagner's truss. The cruel use of the cautery for nearly all purposes, in olden times, even in affections of the head and brain, pre- pares us for its intemperate employment in hernia. Its destructive application seems to be the point upon which all ancient writers are agreed. Albucasis says : " Quando tu non consequeris os cum cauterio, non confert operatio tua." They advised resort to the iron again and again, un- til exfoliation of the bone is induced, and, indicating the required depth of the cauterization, declared that it should be carried " usque ad Didymum ; " many lives were lost by the symptomatic fever thus produced. Under the pre- text of modifying so harsh a method, equally dangerous applications of caustics were resorted to as late as the end of the eighteenth century, and much later. These were applied to the open sac, to all parts of its interior, and to the neck of the hernial sac; dossils of lint greased with stimulating ointments were introduced into the wound and retained there by bandages; long lurches loosely tied at the middle, so that thread after thread could be removed, greased with red precipitate ointment, were used by Reiche ; sometimes the sac was opened only in part and the lint introduced (Schreger) ; or it was opened up to the ring and the lint introduced deeply into the in- guinal canal (Graefe). The destructive effects of such caustics extended, of course, to the cord, testicles, pillars of the ring, bones of the pelvis, reaching the perineum, producing sloughs as extensive, if not more so, than the actual cautery, followed by erysipelas, exhaustive sup- puration, peritonitis, and death. Sometimes the intes- tines were perforated, and stercoraceous matters escaped through wounds which are said to have healed finally, and to have resulted in a perfect cure even in infants. It is important to mention that, in comparatively recent times, similar measures, combined with the yet more dangerous practice of scarification, have been repeated. Kern, in 1808, exposed the hernial envelope, scarified around the rings, and applied a paste of caustic potash, nitrate of silver, and gum arabic freely to the raw surfaces ; and Stolz, in 1853, repeated several times the same operation. It is difficult to give credence to the number of successes which some have claimed for this mode of procedure, which Pott long ago condemned as wholly unjustifiable. Even very recently, Ratier was in the habit of punctur- ing the sac with a trocar-like instrument at its lowest part, and introducing a seton high up through the in- guinal canal; this seton was forced out, by means of the eye-pointed needle, at a level with the inner ring, and left until suppuration was produced. This proved very dan- gerous, and was soon abandoned. Castration.-Castration for the cure of hernia was formerly practised to an unlimited extent; we must there- fore chronicle the exploits of the renowned rupture-cut- ters, as they were called. Castration was performed by stretching the integument of the scrotum and making a vertical incision three inches in length, which commenced near the abdominal ring ; the testicles were then enu- cleated, the cord isolated and tied in two points and cut between. The cord was sometimes transfixed by a needle armed with a double thread ; the ends were then tied on each side and drawn upon with great force to destroy all life in the testicles. The organ was occasionally not re- moved until the next day. Great expertness was required in order to conceal the destruction and removal of these glands from both patient and witnesses. It is related of one of these ambulant quacks, who always travelled ac- companied by his dog, that such was his adroitness in re- moving the testicle, that this was accomplished almost by sleight-of-hand ; inserting two of his fingers into the wound while making the dissection, and drawing out the gland into the palm of his hand, immediately upon its excision, he dropped it upon the fioor, and it was as instantly dispatched by his dog, who, by great practice, had acquired equal skill in acting the part of an assistant at this stage of the operation. To such an extent were these barbarous mutilations car- ried that they had to be interdicted by an edict of Hadrian, in which the physician is condemned to death who shall either tear out or otherwise destroy the testicle ; while he who submits to it shall have his property confiscated. Constantine also decreed the punishment of death to those who should resort to the operation. In a report pre- sented in 1779 to the Royal Society of Medicine by Poul- tier de la Salle and Vicq d'Azyr, the Chief of Police of Paris declares that many presenting themselves for in- spection before entering military service were found to be deprived of one or both testicles ; and the Bishop of St. Papoul states that in his diocese alone five hundred children had been castrated as a preventive means against hernia ; while in Breslau more than two hundred had undergone the same mutilation. Velpeau bears witness to the fact that, within his knowledge, these practices were repeated, even by women, in some of the provinces of France. It should be remembered, however, that Dionis and subsequent authorities united in rejecting this operation, and that Heister has the merit of calling public attention to the abusive use which was being made of celotomy, in an able address published at Helmstadt in 1728, entitled: "Dissertatio medico-politica inauguralis de kelotomise abusu tollendo." Golden Suture.-An operative invention of Birault de Metz, familiarly known since the days of Oribases as the " punctum aureum," or golden suture, next claims our attention, as it introduces the reader to the earliest employment of metallic sutures in surgery, which, though they fell into disuse, were resorted to again, about the end of the last century, by Purmann in Germany, for wounds of the tongue, and by Millies, of England, in hare- lip. The neck of the sac was carefully dissected without 629 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. disturbing the testicle, and a needle armed with a golden thread or wire was passed beneath the cord and sac, as near the ring as possible, and the ligature was twisted with forceps sufficiently tight to obliterate the sac, yet not to interrupt the circulation through the vessels of the cord ; the wires were then cut, left in situ, and the wound closed. This method was in no respect superior to castra- tion, since the ligature of the peritoneal prolongation favored peritonitis, and, when drawn tight enough to ob- literate the sac, soon caused atrophy of the testicle. When the sac was not thus constricted the hernia returned, with the probable chance of the intestine becoming strangu- lated by the metallic wire, and a very common result of the retained golden suture was the establishment of a fistu- lous opening. It need hardly be said that the " punctum aureum " enjoyed but little favor among surgeons. Royal Suture.-The next proposed plan was the royal suture, so called because the procreative power was preserved which gave subjects to the king. The object proposed was the reduction only of the capacity of the hernial sac, leaving the testicles, spermatic cord-indeed, the entire generative organs-uninjured. When compared with previous plans of cure, this stitching up of the sac was spoken of as "curandi modus inculpatus ac regius." But here, again, was exhibited the danger of applying sut- ures as well as ligatures to the peritoneal process; it like- wise happened often that another serous cul-de-sac, pro- jecting through the canal, gave rise to a speedy return of the hernia; and though in its turn this royal suture shared the fate of its congener, the golden suture, yet, it may be said that the first pretensions toward establishing the more approved surgical methods of radical cure date from the introduction of a class of operations practised upon the sac alone, provision being made to exclude and protect the spermatic cord and testicle. Now, the modifi- cations which this operation underwent in diversifying the operations on the sac led to the methods by ligature, in- cision, suture, excision, scarification, and pelottement, which may be considered together. Ligaturing was vaunted as a new' procedure by Freitag, Schuckman, and even continued to be practised by Saviard, Desault, and Dupuytren, according to Bichat, with success. Celsus performed incision, combined with excision of a triangu- lar piece of the serous membrane in the shape of a mitre, so as to straighten the hernial envelope and more per- fectly secure its obliteration. A modification of incision, by the distinguished Jean Louis Petit, proved fearfully dangerous; he made broad incisions throughout the length of the sac, parallel with each other, dressing these as open w'ounds ; disastrous consequences ensued, violent inflammation and death followed in all but one instance, when the patient escaped with his life. Petit himself condemned the operation. Ligaturing and excising the sac continued to be performed by Langenbeck, Saviard, Desault, Dupuytren, Sir Astley Cooper, and others. It appears that the positive risk of such an operation had not at this late period as yet deterred the most distin- guished surgeons from repeating it. Though the wound healed in Sir Astley's case by the tenth day, the hernia returned in less than a month, as bad as ever. Here we learn at least this lesson, that such experi- ments upon the peritoneum are not made with impunity under all circumstances. It is true that but little dan- ger attends a similar operation in cases of strangulated hernia ; but we must remember that changes have taken place in the contexture of the sac upon which the strangu- lation itself depends, and the peritoneum in this situa- tion having lost its character as a serous membrane, active and extensive reaction is not likely to arise, even if the subsequent treatment be that of an open wround. It is otherwise where injury is inflicted upon an almost un- modified serous membrane, hypersensitive, and rebellious against harsh treatment, even against that of the protru- sion and reduction, re-descent and reposition of its own contents. Scarification.-To conclude the enumeration of the methods of this middle period of surgery, w<! must men- tion scarification as a separate operation. Marty objected to this on the one ground of the injury thereby inflicted upon the tendinous structures in the groin, which ever afterward would be found to be weak. Still, up to the time of Velpeau, Seiler opened the sac, reduced the her- nia, and scarified all of its interior, while Reichter carried the knife over the anterior wall only, in order to avoid the cord. A conspicuous improvement on these methods, of German origin, but not found everywhere recorded, consisted in cutting down to the sac without opening it, drawing off its serous contents, and then establishing steady, firm, and prolonged pressure upon its neck, until inflammatory adhesions occurred ; a kind of direct appli- cation of a truss, coupled with the modern use of the aspirator. Velpeau attempted subcutaneous scarifications of the sac, and Blandin invented a particular instrument with which he himself repeated these operations. Guerin and Cardans were among the very few besides Blandin who ventured upon imitating this dangerous manipulation performed by Velpeau, although in his hands it was executed without untoward accidents. Vel- peau, availing himself of the ingenious infolding of the scrotum as taught by Gerdy, performed the operation thus: He forced a wooden gorget and lance into the vaginal fold (Fig. 1645), deep into the canal up to the neck of the her- nial sac, withdrew the gorget slightly backward, pushed the lance onward, and then, freely moving its cutting edge in every direction, carried it also against the abdominal walls, which he supported with his hand, and then ex- tensively and freely scarified the parts, taking care to keep at a certain distance from the epigastric vessel. The Fig. 1645.-Velpeau's Scarification of the Ring. instrument was then removed, a few drops of blood es- caped, and finally a strap of adhesive plaster and a com- press were applied. On the third day Fournier's band- age was worn. Guerin, with a short, blunt-pointed, mounted tenotome, carried these scarifications to a greater extent even than did Velpeau. Raising a fold of skin in the inguino-scro- tal region with a lance-shaped knife, he transfixed its base, carefully protecting the spermatic cord ; with his tenotome he cut from behind forward, and from within outward to the depth of a third of an inch. lie then di- vided the strands of Poupart's ligament and the stretched muscular fibres about the abdominal wall, and scarified the whole canal in every direction. It appears that not many surgeons were disposed thus to weaken every possible anatomical support in the hernial region, and very soon the scarifications were wholly abandoned, though not before Petrali and Cardans had also experi- mented in the same direction. Petrali, in a case of left in- guinal hernia, made an incision into the skin at the middle of the inguinal ring, scarified its edges as far as the sper- matic cord, and introduced into the canal a bougie as high as possible, which he allowed to remain while the edges of the ring and integuments were united by three stitches. Cardans, on the other hand, with a cutting can- nulated trocar punctured the sac, pushed the trocar on- ward, and scarified the serous walls until the blood ran through the cannula, when the trocar was removed. He operated thus on a boy with a congenital hernia that ex- tended half-way down the thigh. He did not consider the plan reliable. Another modification consisted in rolling up the sac 630 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. and packing it up deeply into the hernial canal ; this has been known as pelottement of the sac. Again, connected with this process is a Spanish method, so very remarkable and so closely resembling the ensheathing of an organic plug that we cannot omit mentioning it. The account of this singular operation, the design of which was to obvi- ate the necessity of castrating the patient, was published in 1665, by Henry Moinichen, physician to the King of Denmark : the sac was opened by an incision, and the intestine, with the testicle, was packed up, along with a mass of cellular tissue, into the ring, the operation being terminated by the golden suture and closure of the wound. It was assumed that the function of the tes- ticle was thus preserved. It sometimes happened that the operation was performed on both sides, when it was discovered that sterility was superinduced ; it then became a serious question in the Church whether mar- riage should be interdicted, and a message was actually sent to Rome to ascertain if it were the pleasure of the Holy See that those should enter into the marriage state who were thus rendered impotent. This method was condemned as not only useless, but often danger- ous and fatal from the violent pressure and pain to which the testicle was exposed, when forced into the narrow inguinal canal. This process was practised in some of the Austrian dominions. The reader's attention is here invited to a curious and rare case of cure, through the use of the testicle in this connection, recently published by Dr. C. T. Hunter, of Philadelphia (Amer. Jour. Med. Sci., January, 1878, p. 152); the testicle plugged up the external ring, retained the hernia, and apparently cured the rupture. The rolling up of the sac, well impacted in the uppermost part of the hernial canal, has only once been practised intentionally, as far as we know. The operation was performed by Vidal de Cassis, and we cite the case from his " Traite de pathologic externe," vol. iv., p. 149, Paris, 1855 : " J'avais," dit-il, "a guerir d'un vari- cocele un jeune homme qui avait en meme temps une hernie inguinale gauche qui descendait dans les bourses. Apres avoir reduit les organes deplaces, je passai der- riere les veines du cordon spermatique et dessous le sac un gros til d'argent, puis devant ces organes un autre til. Le tout fut enroule sur les deux fils, comme je le fais pour la cure radicale du varicocele ; seulement, je saisis les veines un peu plus haut qu'a 1'ordinaire. Le sac fut done enroule comme les veines. Le malade fut ainsi gueri de ces deux infirmites, et huit ans apr^s il n'y avait pas de recidive." The interest in this remarkable cure which every one must feel justifies our citing it in the original, more particularly as it shows how little of novelty is to be attached to the more direct methods now' being advanced as original procedures in the radical cure of hernia. Mr. Ball, of Dublin, has recently suggested that after ligation of the neck of the sac, excision of its fun- dus, and suturing the pillars of the ring-in other words, after the direct method-the effectual sealing up of the sac-entrance may be completely secured by twisting the sac and preventing untwisting by carrying the inter- columnar sutures through the sac (Brit. Med. Jour., Sept., 1884). For more abundant tissue, for a firmer hold for the sutures, and for a more durable cicatrix, Hardie, of Manchester (Med. Chron., June, 1885), sug- gests that the sac should not be excised, but should be made use of in suturing the pillars of the ring around even the transversalis fascia. Mr. Southam utilizes the omen- tum and sac. After reducing the bowel, the sac, still con- taining the omentum, is dissected up to its neck. The neck of the sac and the omentum are transfixed together by a needle, with double ligature, and tied in two halves, lie tries thus to plug up the canal with at least a portion of the sac, which is to act as a barrier to reprotrusion of the hernia. The modern tentatives at a radical cure of hernia w hich it may please us to consider now as the devices of a more enlightened period, and to classify as methods of a more legitimate surgery, we shall find are still ex- pressions of the yet underlying idea, that a cure in this distressing disease is to be obtained only by adhesive in- flammation and ultimate obliteration of the hernial en- velope. The varied attempts, confusedly intermingled, but generally inefficient, which continued again to be made toward this supposed most pregnant result, may be best considered under two distinct heads : First, the introduction of foreign bodies-solids or fluids-into the sac ; secondly, the invagination of an organic plug into the canal, which, becoming ultimately absorbed, only leaves the inguinal canal more dilated than ever before, and therefore fails to effect a permanent cure. Bonnet's Needle Operation.-The first of these modern experiments of which we shall speak may be called Bonnet's needle opera- tion. The plan of a safer way of narrowing or obstructing the neck and body of the hernial sac was the invention of Bon- net just fifty years ago. This distinguished chief-surgeon of the Hotel Dieu, of Lyons, insti- tuted certainly the most compli- cated system of suturing, as we may really consider it, that had yet been devised. He based his method on the theory that needles would excite and establish adhesive inflamma- tion in any serous sac, just as they are known to do in veins or arteries or aneurismal tumors ; and he per- formed the operation as follows: After the reduction of the hernia he takes up a deep vertical fold of skin, in- cluding the sac and its envelopes, as near the internal ring as possible, and by manipulation with the thumb and index-finger, he isolates the cord, holding it out of way (Fig. 1647). Next he transfixes this fold, near the pubis, with a needle about one and a half inch in length, armed at one end with a bit of cork, and as the needle pro- trudes its point is also armed with another bit of cork, which is forced up against the first, compressing the interposed structures as closely as possible, and clamped in firm apposition. Another needle is now introduced, in like manner, a few lines below, through the same fold, but is made to pass in front, as the former did behind, the spermatic cord (Fig 1646); thus, according to the size and condition of the parts, he applies two, three, or more needles, as the case may require. Inflam- mation is said to commence on the fourth day, but the needles are not removed for six or twelve days after suppuration is clearly established. In five weeks Bonnet cured a her- nia that had lasted thirty years. Though fail- ure repeatedly followed his operation, es- pecially in large hernite, yet he suc- ceeded perfectly on a child ten years old, whose hernia after continued exer- cise would sometimes reach down to some inches above the knee. The operation is not painful, but is not in- dicated in large or in very recent hernia. Bonnet's procedure was criticised, a n d therefore at once was modified by several surgeons. It was said to be not void of danger, because the abdominal integuments were injured, and more par- ticularly because the intestine might be even pierced. Mayor, whose modified plan has justly received little at- tention, first makes taxis, then draws an axial line in the course of the spermatic cord, through the centre of the inguinal canal, on each side of which line he raises two folds of superfluous skin, with their cellular tissue, which Fig. 1646. Fig. 1647.-Bonnet's Needle Operation, First Step. 631 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are transfixed with needles provided with double threads. These folds of integument are closely approximated and held together by the threads being tied over plugs of cot- ton ; then a compress bandage is applied. The threads are removed on the ninth day. After this a truss is to be worn for some time. What special advantage Mayor's plan presented it is difficult to conjecture. Yet after six or more such punctures were made in a boy nine years of age, with fem- oral hernia, a cure was ef- fected. In place of corks, pledg- ets of cotton, or cylin- ders of adhesive plaster, Fritz adjusted ivory disks or bone dice to his needles, as seen in Fig. 1649, passing them in the same way both in front of and behind the cord (Fig. 1646), always sup- porting the scrotum in a suspensory bag. Ulcera- tion does not occur until the tenth day, when the needles are to be removed gradually one by one. To accomplish the same end more rapidly and easily, a special forceps -was contrived by Henry, which was moved by a spring and armed with eagle-claw teeth, these penetrating into hollowed buttons, powerfully compressing the folds of skin when the instru- ment was shut. These forceps are known as pince aqui- leene. The requirements of the case seemed ■well fulfilled by these forceps by reason of their press- ure power ; for when tumefaction ensued it was always difficult to maintain the involuted and devoluted folds of skin firmly together by the needles alone. Bonnet's needles, with their corks, were sometimes wholly detached, and Mayor often encircled both needle-ends with a figure-of-eight suture as in harelip, in or- der to keep the opposed surfaces together. Jobert's Method.-The seeming necessity of the in- troduction of foreign bodies which should excite greater reaction suggested Jobert's method, in which he con- ducted a cannulated needle of some length upward into the hernial canal beneath the cord, piercing the structures, including the internal pillar of the ring, and then withdrew the needle but leaving the cannula fixed in place, tied with a figure-of-eight sut- ure ; then he passed another cannula, in the same manner, three or four lines higher up, but anterior to the cord, and the needle being re- moved this was also left in, encircled with a waxed thread tightly enough to completely compress the sac, but not to cut through nor injure the cord and its ves- sels. These cannuke re- mained until the requisite inflammation and induration had been induced. Belmas's Method. - A case of spontaneous cure of hernia, in which Belmas dis- covered that the production of a false membrane had ef- fectually sealed up the hernial passage, led him to attempt by art an imitation of nature's process. He, therefore, in 1829, instituted a series of experiments upon animals, and especially upon some thirty dogs who were suffering from rupture, and communicated his results to the French In- stitute in a memoir which recounted in what way he had succeeded in developing adhesions of serous surfaces while circumscribing inflammatory reaction. Small blad- ders of gold-beater's skin, distended with air, were intro- duced into the peritoneal cavity by means of a compli- cated metallic tube, and though it proved difficult to fix them permanently in any particular spot, owing to the movements of the intestines and the capacity of this serous Figs. 1651 and 1652.-Belmas's Method : Cannula, Trocar, and Bladder Introduced and Applied. Fig. 1648.-Bonnet's Needle Operation, Completed. cavity, yet in other situations lie succeeded perfectly, and he was able thus to cure several cases of hydrocele. Even in the peritoneal sac the spot where the foreign body had fixed itself always presented adhesions and plastic deposits of a nodular form and fibrous character, in which absorption of these bladders had taken place. Belmas now concluded that he had discovered an animal substance that would produce a moderate degree of sim- ple local inflammation between the walls of a serous cav- ity, while the direct source of this irritation would itself be promptly removed by absorption ; and, moreover, that the operation was never attended with danger. The con- veyance of the gold-beater's skin was effected by means of a cannulated trocar, that was made to penetrate the lower part of the sac, and was carried thence through the neck and brought out through the integument just above the external ring ; at the other end of the trocar was at- tached the empty bladder, which was inflated after being drawn up into the neck as it lay in the canal, and then was detached and left in contact with all parts of the serous envelope. After the inflated bladder had remained for twenty-four hours, the air was allowed to escape by a stop-cock ar- rangement, but the bladder it- self was retained, as the organic material was to be incorporated with the surrounding tissues ; and at the expiration of four- teen days a truss was worn with moderate pressure. Cures, supposed for awhile to be per- manent, are said to have been effected by this plan, though the hernia returned in many instances. His method became very generally known, and very soon we find the self-same principle carried out in a modified operation at the hands of the distinguished Pirogoff, of Dorpat. This surgeon conducts the operation through three distinct steps : (a) An incision of one inch is made through the base of a transverse fold of skin, after taxis has been accomplished, obliquely over the course of the sac ; (b) each layer of cellular and muscular tissue is care- fully dissected, or incised on a grooved director, until the sac is exposed, while an assistant separates the edges of the wound with blunt hooks, and the sac is then opened with scissors ; (c) the gold-beater's skin bladder is carried high up into the inguinal canal, and is then inflated by Fig. 1649.-Fritz's Ivory Disks. Fig. 1653.-Pirogoff's Instruments. Fig. 1650.-Belmas'e Instruments. 632 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. the breath of the operator through the tube to which it, is attached, tied, and then detached from the cannula ; the wound is now closed and the stem of the tied bladder is pocketed in the wound, just as we would pocket the ped- icle in ovariotomy. Rest is enjoined for a time. Even venesection was employed, and a truss was subsequently worn for some time. Neither Bonnet's nor Pirogoff's procedures seemed to have been repeated, owing doubtless to the complicated instruments necessary for so difficult a manoeuvre; indeed, it required two blunt hooks (Fig. 1650, A); a silver cannula, six inches long, and a stylet with a trocar point, on the end of which was screwed a small, thin tube, upon which is tied a bladder of gold-beater's skin, thin enough to pass readily through the cannula when empty of air (Fig. 1650, B) ; and, finally, another tube to blow up the bag (Fig. 1650, C), composed of two tubes united, b, to one of which there is a stop-cock, c, while the other tube has also a bag, a, by pressure on which the bladder which fits on to the tube, d, is inflated. Pirogoff's instruments consisted of a cannulated trocar, of a peculiar curve, to draw off the serosity from the hernial sac (Fig. 1653, A) ; and a gold-beater's bladder attached to the short tube, through which he inflated it when deeply engaged in the neck (Fig. 1653, B). Belmas operated several times by the above-men- tioned method upon the human subject, but the difficulty of the procedure and other contingent cir- cumstances caused him to substitute quite another plan of inducing the same result, based, however, upon the same principle, but requiring another in- strument, which, though apparently not less com- plicated, we are told was of easier application. This latter instrument (Fig. 1654) consisted of a cannula divided at its centre, and so constructed that by governing screws, a, b, placed at the handle, the combined halves could be disunited at will; and of a needle which traversed the united cannula and could be drawn directly through it. With this instrument Belmas performed his second operation by first reducing the hernia, then plunging this cannulated needle through and through the sac, and transfixing the integument; the trocar is then withdrawn through the emerging end of the cannula, but the latter instrument is left in this position of transfixion; now, by means of the governing screws at its handle, the can- nula is divided into its halves, which the operator deflects at a considerable angle, making them play the part of two hooks that serve admirably well to separate the walls of the sac, as is seen in Fig. 1655 ; he next proceeds to introduce through these two pieces of the cannula, into the sac, a bundle of small rods of the thickness of an ordinary knitting-needle, which he pushes one by one into its interior until in his judgment a sufficient quantity have been employed ; these are little sticks of gold-beater's skin, encapsulated in dried and hardened gelatine ; when this is accomplished, the next step is to distribute these rods in various directions within the cavity of the sac, so as to bring them everywhere in contact with the se- rous surface. As experience had taught Belmas what amount of organic material was properly required, and had shown him that the bladders were not only difficult to manage, but redundant in quantity, he was thus led to substitute this latter and more delicate method in the use of rods enveloped in gelatine, which soon became dis- solved, leaving just the necessary amount of organic sub- stance in juxtaposition with the serous membrane. A prepared truss was to be worn for a definite period as usual. In ten operations, three were represented as cured ; a fresh escape of the gut occurred in four ; the other cases were, perhaps, very doubtful. Besides these isinglass cylinders of Belmas, it must be remembered that many other surgeons had previously sought to bring about the necessary inflammation by in- troducing pledgets of lint and wicks of varied substances into the hernial canal, such as soft linen plugs and setons greased with different kinds of ointments ; red precipitate ointment was frequently used. The dangerous results of this kind of treatment were suppuration, the forma- tion of depots of pus, and extension of inflammation into the abdominal cavity. It was soon surmised that it was not necessary to retain these meches until suppura- tion occurred, but that all that was required was a low degree of inflammation. Now far more simple means of exciting adhesive inflammation in serous sacs were well known to surgeons, and consisted in the injection of some irritant into these cavities. This treatment had been long in vogue in cases of hydrocele, and it, therefore, occurred to many to resort to some of these. Schreger introduced red wine and even air, which injections were repeated until sufficient irritation was produced. It was even thought advisable to try the effect of blood itself, on the Fig. 1655.-Belmas's Second Method. principle that it would clot, the serum would be absorbed, and the fibrin would fibrillate or become organized. This was von Walther's mode of treating the sac. Iodine Injections. -Wearied, though not satiated, with these trials upon the sac, as the only apparent means of curing hernia, the highest authority in France pro- posed and tried another fluid. About his time Vel- peau's use of iodine in hydrocele and the results of his experiments with this fluid on serous membranes had attracted so much attention that, through his suggestions and predictions, it was employed both in America and in France by Professor J. Pancoast, of Philadelphia, by Jobert, Maisonneuve and Velpeau, in Paris. Velpeau demonstrated the possibility of obtaining a radical cure by means of iodine injections, but the difficulty of intro- ducing the instrument into the hernial sac was sufficient to deter surgeons from following his suggestion. Seven- teen years after (1837) M. Jobert made some new trials, and with satisfactory results. Maisonneuve, surgeon of La Pitie, proposed a new and simple method of mak- ing the fluid penetrate the hernial sac without danger of its passing into other parts. He seizes the middle part of the scrotum between the thumb and index-finger of the left hand, opposite to the point where lies the empty sac ; he pierces it with a long trocar introduced up to the hilt, and then withdraws the perforator, leaving the cannula in the wound. The skin of the scrotum is then drawn over the cannula in such a way that the two openings, of entrance and of exit, are separated as widely as possible. Lastly, the cannula is slowly withdrawn, and when its point is fairly within the sac, the fact is known by its great mobility. Fig. 1654.-Instruments used by Bel- inas in his Second Method. 633 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. M. Follin unfolds the sac in another way, by allowing the hernia to descend, then reducing it so as to leave the sac fully distended yet empty, after which the injection of iodine is carefully forced into contact with all parts of its walls. M. Ricord makes use of an instrument of his own invention ; this consists of a long cannula which traverses the structures from side to side, and has at its middle an opening which allows the injection of any fluid through it. All that is necessary is to close the end of the can- nula, when the injected material escapes through the above-mentioned opening and is spread over the sac in all directions without danger of its penetrating into the sub- cutaneous cellular tissue. Prior to these essays Professor Joseph Pancoast pub- lished an account of similar injections which he had been in the habit of making for the radical cure of hernia ever since 1836, before the classes at the Philadelphia Hospi- tal. He gives a minute detailed history of his operation in his work on " Operative Surgery," and as one of the early attempts in this direction made in the United States, we shall take much satisfaction in quoting it in part. "The surgeon presses with the linger at the external ring, so as to displace the cord inward and bring the pulpy end of the finger on the spine of the pubis. At the outer side of the finger he now enters, with a drilling motion, the tro- car and cannula, till he feels the point strike the horizontal portion of the pubis just to the inner side of the spine of that bone. The point is then to be slightly retracted and turned upward or downward ; the instrument is then to be further introduced till the point moves freely in all directions, showing it to be fairly lodged in the cavity of the sac. The point of the instrument should now be turned into the inguinal canal, for the purpose of scarifying freely the inner surface of the upper part of the sac, as well as that just below the internal ring. The trocar is now to be withdrawn, and the surgeon, again ascertaining that the can- nula has not been displaced from the cavity of the sac, throws in slowly and cautiously with the syringe, which should be held nearly ver- tically, half a drachm of Lugol's solution of iodine, or half a drachm of the tincture of can- tharides, which should be lodged as nearly as may be at the orifice of the external ring. The cannula is now to be removed, and the operation is completed. A compress should be laid above the upper margin of the exter- nal ring, pressed down firmly with the finger, and the truss slid down upon it. The patient is to be kept from changing his position dur- ing the application of the truss, and should be confined for a week or ten days to his bed, with his thighs and thorax flexed, keeping up steadily as much pressure with the truss as can be borne without increasing the pain, in order to prevent the viscera from descending and breaking up the new adhesions while they are yet in the forming state, or avoiding the risk of their becoming strangulated or being rendered irredu- cible by the lymph effused into the cavity of the sac. "The author has practised this operation in thirteen different cases, in but one of which was there any peri- toneal soreness developed that excited the slightest ap- prehension, and in this case it subsided under the appli- cation of leeches and fomentations. . . . While under the cognizance of the author, they were employed with- out a truss as laborers on the farm attached to the insti- tution (Philadelphia Hospital), and in no one of the cases during this period had the hernial tumor recurred." Although the credit of first using iodine injections has been ascribed to Dupierris, of Havana, there can be little doubt that Velpeau inaugurated, at an earlier date, re- peated experiments proving the utility and advantage of these injections in serous sacs; and established the fact, by personal experience, that hydrocele was more perma- nently and easily cured by iodine than by any other sub- stance hitherto used. It appears equally true, after Vel- peau's suggestion that the hernial sac might also be subjected to the same means of cure, that Professor J. Pancoast was the first to have experimented with it on a large scale in this direction. He was followed by others in Europe and this country, but, unfortunately, these tentatives proved of no greater avail than others that had been resorted to for this single purpose. Similar attempts have been revived of late. Heaton, after many years of experimental inquiry, informs us that he has discovered a means of exciting a mild grade of inflammation amid the ligamentous structures involved in hernia. This he calls his "method of tendinous irri- tation," brought about by the use of a special irritant, in a gelatinous or more fluid state, of his own recipe, placed in contact with the exterior of the neck of the hernial sac, thickening and con- solidating the tissues and effecting con- traction of the openings; a contraction due not only to the astringent used, but largely to the peculiar distribution of the fibres about the rings. These injections are not to be con- founded with those formerly made by Pancoast, Velpeau, and others, since they are made not into the sac, but ex- ternally in the neighborhood of the neck and rings; indeed, Heaton insists on re- turning the sac if possible. The special syringe used is seen in Fig. 1656. The needle is made of steel, and is provided with lateral openings near its point. The fluid of his own composition he thus describes: Take of Thayer's fluid extract of quercus alba, prepared in vacuo, 3 ss., of alcoholic extract of quer- cus, about fourteen grains ; add to this morph, sulph., gr. ss. He first reduces the hernia and returns the sac also. The beak or nozzle of the syringe is then introduced into the canal, and held outside of the sac if this re- mains ; the spermatic cord and sac being pressed out of the way, nothing remains between the external pillar of the ring and the finger except integument and superficial fascia, through which the noz- zle is made to penetrate, just passing, but not grazing, the external pillar, and entering the canal at once ; having as- certained that the needle is in position, the operator deposits ten drops of the liquid irritant from the syringe, spread- ing it as much as possible by sweeping the beak of syringe well about while de- livering its contents, passing around the exterior of the sac, if unreduced, and wetting all the fibrous tissues, particu- larly the intercolumnar fibres and inner edges of the external ring ; a bandage and pad are applied, which are not to be removed for six or eight weeks. The above process he terms the liquid method. Heaton prepares a thick paste or semi- fluid mixture by triturating the solid with the fluid extract of white-oak bark until he obtains a viscid mass, so soft as to be easily spread over the fibrous surfaces. The advantage of using this paste is that very little of it (about two grains or less) produces sufficient irritation, and it can be smeared over the structures with less risk of irritating other parts, and the irritation thus produced is also more sustained. Dr. Joseph H. Warren has recently advocated a spe- cial injection, consisting of the fluid extract of white oak reduced to a syrupy consistency, diluted with alcohol, to which are added sulphuric ether and morphine. These recent modifications of the operation of Velpeau consist in injecting the tissues of the hernial rings. The material used for injection is thrown against these rings. Fig. 1656.- Heaton's Syringe. Fig. 1657.-Dr. Jo- seph H. Warren's Improved Latest Model Syringe for Radical Cure of Hernia. 634 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. rather than into the hernial sac itself, and Warren's im- proved syringe is specially designed to accomplish this safely (Fig. 1657). After the syringe is charged by the action of its valve, he thrusts the needle gently over the region of the ring. During this act the needle revolves because of its twisted form ; when it has passed through the skin, pressure on the spring allows such quantity of fluid to escape as is deemed sufficient. Great precaution must be taken that none of the injec- tion enter the peritoneal cavity, and the needle must not wound the arteries. Rest is enjoined until the reactionary process is over, as in some instances this is carried to suppuration. A truss is worn for a time, since the slight adhesions would yield to the pressure of a rapidly return- ing hernia. To avoid any danger of injury by the needle at the rings seems to be De Garmo's object in the construction of his syringe (Fig. 1658), while the screw piston arrangement concavities looked upward, were made to approach one another toward the upper part of the hernial oritice, leav- ing space sufficient for the nutrition of the flap. This was introduced into the orifice to form a plug, and the edges of the ring and of the skin were now united by drawing firmly together the edges of the wound. A small gorget having been introduced into the transverse aperture, the integuments and the aponeurosis were connected by means of a small trocar. A platinum wire, with screw adjustment at each end, was passed through the cannula, and an oval piece of gutta-percha, with central hole, was passed on each side over the wire and brought in close apposition with the skin. These were tightened together by the screws, and the wound was closed longitudinally, an exit for pus being left at the lower part. Roubaix claimed many advantages for his method, among which we should mention that no portion of the peritoneal sac being in- volved no peritonitis is likely to occur ; that the flap has its pedicle upward, and is not likely to be drawn out or down by the weight or movement about the parts ; and finally, that a firm cicatrix narrows and obliterates the hernial orifice, which, in its connection with the plug and the adjacent parts, constitutes an impassable barrier to the descent of the viscera. Gerdy's Method by Invagination of the Scrotum. -Akin to this idea of transplantation of new tissue through means of a bloody operation, was the famous ex- ecution of invagination of the scrotum into the inguinal canal, which method Gerdy invented. The simplicity and originality of this conception for conveying an organ- ized mass of tissue, without the use of the knife, imme- diately into position, and there retaining it, exemplified the genius of its author, and inspired the most sanguine expectations for the future success of this operation ; in- deed, it was confidently believed that at last Gerdy had reached the goal, and that there could be no such word as fail. It is just here that we may be allowed to indulge in legitimate criticism upon any surgical pro- cedure that is not based upon the proper principle of cure. The propriety of borrowing highly organized cellulo-vascular elements from contiguous or adjacent parts, indeed this transplantation of vascular tissue or engraftment, so to speak, upon previously denuded surfaces, notwithstand- ing whatever objections Dieffenbach may have made, cer- tainly expresses sounder principles of pathology than are implied in the method of Gerdy, though he captivated the mind of the thinking public, and held every surgeon of any note busy for years in modifying and perfecting the so-called sure method of invagination. Yet we must look at the present time with surprise at the want of forethought that could have anticipated a successful occlusion, or even operculation, of the inguinal canal by such means as these, which preternaturally enlarged and divaricated its walls with solid and expanding bodies-distending a natural opening with rigid dilators-a principle false in itself, and not devoid of danger, since upon the absorp- tion of such inflammatory deposits as may take place, permanency is given to the dilatation upon the most familiar principles of surgical treatment. The infatuation with Gerdy's operation was such, nevertheless, that no method has been so frequently repeated, and none has received such almost endless modifications. Gerdy's first invaginations consisted simply in pushing up a fold of the scrotum deeply into the inguinal canal with his left index-finger, which involuted fold was re- tained in position by a wooden clamp-like instrument, the simple construction of which, as seen in Fig. 1659, will be found figured in the Archives Generales de Medi- cine. This primitive-looking instrument reminds us of the pince aquileene of Henry, and may be said not only to have carried with it the fold of scrotal integument which Gerdy drove into and through both rings, but car- ried itself as the exemplar of every forceps, clamp, or in- vaginator that has since been invented. It is, therefore, a curious part of the history of such contrivances, that, Fig. 1658.-De Garmo's Hernial Syringe. enables the measured introduction of the irritant. The principle in the needle construction is that of the ' ' dome trocar" of Fitch, which, of course, protects all impor- tant structures on penetrating the tissues. We cannot say that these recent attempts have realized the anticipations of either their inventors or advocates, though for a time so generally resorted to in our hos- pitals. Plastic Method.-Up to this period surgical inge- nuity, as we have clearly shown, had been preoccupied in attempts to seal up the peritoneal communication, which existed between the scrotum and the belly, as the only feasible means of curing reducible hernia. We now come to an entirely new phase of operative surgery, which seeks to supply by the artificial means of trans- plantation of tissue the deficiency in the abdominal walls which led to the abnormal protrusion of a hernia of any kind. Dzondi was the first to suggest a plastic operation, in which a portion of the skin is to be borrowed from an ad- jacent part and inverted by transplantation into the her- nial canal. Jameson, of Baltimore, carryingout the idea, was the first to operate after this method upon a young woman for strangulated femoral hernia. From the inner side of the femoral ring Jameson formed a flap of about three inches in length by three-quarters of an inch broad, the greater part of which was below the femoral ring, and the base of this flap was connected with the skin above Poupart's ligament; an incision was then made into the fascia, and the intestines were replaced ; the flap was now inverted into the hernial opening, and the wound was closed with the interrupted suture. After cicatrization the flap is said to have contracted over the opening, form- ing a firm and permanent plug that effectually closed the herniary canal. This operation Rothmund performed five times for femoral hernia, with complete success on one occasion, twice with improvement, but he was un- successful in two other instances. This transfer of in- tegument into the incised Inguinal canal, and its retention by bandage until adhesion was complete, was not, there- fore, recognized, though highly recommended by Dzondi, until it received the imprimatur of our Maryland sur- geon. Later on this plastic method was repeated by sev- eral other surgeons, and it was notably modified by M. de Roubaix, in an aged woman, who, for twelve years, carried a femoral hernia which descended as far as the patella. Roubaix raised a fold of skin over the femoral vessels and transfixed it with a bistoury ; from the ex- tremities of this incision two semicircular incisions, whose Fig. 1659.-Gerdy's First In- strument. 635 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. though used originally by Gerdy, who abandoned the idea at once, they have, one by one, all fallen into' disuse and merited oblivion ; consigned to the museum of chi- rurgical antiquities, to give place to the needle, which he employed afterward, although he still made this latter subservient to his original purpose of invagination. This clumsy instrument not fulfilling the purpose for which it was designed, Gerdy laid it aside, and then per- formed the operation which follows: Conveying the scrotal fold of skin upon his finger, in the same way through the external ring into the entire depth of the canal as high as it could possibly be made to pass, he used a long needle passed through a cannula and armed with a double silk waxed thread, which was carried through the invag- inated skin and also through the tendon of the external oblique muscle and ligament, making its exit an inch and a half above Poupart's ligament. The loop of thread was disengaged from the needle by an assistant; the instru- ment, now drawn back into the inguinal canal, was again made to penetrate, four lines distant from the first point of exit, in like manner, through integument and tendon, including so much of the skin between the threads; these were now tied over pieces of bougie, so as to retain the enfolded skin within the canal. The interior of this cul- de-sac of skin was painted thoroughly with liquor am- moniae to insure vesication of the cuticle, the denuded surfaces of which would thus inflame, adhere, obliterate the integumentary canal, and form a plug firm enough to prevent any future return of the hernia. Where the canal was inordinately large, Gerdy practised several separate invaginations ; when, on the contrary, it proved too small for the finger, or even for his newly invented needle to enter the ring, he pushed the scrotum up with a grooved director, upon which the needle alone, without its can- nula, was directed into the bottom of the vaginal fold. The application of ammonia always produced intense pain, which opiates seldom relieved, which lasted several days until suppuration occurred, and the patient had to keep his bed for several weeks. The nodular tissue thus formed served in some instances to effect a cure, with the aid of the truss. Here, again, after a time, absorption not only removed all exudative deposit, but it was found that the attenuated and partly disorganized integumental fold gave way and descended into the scrotum, leaving no trace of the operation that had been performed. The popularity of this original scheme of invagination did not protect it wholly from certain objections raised against the procedure, and from the charge of its not be- ing altogether original with Gerdy, since it was said that Arnaud had somewhere recorded two very curious cases, within his experience, in which a fold of skin from the scrotum had become engaged accidentally in the inguinal canal during taxis, remained adherent in this situation, and permanently cured the hernia. Some of the objec- tions urged against Gerdy's operation were, that in those instances in which the peritoneum is closely adherent to the walls of the canal, or to the circumference of the ring, there would be danger of its being compromised during the passage of the needle, or that this might pierce either an artery or vein in the hands of a careless opera- tor. Both of these latter objections were actually veri- fied in subsequent operations, for death from peritonitis occurred on several occasions, and in Prentiss's case fatal hajmorrhage was the result of the needle wounding some artery, possibly the epigastric or spermatic. The details of the operation were, therefore, modified by many sur- geons, and so also were the instruments. Bruns sought carefully to avoid the sac, holding his finger with the volar side firmly against the posterior sur- face of the tendon of the oblique, crowding and packing the serous membrane into the inner and posterior part of the canal, carrying up a double fold of scrotum overlapping the finger, pushing it over the spermatic cord upward and outward, and retaining the finger in this secured relation with the structures about the rings during the entire pro- gress of the operation. He arms Gerdy's needle with a double thread to which he attaches a tampon of lint of adequate size to fill the canal, introduces the needle so as carefully to penetrate only the anterior wall of the in- guinal passage; detaches one thread, partly withdraws the instrument still threaded and within the vaginal fold, and again thrusts it through the inner pillar of the ring near the mesial line ; he now unthreads the eye and re- moves the needle. The plug of lint is drawn high up into the scrotal fold, and is made to distend all parts of the same, while it is tied in place over rolls of bougie, quills, or plaster, tightly enough to cause considerable pain. Bruns assumes that thus the sac is not plugged in with the skin, but remains in the posterior and extreme upper part of the canal, compressed by the parts which occlude the passage, and that neither sac nor peritoneum are punc- tured in the operation. Bruns places no reliance what- soever upon the infolding skin ever adhering together, however well cauterized it may be with ammonia or with cantharides, for it invariably falls into continuity with the rest of the scrotum. He seeks and claims to produce a shortening and compression of the sac that effectually obliterates its neck, in consequence of the suppuration produced in the subaponeurotic and cellular elements nearest the surface of the peritoneum. This adhesive in- flammation glues all parts together, and a flbro-cellular mass of tissue, growing out of the granulations from the several punctures, clamps the whole environment and cures the disease. The difficulty some encountered with Gerdy's needle induced Schuh to resort to Freire Come's sonde A darde. Lehman used two needles of his own construction, so as to hasten the operation, as they were both at once threaded, and of easy introduction owing to their length and degree of curvature. He urges the multipli- cation of these punctures in large hernias, for, hav- ing failed twice with two puncture-sutures in a cer- tain obstinate case, he re- sorted afterward to as many as six punctures, thereby engaging and incorporating almost the entire scrotum, and permanently cured his patient. Such changes of shape as were made by Wattman, Gunther, Schmidt, and many others, scarcely deserve mention or a special delineation, since the exag- gerated semicircular curve of them all is perhaps fully expressed in Zeis's instrument, which wTe here figure (Fig. 1660). The unguarded needles of Gerdy, with imperfect curve, too short and too straight, often injured the opera- tor's fingers, but Zeis aimed at performing invagination with the utmost speed, without incurring this risk. His needle is not threaded until it has transfixed the part, then the blunt cannula ensheathing it, promptly conveys the suture in any determinate number of directions; which manipulations are accomplished expeditiously. Upon the irritation which these many stitches, executed with newly invented needles, were to produce, seems to have been the dependence for cure upon which Schuh, Wattman, Bruns, Zeis, and others chiefly relied, since none of these experimenters believed in any advantage derived from painting the vaginal fold with acrid fluids, but re- cognized that in the vast majority of instances the depen- dent scrotum must drag it down again. It appears that the whole object was defeated for which Gerdy's invagi- nation was designed. He invented an artificial hernia re- versed from without inward, that was to take the place of the hernia from within outward-a veritable transplanta- tion of organic tissue that was to occlude an abnormal opening. At the hands of his contemporaries, however, we find denied the absolute principle involved, while op- erations innumerable are deftly and naively performed which translate us to that ancient period when just such futile attempts were made upon the sac and its vicinity. That there were those who, in full accord with Gerdy, labored hard to secure the most complete vagination pos- Fig. 1660.-Zeis's Needle. 636 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. sible, and to make this permanent, is amply proven by the different instruments and modified ways of perform- ing the one operation that were subsequently invented. Wiitzer maintained the invagination, not with a suture, as Gerdy did, but with an invaginatorium similar to one which Gerdy first used, except that this ivory piece was pierced through its entire central length by a long needle which passed out near the point. An ivory plate, perfor- ated by a hole near its end, is placed over the integuments on the outside, parallel to the invaginatorium. The nee- dle is pushed through the invaginator, passes through it, through the fold of skin in the ingui- nal canal, then through the walls of the abdomen, layers of integument most firmly together (Fig. 1665). To assist in exciting the requisite amount of inflamma- tion, the invaginatorium is smeared over with ammoniated ointment. The same attempt, in cases of large hernias, to fill the enlarged canal is made by Rothmund, though he only modified the size and number of nee- dles of Wiitzer's instrument. Roth- mund flattens out the invaginator and drills three central canals for his three needles (Fig. 1666), applies the apparatus, and conducts the treatment precisely as in the previous instances r e- corded. Leroy d'Eti- olles, without sutures, seton, needles, or caustics, retains the scrotal fold in the inguinal canal by the aid of a pair of forceps which strikingly resemble a pair of tongs, as they touch only at their points, regulated by a screw at the handle, so that any degree of compression can be exerted, and this, as he apparently desires, only at or near the neck of the sac. One leg of these forceps (Fig. 1667) acts as the invaginator, while the other represents the outer plate or cover of Wiitzer's apparatus. When adjusted and in place, any amount of pressure can be regu- lated by turning the screw, and is carried in some cases to the production of exfoliation or gangrene just at this point. Cicatrization then holds the scrotum in its proper position. Fig. 1663. and finally through the perforated cover - plate, and the apparatus is screwed down firmly by an adjustment near the handle, and a button put on the protruding point of the needle. This is retained in place for many days, until suppuration is established (see Fig. 1661). The mechani- cal simplicity and safety of Wiitzer's operation placed it within easy reach of the most mediocre surgical ability. No operation has been more frequently repeated ; but it soon began to be discovered that the cure was only ap- parent, that the fold of skin descended, and the hernia was reprotruded ; and this was specially the case where the rings and canal were large. At a much later period Wiitzer's hernia instrument was so changed in construction by Redfern Davis as to adapt itself to the enlargement of the rings or of the canal, as is shown without description in Fig. 1662. The invagi- nator itself was split and, working on a hinge, could be made to fill a more capacious canal if necessary. Sotteau now modified the operation by practising what we may call a double invagination with a du- Fig. 1661.-Wfltzer's Hernia Instru- ments. Fig. 1664. plicate metallic plate, which he designed to meet the above- mentioned objection in cases of very large hernias. He placed between the cover-plate and ivory cylinder of Wiitzer a metallic plate similar to the cover-plate, and he performs the operation in this way : Seizing a considerable fold of the scrotum between the invaginatorium and me- tallic plate, as seen in Fig. 1663, he clasps these together and pushes the whole into the inguinal ring as far as pos- sible (Fig. 1664), thus producing a duplicated involution of the scrotum which serves to fill the largest passage-way toward the abdomen ; and after passing the needle through the cylinder, and thence through the several folds of re- duplicated skin until it protrudes through the walls of the abdomen, he now adjusts the cover-plate on the outside, as in Wiitzer's instrument, and compresses these several Fig. 1662.-Redfern Davis's Hernia Instruments. Fig. 1665. Figs. 1663, 1664, and 1665.-Successive Steps of Sotteau's Modification of Wiitzer's Method, and the mode of adjusting the Instrument. Precisely in this same way does Max Langeubeck, of Gottingen, contrive to not only maintain the vaginal fold, but also to produce a more extensive slough, by a somewhat analogous forceps (Fig. 1668), the branches of Fig. 1666.-Rothmund's Instrument. 637 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which, however, are perfectly straight, so that when ap- plied they compress the entire anterior wall of the inguinal canal. The slough resulting from pro- longed pressure with this forceps is intended to lay open the canal throughout almost its entire length, when an indestructible cicatrix fills the extensive breach and effectually deter- mines the cure. Without intending to bring about such d e - structive ad- hesions of surrounding parts, but merely with a view of maintaining mechanically the artificial external herniated condition, as a permanent obstacle against the descent and reprotrusion of the true hernia, Christophers fills the canal with a tampon, in the form of a glove-finger, en- veloped with a material which will not absorb moisture M. Valette. Indeed, it may be said that the destructive use of such an agent as the escharotic he uses-Vienna- paste-whose action it is always so difficult to measure and control, perhaps more than any other procedure ex- poses the patient to imminent risks ; besides, the hernia is often not cured, even when the individual escapesail the dangers to which we have referred. A simpler and far safer way of tucking back and retain- ing the invagination is that of Wattmann, who makes two sutures with two large needles, carries up a double thread upon which is fixed a bit of cork drawn home within the fold, while the ends of the threads are tied over another piece of cork placed in the groin. Gunther uses a curved lead cannula, and Schmidt secures not only the attachment of the apex of the fold with- in the canal, but transfixes and ligates the base of the same over the margin of the external ring ; the threads are tied over small horn cylinders. Signorini recom- mended the twisted suture for uniting the invaginated fold. The invaginated por- tion is retained in place by means of a female catheter, and then the upper pillar of the ring is laid bare and scarified on its internal side ; three long hare-lip needles, a distance of about four lines parallel, and separated from each other, are then inserted. They are passed through the base of the cone of skin and retained by a figure-of-eight suture. He has termed this method chilissochisoraphia. But perhaps the most signal effort ever made in this di- rection, for completing and maintaining a most exagger- ated tucking up, plugging, and invaginating of the scro- tum, was accomplished by Signorini in a case of right inguinal hernia, where the inguinal canal was so large as easily to admit two or more fingers, and, properly speak- ing, consisted of a single wide ring, so entirely had the rings and canal coalesced. He turned the fold into the ring, bent the fingers downward and outward, and pushed the cul-de-sac beneath Poupart's ligament as far as the femoral ring, and carried it on through the crural opening on the inner side of the femoral vessels, where the fingers were made to project. Through this projec- tion a curved needle was introduced above the point of the finger, and a second needle was carried through the base of the fold in the inguinal region. He then made an incision an inch long through the apex of the fold in the hip, and twisted threads around both needles. This retrovaginated method is without parallel. Professor Agnew modified Wiitzer's operation and Fig. 1667.-Leroy d'Etiolles's Instrument. Fig. 1668,-Wiitzer's Invaginatorium. nor engender too much heat or irritation. This infundi- buliform tampon invaginates the scrotum, and is then fastened to a wooden plate upon which several small but- tons and straps enable us to adjust the contrivance, with its perineal band, around the waist and pelvis. Some considerable pressure can be here exerted, and the invag- Fig. 1670.-Valette's Instrument. Fig. 1669.-Max Langenbeck's Forceps. mated skin, can be thus kept indefinitely in c;lose contact with the hernial canal. The next step toward the same end was sought to be accomplished by Valette, of Lyons. His apparent de- sign is to bring about the supposed necessary destruction of tissue, or general sphacelation, more rapidly than can be accomplished through prolonged and oftentimes pain- ful and dangerous pressure ; so that, while resorting to Wiit- zer's " kelekleison," as it is called, he leaves a fenestrated opening in a metallic outer-plate, into which is placed Vienna-paste, whose rapid necrotic action fulfils the indication with singular rapidity. To hold the apparatus in place, notwithstanding that he uses the needle, which passes as usual through the instrument and the tissues, the invaginator is also secured to a metallic rod, which is fastened to a padded belt that surrounds the pelvis (Fig. 1670). The speedy operation of the Vienna- paste converts the superior portion of the inguinal canal, the fornix of the invaginated fold, and all intervening tissues or structures, into an eschar which, if not deemed sufficient, can be supplemented by excoriating the entire fold of skin within with some safe escharotic. The accidents most to be dreaded in these varied at- tempts at a radical cure are obviously erysipelas, dif- fused abscesses, peritonitis, pyaemia, or septicaemia; against none of these are we protected by the method of Fig. 1671.-Agnew's Instrument. contrived a special invaginator, the description of which is here taken from Gross's " Surgeiy." "The appara- tus required for its performance (Fig. 1671) consists : first, of a steel instrument closely resembling a bivalve speculum, the blades of which have two longitudinal grooves, being three inches in length and connected by a hinge near the handle, which is itself controlled by a screw ; secondly, of a very long, slender needle, 638 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. mounted upon a wooden handle, and terminating in a curved point pierced by an orifice; and thirdly, of a common stout suture-needle, two inches and a half in length. The instrument, with its grooved blade toward the abdomen, carries by gentle pressure the invaginated plug to the upper extremity of the inguinal canal. The long needle, armed with silver wire, is inserted into one of the canals of the inner blade, widely separated from the others, and perforates the superimposed structures. The needle, being withdrawn, is then carried along the other gutter, across the tissues, the two punctures being about half an inch apart. The base of the plug is thus embraced by the loop of the wure, the ends of which are then twisted over a roll of lint upon the abdomen. The instrument being kept steadily in position, the sides of the inguinal canal are next approximated by three horizontal This seton operation has also been resorted to by Dr. Riggs with remarkable success. His method is particularly no- ticeable by reason of the large size of the meche which he employs, and of the ingenious stop-needle of his inven- tion, which we here represent, Fig. 1673 (copied from that given in the New York Journal of Medicine and Sur- gery for March, 1858, 3d series, page 215). Dr. Car- nochan has also successfully used Riggs's method. It can be a matter of no wonderment to those who have duly considered the principles involved in this long train of persistent endeavors at closure of the hernial canal, that they have all fallen into merited oblivion. Operations on the sac alone must have proven wholly in- efficient in preventing the descent of the gut, so long as the congenital malformation of a preternaturally enlarged inguinal region still remained ; and, again, no modifi- cation of the process of invagination-whether this was maintained by suture in the one class of operations, or by a solid and foreign body in the form of an invagina- tor in the other methods, based as they all are upon a false principle of cure-could possibly induce co-arctation of this congenital abnormality, but could only serve to insure a more determined dilatation of the inguinal cleft. It is in connection with these reflections that we must fully appreciate the immediate advance which this province of surgery made, when Mr. John Wood, of London, reached the full fruition of a ripe and obviously surgical basis for rectifying this congenital deficiency of structure (upon which the writer believes all hernias de- pend), by suturing the pillars of the ring, or by co-ad- justing the walls of the canal with pins, as in the ordi- nary operation for hare-lip. Without detracting from the wisdom which carried out its own rational suggestion, or without reflecting upon the credit, which belongs to Mr. Wood, of having shown us the only real way of remedying a natural de- formity, just as we wmuld an arrest of development in any other part of the body, it must be admitted that the same operation had previously been executed by others after relieving strangulated hernia. Thus, in 1849, Jo- siah C. Nott, after operating for strangulated hernia, and wishing so to close the inguinal canal that the patient would require no truss, brought the pillars of the ring together with leaden wire ; and Professor S. D. Gross in- forms us that, in 1861, he performed the same, " in the case of a large old scrotal hernia, in a man sixty-two years of age, ... at the Philadelphia Hospital. The cure was perfect, although the parts had been seized with an alarming attack of erysipelas." Fig. 1672.-White's Instrument. sutures half an inch apart, the needle, armed with a stout silk thread, being passed between the blades of the cylin- der. In this way all danger of including the spermatic cord and peritoneum is effectually avoided. The hori- zontal sutures are not removed for ten to fourteen days- the wire thread may remain indefinitely." The latest variation in the construction of Wiitzer's " kelekleison," or rupture-clamp, is the invention, some years ago, by Dr. O. A. White, of New York, of an in- strument designed obviously to fulfil a like purpose ; since it invaginates the scrotum, pierces the structures with needles, clamps the parts, and is retained until in- flammation and exudation result. Composed of hard rubber, it is light, weighing only half an ounce. The invaginator, of no great size nor length, gives passage to two needles, which diverge when pushed through the plug and integuments. The handles play upon hinges, and, when the ordinary operation of invagination and transfixion is performed, are turned up in the direction of the plug. These several parts are then lashed together and remain in situ. Dr. White informs us that he has frequently operated with success. The annexed figure (Fig. 1672) explains the mechanism above described. Setons.-Although reference has been made in the beginning of this paper to the ancient way of using setons for the cure of hernia, yet we cannot dismiss this latter class of " invaginations" without calling at- tention to a method devised by Mbs- ner, which properly belongs to in- vagination. He invaginates as usual, but instead of using the needle as a permanent arrangement, as in Wiitzer's plan, he carries up a thread, which is seized, the needle is withdrawn, and the fold of the skin is allowed to descend, so that the thread now occupies the entire length of the in- guinal canal, and acts as a seton, remaining from eighteen to twenty days in place, during which time care is taken to exercise due pressure precisely along its course with a spica-bandage. This method, neither difficult nor pain- ful, is not without danger, since death has resulted. It has been repeated by Gross, Rothmund, and Schlosser. Ratier previously performed the operation differently. He opened the sac at the external ring, introducing a grooved director, upon which an incision was made about the in- ternal ring, after which a seton of cotton threads was in- serted, the threads being gradually withdrawn one by one. Armsby, of Albany, has performed the identical operation. Fig. 1673.-Instruments for Riggs's Seton Operation. The principle upon which Wood's operation rests is in the approximation of the tendinous structures of the hernial canal, and in the production of plastic effusion around and about the invaginated sac. Professor Wood described this operation as follows at a meeting of the West Kent Medico-Chirurgical Society : He invaginates the hernial sac without including the skin, and by the arrangement of the sutures draws up its fundus into the deep hernial opening. The pillars of the superficial rings are bound together, no skin intervening. The conjoined tendon and Poupart's ligament are made to adhere across the cord, and are blended in one mass of adhesion with the invaginated sac and pillars of the superficial ring. The needle, made for splitting rather than cutting the tissues, is introduced each time unarmed. While the tis- 639 Hernia. Hernia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sues are transfixed by it, a piece of stout copper wire, silvered, about two feet long, is hooked on the needle's eye and drawn back with it through the tissues. An Ob- lique incision, about an inch long, is carried through the skin of the scrotum over the fundus of the sac. The skin is carefully separated from the fascia by carrying the knife around, on its flat side, to the distance of an inch in every direction. The dissected fascia and fundus of the sac are invaginated. The lower border of the in- ternal oblique muscle is lifted forward on the ends of the fingers; thus the outer edge of the conjoined tendon is felt to the inner side of the finger. The needle is then carried carefully up to the point of the finger, along its inner side, and made to transfix the conjoined tendon and also the inner pillar of the superficial ring. When the point is seen to raise the skin, the latter is drawn over toward the median line, and the needle pierces it as far to the outer side as possible. A small hook, bent on the end of the wire, is now attached to the eye of the needle, drawn back with it to the scrotum, and then detached. The finger is next placed behind the outer pillar of the ring, and made to raise this and Poupart's ligament as much as possible from the deeper structure. The needle is then passed along the outer side of the fin- ger, and pushed through Poupart's ligament a little below the deep hernial opening. The point is now directed through the same skin puncture before made, the other end of the wire hooked on to it, and drawn back into the scrotal puncture, and then detached. Next, the sac at the scrotal incision is pinched up be- tween the finger and thumb, and the cord slipped back from it as in taking up varicose veins. The needle is then passed across the sac, entering and emerging at the oppo- site end of the scrotal incision. The end of the wire is again hooked on and drawn back across the sac. Both ends Mr. Wood enjoins upon us the necessity of using the horseshoe truss for several months, more particularly if the patient is subjected to violent strains or liftings. Professor Druitt describes certain rectangular pins as used by Wood in cases of congenital and small hernias. Two of these needles are employed (Fig. 1674); one traverses the structures from above downward, passing thus through the conjoined tendon and inner pillar ; the other passes upward beneath Poupart's ligament; the points of exit of one and of entrance of the other are at the same cutaneous opening, and they lock together. Van Best's Subcutaneous Suturing of the Rings. -This operation, like all the others, has been varied in its execution. Van Best, surgeon to the European Gen- eral Hospital in Calcutta, carrying out the all-important principle of directly closing the inguinal ring by sutures, as taught us by Professor Wood, practises the operation subcutaneously, using a long-handled flat naevus needle, well bent, with eyelet a fourth of an inch from the point, and a strong salmon-gut ligature, which-it is ab- solutely necessary-should be soaked in warm water for some minutes before being used; long round threads should be selected, and the needle is threaded from the concave side. The finger, as usual, is pushed within the internal ring; an assistant draws the skin of the abdomen firmly over toward the opposite groin; the threaded needle is then passed close to the finger, a small piece of wax having been moulded on its point (instead of a cannula); the han- dle of the needle is raised and the point pushed through the internal pillar and abdominal wall close within the internal ring; the needle, still threaded, is now with- drawn through all the structures except the temporarily invaginated skin. The finger being maintained in posi- tion, the needle now transfixes the outer pillar, while the abdominal skin is drawn toward the crest of the ilium, so that the needle passes through the original aperture when it is unthreaded, and it and the finger are withdrawn. There is therefore one scrotal and one abdominal aperture, the latter directly above the aperture of exit of the hernia. The two ends of the salmon-gut ligature are tied firmly together, cut close to the knot, and allowed to drop into the wound. The knot of salmon-gut will be either encysted or come away ; in either case Mr. Van Best regards the approximation of the pillars as certain-of which an as- sistant is made perfectly aware when he distinctly feels the fingers grasped while the ligature is tightened. Van Best has had no haemorrhage. He has operated in direct as well as oblique inguinal hernia. One unsuccessful case occurred in the Calcutta hospital, where the patient, a sailor, leaped over several beds within a week after the operation, and reproduced the hernia. Dr. Best suggests that this operation be employed when a very large ring exists, as the aperture being thereby diminished, the pro- trusion might thus be brought under command of an ordinary truss. Dr. J. J. Chisolm performs the same operation of sewing the columns of the inguinal ring together subcu- taneously, except that he uses silver wire designedly, since he leaves the wire permanently in the tissues to act the part of a permanent internal clamp, that restores to a great extent the virgin condition of the external oblique tendon. In Dr. Chisolm's operation no truss is therefore worn, as the wires, encapsulated and permanently residing within the tissues, restore the support of the abdominal wall; the truss, moreover, would act injuriously by pain- fully compressing the parts against the incarcerated wire suture. Several wires may be required in large hernias. A point of much importance is that of introducing the needle the second time exactly through the same orifice in the scrotal skin, should the needle escape at any time the invaginated fold ; for, should a portion of skin be in- volved in the loop of the wire, the ready dissection of the scrotal fascia cannot be effected without much force, and the scrotum becomes invaginated in the canal. The same rule holds good for the abdominal puncture, other- wise the twisted wire will not slip under the skin and be- come embedded in the subcutaneous fascia. If the wire engages no portion of the scrotal skin, which therefore Fig. 1674.-Wood's Rectangular Needles. of the wire are then drawn down, until the loop is near the surface of the groin above, and are twisted together down into the incision, and cut off to a convenient length. Traction is then made on the loop ; this invaginates the sac and scrotal fascia well up into the hernial canal. The loop of wire is finally twisted down close into the upper puncture, and bent down to be joined to the two ends in a bow or arch, under which is placed a stout pad of lint; the whole is held steady by a spica-bandage. The wire is kept in for ten days or a fortnight, or even longer, if con- solidation and adhesion are not satisfactory. Very little suppuration usually follows, but after a few days the parts traversed by the wire can be felt thickened and hardened by extensive deposit, which blends together the sac, the pillars of the superficial ring, and the tendinous boundaries of the hernial canal into a resisting mass, the wire becoming more and more loosened by ulceration in its track, until it can be untwisted and withdrawn. Mr. Wood has operated over two hundred times, and claims wonderful success-at least fifty per cent, in adults, and seventy to seventy-five per cent, in cases under puberty. Deaths have occurred from erysipelas, peritonitis, and pyaemia. It is difficult, however, to rely upon such consolidation of tissue as could possibly result from irritation induced by metallic wires. More reliance by far is to be placed, in the writer's opinion, in the co-arctation of the pillars of the ring, and in the tissue adhesions from the invaginated sac. 640 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Hernia. readily descends, it will, when the ends are drawn upon, tear or dissect up the scrotal fascia to the immediate vicinity of the ring ; and such an amount of this tissue serves aptly to till and occlude the canal. The writer has tried this permanent internal wire-truss operation, as he is inclined to call it, on several occasions, but his patients having long since passed from observa- tion, it is impossible now to state with what permanent suc- cess. This remark applies to all but one gentleman, who was operated on in 1862. In this last case the cure seemed to have been satisfactory, as the patient, shortly after the operation, became engaged as an officer in artillery service, during five years of active military duty, without a return of the hernia, although, as he states, he always wore a truss, but without pain or inconvenience whenever it became necessary for him to exert his strength in raising or in working heavy artillery pieces. Notwithstanding the success which may attend this procedure, we cannot forbear to express the opinion, that the retained wire sutures may become perhaps the source of imminent danger to life, should the re-descent of the gut occur at any time during physical exertion ; for then, with such an unyielding stricture across the rings as this incarcerated metallic band, there would be necessarily great risk of strangulation. We should also remark that the execution of this operation is by no means very easy; in the attempt to pass the needle always through the same aperture the wire entangles adventitious tissue enough to endanger it and sometimes cause the tucking back of the skin itself. In 1851, before the Medico-Chirurgical Society of Cin- cinnati, Dr. Thomas Wood described his ' ' subcutaneous suture with braid." The needle he uses is curved so as to form one-third of the circumference of a circle of two inches radius ; it has two spear points, with an eye in the centre of the shaft large enough to admit a silk braid one- eighth of an inch wide. The needle is pushed through the integuments and through the internal pillar as near its pubic insertion as possible, about one-eighth of an inch from its margin ; the point of the needle is turned upward as it is pushed across the ring to the opposite column, so as to become entangled in the cellular tissue of the inverted scrotum that caps the finger. When the point of the needle is carried far enough to reach the column opposite its entrance the finger is withdrawn, so that we may be sure that part of the scrotum hangs on the needle's point, and it is again introduced ; then, as the finger is a second time gradually withdrawn from the ring, the side of the needle is made to press against its end, until the point is brought nearly to the insertion of the outer column in the pubis. ' ' The needle is then thrust through the tendons, and is made to appear out of the integument on the opposite side of the ring from its entrance, when it is to be gradu- ally drawn through, carrying the ligature with it, until the second point of the needle escapes from the outer col- umn, but not from the integument. The movement of the needle is now reversed. Its inner point is to pass over the margin of the outer column, and under that of the inner one, so as to traverse the first puncture made in the tendon, which is now occupied by the tail of the ligature, and is to pass out in the opening in the integument, stop- ping when its first point arrives at the same position it was in just before it entered the tendon. The motion of the needle is again changed into progression, and is made to sweep over both columns of the ring, on their anterior surface, carrying the head of the ligature with it out of the last opening made in the integuments. The needle is now removed, leaving the two ends of the ligature in the punctures on opposite sides of the internal ring. The ends of the ligature are now to be drawn firmly, so as to draw the tendinous fibres embraced in the loop into the slit made by the needle in the opposite column, and they are to be fixed by tying over a roller laid between them." Dr. Thomas Wood has several times been successful in this subcutaneous figure-of-eight suture, as we would venture to call it. These several different procedures, designed to bring the needles and sutures subcutaneously to the rings, recall the last of this class of operations to which we shall refer. The late Dr. Greensville Dowell, professor of surgery in the Texas Medical College, made use of a double spear- pointed, semicircular needle, here represented (Fig. 1675), with which he conveys the silver-wire to and fro beneath the pillars of the ring, finally fixing their ends over cork, soft wood, or a roll of adhesive plaster. He claimed great success from the operation. In a table of all the cases, 96 in number, operated on up to 1876, there were 80 cures and 16 failures. We cannot dismiss this part of our subject, relating to the most legitimate and classical of all operations of its kind, having for its object the approximation of the pil- lars of the ring, and the restoration of the normal shape and dimensions of the inguinal canal, without putting the readers of the Handbook in possession of the latest novelty in hernial operations, as practised by William Dunnett Spanton, Surgeon to the North Staffordshire Infirmary. This was made known to the profession for the first time, in his paper read before the British Associa- tion at Cork, in August, 1879, and since better known from his paper read before the Surgical Section of the International Congress held in London in 1881. Believing that success depends upon complete union throughout the entire length of the hernial canal, and not upon one or two interrupted points of adhesion in- duced by transfixed wires, as is the case in most of the procedures already described, he proposes to unite the tendinous walls of the hernial passage continuously to- gether throughout their entire extent by multiplying the points of security ; and, what is of equal importance, to adjust in proper relation to these walls the subcutaneous invaginated tissues that are so necessary to fill up the deficiencies of an abnormally en- larged natural opening. He accom- plishes all of this with the most sim- ple, yet most ingeniously devised, cork-screw-like cutting and piercing instrument, which in its gyrations through the fibrous boundaries and weaker structures of the part, em- braces and constricts the divaricated fibres of this ligamentous region, co- ercing them into apposition and sub- sequent union by the retention of the instrument, or sometimes of a ligature, for several days. This instrument is called the ' ' strephotome " (the deriva- tion of the term is evidently from <rrpe0«-I twist, and re^eiy-to cut), and is shaped exactly like a cork-screw, tapering toward its base; the point transfixes without tearing, and has an eye at its end for the ligature, should it be used ; the handle consists of a movable bar, which can conveniently be left in position (Fig. 1676). The necessary instruments for Spanton's " immediate cure " are : the strephotome, dissecting forceps, a teno- tome for scrotal incision and dissection, and a glass rod perforated at both ends for securing the ligature. Mr. Spanton's plan of operating we will give almost in his own language. He makes an incision in the scrotum over the fundus of the hernial sac, usually an inch and a half to two inches below the spine of the pubis, through which the skin is separated from the subcutaneous tissues Fig. 1675.-Dowell's Hernia Needle. Fig. 1676-W. D. Span- ton's Strephotome for Radical Cure of Her- nia. 641 Hernia. Herpes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. throughout an extent proportionate to the size of the rupture and the length of the inguinal canal (Fig. 1677). The left forefinger is passed up to the internal abdomi- nal ring, pushing before it, and so invaginating, the fas- cia and hernial sac to the same extent; the finger is re- tained in the canal to protect the spermatic cord, which lies situ. Sometimes a cat-gut or tendon ligature may be used attached to a glass rod. In those cases in which a ligature is employed, the ends are cut off level with the skin as soon as consolidation takes place, which occurs in about ten to fourteen days. The scrotal wound should be closed with a single wire or hair suture when the operation is finished. By this time the number of Spanton's operations must exceed one hundred. The patients varied in age from five months to thirty-four years, and the hernias differed in size from small tense ones to enormous lax ones. All were inguinal, some direct, some oblique, many congeni- tal. It is claimed that up to the present time the opera- tion has proved invariably successful. Direct Method.-We come now to a far more ra- tional and immediate mode of relieving and permanently curing reducible hernia. The late Professor S. D. Gross cut down upon the parts, vivified the edges of the rings, and united them with wire sutures. Some have thought proper to remove the sac, while others, with better chances of success, simply tie the neck of the sac with a catgut ligature, and by a pelottement of this serous structure in- vaginate it within the hernial opening ; after which the inguinal canal is constricted and drawn together by sil- ver wires until restored to a more normal condition and relation with the surrounding parts. Czerny, of Heidel- berg, has published an account of his plan of performing this operation. It consists in exposing the sac under an- tiseptic influences, ligating it and cutting it away, return- ing the stump into the abdomen, and finally suturing the fibrous elements within the wound with silver wire. This procedure has been largely resorted to in England. Cat- gut is employed for the neck of the sac, but silver wire for the pillars of the ring. In over one hundred and fifty operations in the combined performances of Banks, Alex- ander, and Parker, not a single death occurred. It is only from more extensive statistics that we can derive determinate information, and we will therefore ter- minate this account by quoting the combined results of 515 operations for reducible and strangulated hernia?, collated by Leisrink, of Hamburg, and published in 1883. Only 9.3 per cent.'died, of which about two percent, may be ascribed to the strangulation alone, since the mortality of the operation for reducible hernia, as shown by Leisrink, is 7.4 per cent. The commentator's remarks on these results are : " The natural conclusions at which we would arrive from a consideration of the foregoing facts are, first, that although the modern operation kills about one patient in every thirteen or fourteen, and fails in about one case in every five in which it is resorted to as a matter of expedi- ency, it none the less is of great value in restoring many persons to comfort and the possibility of earning their living ; and secondly, that it should be practised in all op- erations for strangulated hernia, in which the gut can be returned into the abdomen." This method has been very appropriately called the di- rect method by Dr. Gross. After these long and futile endeavors, which at consid- erable length we have given as the complete history of the radical cures for hernia, all of which, except the direct method, have been met with undisguised distrust by those properly appointed to decide upon their value as surgical expedients, it seems strange that the simplest, because the most direct, orthodox, and truly surgical of them all, should be the last to have been proposed, and ultimately to have been adopted, as the final verdict in operative sur- gery. To cut down upon the trouble ; to meet the diffi- culty as we would any other deformity resulting from arrest of development, in the evolution of a natural outlet or opening of the body ; to treat the malformation as one would a hare-lip or a cleft-palate ; to emarginate the bor- ders of an abnormal cleft in the parts ; to co-arctate their edges and restore the integrity of a normal opening, should long ago, it would seem, have suggested itself as the best, as it must prove to be the only veritable, means of finally curing this vice of conformation. It is with something like national pride, therefore, that we announce that to Professors Nott and Gross belongs the credit of this direct method. Middleton Michel. Fig. 1677. underneath, and at the same time to close the internal ring; the strephotome, held in the right hand (Fig. 1678), is passed into and through the skin of the groin so as to transfix the outer pillar of the internal ring at little above the point where it has to pass through the conjoined ten- don. The strephotome having been given a turn, it is next made to pierce subcutaneously the conjoined ten- don, the left forefinger guarding the point. Other turns are now made through the invaginated tissues and across from the external to the internal pillars as many times as the nature of the case will permit. When the point of the instrument appears through the scrotal open- ing it is protected by a ball of solid rubber ; the handle lies flat on the abdomen, and the strephotome remains in Fig. 1678. 642 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hernia. Herpes. HERPES. A skin affection, characterized by the ap- pearance of one or many discrete, transparent vesicles, varying from the size of a pin-head to that of a small pea, commonly occurring in groups or clusters and seated on an inflamed base. The eruption is apt to occur along the line of distribution of nerves. The lesions run a pretty uniform course, lasting from eight to ten or four- teen days. The clear serous contents of the vesicles first become clouded and then gradually dry up, with the for- mation of yellowish crusts, which fall off, leaving tran- sitory spots of pigmentation. The appearance of the eruption is usually preceded or accompanied, or both, by more or less burning, and, in the case of herpes zoster, by pain either localized in the eruption or distributed along the line of the nerve-supply. There are three forms of herpes : II. facialis, II. pro- genitalis, and H. zoster. The affection known as H. iris, on account of its herpetiform lesions, is a variety of ery- thema multiforme, under which head it will be found described. The three forms of herpes are so different in their loca- tion and course that they are usually described as'entirely separate and distinct diseases. H. zoster, for instance, never, or most rarely, recurs in the same individual. II. facialis may recur at any time, and in some cases does recur periodically, while II. progenitalis recurs inveter- ately in some cases. But there is some link of union between the affections, in addition to their close adherence to the herpetic type of lesion, and to their occurrence along the distribution of nerves and as a result of nerve-ganglionic or reflex causes. This is shown by the fact, occasionally observed, of the simultaneous occurrence of the different forms of herpes. The writer has at present under observation a case in which well-marked herpes zoster of the front of the neck and cheek is accompanied by a characteristic H. facialis (var. labialis), "fever blisters." Another case, also under observation at the present time, shows a simul- taneous outbreak of II. zoster of the buttock and II. progenitalis. Arthur Van Harlingen. and a shallow ulcer, the well-known "canker" of the mouth, results. Herpes of the nostril and alee nasi is a frequent result of a cold in the head. It presents no peculiarities other than those mentioned in speaking of herpes of the lips. Herpes of other parts of the face is sometimes quite a striking affection. The following case will give an idea of its appearance and course : A hackman was exposed during the greater part of a raw, inclement night without adequate clothing. Re- turning home at daylight, he washed his carriage and then, thoroughly exhausted and chilled through, flung himself down in his wet clothing and slept for several hours. On waking he had a severe chill, followed by feverishness and general soreness about the limbs, which, however, did not confine him to bed. Forty-eight hours later, on shaving in the morning, he began suddenly to experience a burning sensation in the face, which soon swelled up and displayed numerous incipient vesicles. The sensation of burning continued to grow more severe until the patient was deprived by it of sleep. The affec- tion reached its height in about three days, when the whole face was covered and disfigured by a copious eruption of discrete vesicles, with clear or cloudy con- tents, grouped chiefly about the lips, the angles of the mouth and nose, and to some extent upon the cheek and chin, a few scattered lesions being also seen elsewhere. The vesicles were seated upon inflamed bases, and these centres of inflammation coalesced and caused such a swelling of the lips and the skin as to make the features and expression almost indistinguishable. On the mu- cous surface of the lips within were numerous herpetic ulcers. Under appropriate local treatment the eruption quickly subsided, and at the end of ten days the patient was well. Herpes facialis is almost unquestionably a nervous dis- ease of the skin. Although in no case has any anatomical change in the nerve-trunks, in the ganglia, or in the nerve- centres, been found, as in H. zoster, to account for its oc- currence, yet the facts that it is found in the areas of dis- tribution of certain cutaneous nerves, that it resembles so closely H. zoster, and that it seems sometimes to occur as the result of reflex impressions, all point to a nervous origin. The diagnosis of herpes facialis is rarely difficult. The peculiar discrete character of the eruption, the well- filled vesicles, each on a more or less inflamed base, some- times coalescing in the later stages, but always showing the character of distinctness, the fact that the group of lesions is sharply defined, and also that the lesions tend to dry up in their entirety rather than to run together, point toward the disease in question. Moreover, the fact that herpes runs a regular and strictly limited course is highly characteristic. Herpes upon the line of junction between the skin and mucous membrane, and upon the mucous surface of the lips, especially when it occurs near the commissure, may sometimes be mistaken for the initial lesion of syphilis, or for mucous patches. From the initial lesion herpes is distinguished by its more superficial character and its absence of infiltration, as well as by the absence of glandular involvement-the submental and other neighboring glands being invaria- bly involved in connection with the syphilitic lesion. Mucous patches in the oral cavity are sometimes mis- taken for herpes, but the mucous patch is almost always much larger and more superficial, with a squarish out- line and a gray floor, with usually a narrow red border. The herpetic ulcer is small, circular, or "polycyclic" in outline, and concave, with sharply defined edges. Herpes upon the skin of the face may be mistaken for herpes zoster and for eczema, and, possibly, in rare cases, for dermatitis venenata. From H. zoster it is distin- guished by the absence of neuralgia and the more diffuse outline of the grouped lesions. Moreover, herpes zoster never, in the writer's experience, attacks the opening of the nostrils or the muco-cutaneous juncture of the lips. H. facialis likewise runs a more rapid course than H. zoster. HERPES FACIALIS. This form of herpes was for- merly known as H. labialis, but this designation is too narrow, as the eruption may be, and frequently is, met with in other parts of the face-the cheeks, ala? nasi, eyelids, and ears being occasionally attacked. Occurring about the lips and nose the eruption is popularly termed "fever blister" or "cold sore." There is a form of her- petic eruption about the tonsils and adjacent parts, accom- panied by high fever, and occasionally appearing epi- demic in character, which closely resembles follicular tonsillitis, but may readily be distinguished by the strictly herpetic character of the lesions. When the lips are attacked by herpes facialis one only is usually affected, the lesions commonly occurring at the boundary between the skin and mucous membrane. The lower lip is most frequently attacked. The lesions here not infrequently coalesce and form a bleb. The contents of the vesicles dry up within from three to six days, and form brownish or yellowish crusts which loosen and fall off spontaneously.' When the crusts are prematurely de- tached the cure is delayed. Herpes of the lips is a frequent concomitant of various general disturbances. Slight ailments of the digestive organs, affections of the chest, as pneumonia or pleurisy, malarial fevers, etc., are often accompanied by an out- break of herpes of the lips. This was formerly believed to be of critical significance, but is now thought to have no connection with the course or severity of the domi- nant affection. Some women have an eruption of herpes on the lips before, during, or after each menstrual period. The writer has observed eruptions of herpes of the lip repeatedly following the use of a dental instrument in filling the teeth. Herpes may occur upon the mucous membrane of the tongue and of the oral cavity generally. The lesions here lose their vesicular character, because the epidermic cover is macerated away almost as quickly as it forms, 643 Herpes. Herpes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eczema vesiculosum of the face is always marked by the fact that the commingled lesions run together, and are never made up of discrete vesicles. There is also an absence of the red base observed in the lesions of H. facialis, and in eczema some characteristic lesions are almost always found in places rarely or never attacked by herpes. Finally, the course of an eczema is not a brief and limited one like that of herpes, but tends rather to an irregular and often chronic prolongation. Dermatitis venenata shows lesions often resembling those of herpes, but the distribution is almost invariably different, and the tendency to spread and to appear in other localities is quite marked. There is, furthermore, in dermatitis venenata almost always a history of expos- ure to the emanations of the poison virus. The treatment of herpes facialis is very simple, being confined to the local use of soothing and emollient ap- plications. In herpes of the lip a little cold cream, diachylon, or diluted oxide-of-zinc ointment, is all that is required. Care must be taken not to detach the crusts prematurely, as this lengthens the duration of the affec- tion. In cases of extensive herpes of the face, like the one described above, a soothing application, as a poultice of bread-crumb and dilute lead-water, will give relief, a mild ointment being substituted for this when the crusts begin to form. The prognosis is very favorable in all cases of herpes facialis, the affection running a definite course. Its du- ration, however, cannot be shortened, and all the pop- ular remedies for cutting short an attack of herpes of the lips must fail, except in cases in which the lesions themselves are abortive and ephemeral. Arthur Van Harlingen. examinations in regulated cities. In some of the women subject to biweekly examination herpes occurs with every monthly period. Other physicians than those who make periodical examinations see the disease in women very seldom. At the discussion of a paper on Herpes Progenitalis, by Dr. Greenough, in the American Derma- tological Society, in 1881, it was the general opinion that the disease was rare in women. My personal observation of the disease in the female is confined to a single case. A man, who had reason to feel nervous about an old syphilis, brought me his wife within forty-eight hours of his marriage, as he feared he had communicated something to her. On her labia minora was a most beau- tifully marked efflorescence of herpes. Authors differ somewhat as to the character of the dis- sease. By certain writers it is supposed to be practically identical with herpes of the lips. The disease of the gen- itals certainly recurs more often, and is usually of less importance locally than herpes labialis. By other authors herpes progenitalis is supposed to be a form of zoster. Undoubted cases of zoster occur on the genitals, but they are infrequent and very different in appearance from the ordinary cases, and are often accompanied by pain, as is zoster in other situations. The pain may be very severe, involving the sacral plexus of nerves. Mauriac has de- scribed such cases very fully under the name of neuralgic herpes of the genital organs. The disease has, strictly speaking, no etiological relation with the venereal dis- eases ; it is, however, very frequent in patients who have had some previous venereal trouble, and the venereal dis- eases are apparently predisposing causes. Many other predisposing causes are given, all of which are included by Unna under a single head, viz., excessive congestion of the genital organs. In many individuals subject to the disease it recurs with great frequency, reappearing at intervals of a few weeks, and especially after irritation of any sort. Its re- currence with every monthly period, in certain women, has been already mentioned. To this recurring disease Doyon has given the name " relapsing herpes." The superficial ulcerations of herpes may be occasion- ally mistaken for chancroids. They are also used as a means of extortion by unscrupulous practitioners. Pa- tients with the relapsing variety often say that the first, and perhaps subsequent, attacks have been diagnosed as chancre or chancroid, and cauterized. Occurring, as herpes so frequently does, in patients who are repeatedly exposed to contagion, the abraded spot furnishes a favorable opportunity for syphilitic in- oculation, and a case like the following occasionally oc- curs : A patient presents himself with typical herpes. All the efflorescences heal save one, which continues open. This one gradually enlarges and grows a trifle deeper, but not sufficiently to cause any special alarm ; it seems simply slow to heal. The patient, however, is very anxious about it, and pulls and pokes at it a dozen times an hour. Presently a little thickening of the subcutane- ous tissues appears, but no more than might naturally fol- low the irritation of such constant examinations. The ulceration persists, the induration becomes more marked, and at last the little ulceration shows itself to be a typical chancre, and is followed by secondary symptoms. Such a course of events shows itself just often enough to throw a shade of uncertainty into the prognosis of the simplest herpes which follows a suspicious connection. The ul- ceration may heal entirely, only to break out again as an initial lesion exactly as any abrasion may do. Of course, these cases do not occur because there is anything syphi- litic in the herpes, but because the little abraded spot due to the herpes has served as an open door through which the syphilitic virus has found entrance. Occurring in individuals who are not exposed to infec- tion the disease is of little consequence, and usually at- tracts little notice. The treatment is very simple. It consists simply in cleanliness and some slightly astringent application. The dilute lead-water cannot be surpassed as a liquid, but generally a dry powder is preferable, and either cal- omel or oxide of zinc fulfils all indications ; fuller's earth HERPES PROGENITALIS. This is, as its name im- plies, a vesicular eruption of the genitals occurring in both sexes. It is characterized by a few little vesicles, seldom less than two or three or more than six or eight, each vesicle hardly exceeding in size the head of an or- dinary pin. In itself a lesion of little gravity, it gains importance from its situation and by its habit of appear- ing at a time when the patient is in dread of some more serious lesion-that is, after suspicious intercourse. It was, not long ago, quite generally known as herpes pree- putialis ; a name which is evidently improper, as the dis- sease is confined neither to the prepuce nor to the male sex. The place of its most frequent occurrence in the male is in or about the sulcus on the dorsal surface. The pa- tient's attention is first attracted to the spot by a slight sensation of heat or burning, and examination reveals a little group of vesicles or, more commonly, of minute spots deprived of their epithelium, the little vesicles being already ruptured. The group of vesicles is situated on a slightly reddened base, and might be comprised within a circle of perhaps half an inch in diameter; two or more such foci may exist. Occasionally there is a still further desqua- mation-the loss of substance is so slight as hardly to de- serve any other name-by which the exulcerations become united into a single spot, which may excite suspicion as to its character. Its crenated outline is usually sufficient to show that it has been made up of several smaller ulcera- tions. When the herpes occurs in places less protected, where the epithelium is consequently less delicate, or upon the true skin of the prepuce, the vesicles remain unbroken ; their contents, at first translucent, become opaque, and the delicate covering becomes transformed into a brownish crust or scab which falls off at the end of a few days, leaving a slightly reddened surface beneath. Reports of dermatological clinics show that the disease is rarely seen among skin diseases ; in venereal clinics it is seen more frequently, but it is very common in private practice. In women the disease may be seated upon the labia majora or minora, about the meatus urinarius, in the vulvo-vaginal fold, and more rarely upon the pubes and even upon the uterine neck itself. It is not commonly seen, except among prostitutes, and for our knowledge of it in the female we are chiefly indebted to the periodical 644 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Herpes. Herpes. is also a good application. When the little ulcerations prove somewhat obstinate, iodoform may be used, or possibly iodol, which there is reason to hope will prove as valuable as iodoform without its disagreable odor. The prevention of the recurrence of the attack is greatly desired by the victims of the disease. Something may be done by the use of astringents to harden the delicate mu- cous membrane. Washes of tannic acid or carbolic acid, used regularly as a part of the toilet, have, according to Greenough, some effect in checking the recurrence. cases have been reported from this cause that I think their occurrence must be more than a coincidence. According to Erb, zoster is only the local manifestation of a constitutional malady derived from an external cause, viz., the deposition of an infectious germ. This applies only to the so-called spontaneous zoster, and has nothing to do with the traumatic or secondary forms, which, if 1 he theory be accepted, must be regarded as differing es- sentially from genuine herpes zoster. All writers admit that zoster is very apt to become epidemic, especially in hospitals devoted to skin diseases ; and this circumstance, never hitherto intelligibly accounted for, is attributed by Landouzy to the prevalence of atmospheric conditions favorable to the ripening of the specific germ. Believers in the germ origin of the disease hold that the specific microbe produces an irritation of the spinal ganglia, and the cutaneous symptoms are simply an indirect conse- quence of trophic disturbance due to an irritation of the nerve-elements. The special germ has thus far not been discovered. Dr. Gerne6 thinks that an analogy exists between the disease and the eruptive fevers, and in this view, although he does not so express himself, favors the germ theory of the disease. The writer is, however, not yet willing to accept this view of the nature of zoster. Syphilis has been known to be the exciting cause, and when so produced the eruption of vesicles is bilateral. Barensprung and Charcot,'1 as a result of their many in- vestigations, conclude that: 1. Inflammation of spinal ganglia, anatomically characterized by a well-marked vascular injection and a proliferation of the perineurium, without lesion of nutrition, produces in the portion of the skin which receives innervation from the parts affected a special lesion of nutrition of the nature of zoster. 2. The neuralgia which accompanies or precedes the erup- tion is the result of excitation of the sensitive nerve-fila- ments passing through the ganglion. 3. The spinal gan- glia contain the trophic nerve-filaments of the skin. . . . Zoster appears to be due to disease of the ganglionic sys- tem more often than dependent on affections of the spinal cord ; it occurs infrequently as a reflex neurosis. Anatomical Characters of the Vesicles of Zoster*-In a horizontal section we find the epidermis raised, the cori- um more or less laid open, and septa spread out between the two in such a manner as to subdivide the vesicle. The external covering of the vesicle consists of the non- nucleated cells which make up the epidermis, arranged in layers one upon the other ; these cells do not stain with carmine. The next layer is made up of cells containing nuclei, which do stain with carmine; these are flat and arranged in layers, the innermost adhering to the superior surface of the stratum Malpighii. The interior of the vesicle is divided and subdivided by thick septa which traverse it in all directions ; these septa consist of different layers of tightly packed, long, spindle-shaped cells, which show a nucleus when car- mine is added. On the superior surface of the corium in many places adhere long cells, which are separated by epithelial and other cells, mostly round, and only par- tially stained by carmine ; these are like those of which the corium is made up. In the puffed-up areolar tissue of the corium are a few round, granular cells, as large as white blood-corpuscles, which assume a rosy tint when stained by carmine. The vessels of the papillae are en- larged and contain many blood-globules. When a vesicle is becoming changed into a pustule, the rose-colored cells, the cells on the corium, and those in the septa increase, and by this process push apart the epithelial cells on the floor of the vesicle. The cells are often so enlarged as to contain two and three nuclei, and those upon the corium arrange themselves along the blood-vessels as far as the subcutaneous areolar tissue, where they surround the nerve-trunks and sharply press upon the nerve-covering. They cause the neurilemma to puff up and the white substance of Schwann to disappear, leaving the axis cylinder alone. This pathological fact makes easy the explanation of the severe attacks of neu- ralgia that not only accompany, but usually precede, the eruption of vesicles. Bibliography. Doyon : L'herpes recidivant des parties p6nitales. Paris, 1868. Fournier: Gaz. des hopitaux, 1878, pp. 890-950. Greenough: Archives of Dermatology, vol. vii., No. 1, Jan., 1881. Hardy : Nou. Diet. d. Med. et de Chir., Art. Herpes. Mauriac : Lefon sur l'herpes nevralgique des organs genitaux, Gaz. d. hop., Paris. 1876, xlix. Unna : Journal of Cutaneous and Ven. Dis., vol. i., No. 2, August, 1882. Abner Post. HERPES ZOSTER. Herpes, from epww, I creep ; Fr., herpes ; Ger., Flechte ; Zoster, from TAvn a girdle. Her- pes Zoster, called by the French, zona; by the Germans, Zoster or Gurtelrose. In early times it received various names, as Feu de Saint Antoine, Ignis sacer, and Dartre phlyctenoide en zone. Herpes zoster is an acute inflammation of the skin, oc- curring along the course of a cutaneous nerve, and is pro- duced directly by nervous influence. One of the most remarkable characters of herpes is its occurrence on one side of the chest, where it forms a half-girdle or belt, which but rarely encircles the entire thorax. This pecu- liarity has gained for the affection the various names of zona, a woman's girdle ; zoster, a man's girdle or belt; and our popular expression of "shingles," which Dr. Johnson derives from the Latin, cingulum, a girdle. That zoster may occur on both sides of the body simul- taneously cannot be denied, yet it is extremely uncom- mon. Etiology.-Herpes zoster may be produced by either traumatic or pathological influences. Traumatic zoster is the more rare form, and usually results from a heavy weight falling on some portion of the body, as in the case reported by Dr. Taylor,1 in which a traumatic neuritis of the cervical plexus on the left side caused a severe zoster on the skin areas to which the nervous filaments were distributed. An injury sufficiently severe to produce a neuritis of a cutaneous nerve-trunk will, as a rule, be fol- lowed by an eruption of vesicles along its course, cases of which have been reported by Weir Mitchell, Rouget,'2 and Oppolzer.3 The pathological influences that produce the vesicular eruption of zoster are many and diverse. Bazin4 consid- ers many cases to be due to an arthritic influence, and when occurring in children always so. Exposure to cold often occasions its development, and has a marked influence on the arthritic variety. Strange as it may seem, an indirect cause of the affec- tion is sometimes found in the emotions, such as sudden joy or grief. This influence, felt in the central nervous system, is reflected to some of the peripheral cutaneous nerves, and nutritive changes in the skin are the result. Cases are on record in which the pain of zoster has been felt immediately after some exciting emotion of this nat- ure. Mr. Hutchinson,5 of London, has reported a number of cases in which the cause seemed to be the internal use of arsenic, and other observers, both in England and the United States, have noticed the same thing. In all these cases the arsenic was administered for the relief of some chronic skin affection. In 1871, when the writer was in charge of the New York Dispensary for Diseases of the Skin, he saw a patient, aged fifty, with an acne of the face ; after treatment for a month by the use of external remedies, liquor potassse arsenitis was ordered in doses of three minims after each meal, to be gradually increased ; after continuing this for two weeks she complained of pain on the right side between the sixth and eighth ribs, midway between the spinal column and the vertebral border of the scapula, and examination revealed the vesic- ular eruption of zoster in the painful region. So many 645 Herpes. Herpes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The microscopic appearance of a vertical section of a vesicle of zoster (magnified 450 diameters) is shown in Fig. 1679, and the microscopic appearance of the deep layer of the corium in zoster is represented in Fig. 1680. In addition to the appearances found in the vesicles of zoster and of the nerves, as studied by Haight, similar and even more marked changes have been noted by other observers. Danielssen9 gives an account of the autopsy of a per- son dying of pneumonia, who had had the pains of zoster in the left side of the chest for two months before death. The sixth intercostal nerve was greatly swollen through- out all its ramifications to the skin. The swelling was caused by a hard transudation sub- stance poured out into the neurilemma; the axis cylin- der was, however, normal. Barensprung10 reports the autopsy of a patient dying of zoster, in whom there was gangrene of the skin be- points of interest which are peculiar to itself, and which transcend those referring merely to diagnosis and treat- ment. It is an instance of an acute inflammation of the skin produced directly by nerve influence. Probably there are many other forms of inflammation, both of the internal organs and of the surface of the body, that are thus produced, yet " shingles" is by far the best example. In traumatic zoster the symptoms usually come on in a few hours after the injury, and the eruption occurs along the course . of the cutaneous nerves arising from the nerve or plexus injured. When appearing idiopathically, it is usually preceded by general malaise, fatigue, nausea, and headache; in some cases there is elevation of temperature. In the skin about to be the seat of the eruption, a sensation of warmth, or oftentimes a severe neuralgic pain, is felt. On removing the clothing to discover the cause of this warmth or pain nothing will be seen, not even redness of the skin. In a few hours, varying from twenty-four to forty-eight, on the painful area of skin red points, ar- ranged in oval groups, will be found, and very soon each point shows a vesicle, the largest of which is about the size of a millet seed. These are at first very clear and pel- lucid, and often are found grouped together, not exactly confluent, but very closely associated ; sound skin exists between them, in which respect the affection differs from Fiq. 1680.-The Deep Layer of the Corium in Herpes Zoster, a, Tightly packed tissue of the corium ; N, transverse section of a nerve ; b, puffed-up neurilemma; c, loose tissue surrounding the nerve, filled with pus-cells. erysipelas, for which it has often been mistaken. The vesicles may, at a later period, contain blood-stained se- rum, and afterward opaque pus. The eruption runs a more or less definite course of from ten days to a fort- night, at the end of which time the scabs fall off, leaving generally deep cicatrices like those from variola. The eruption will be found, as a rule, upon one side of the body only. It the fifth cranial nerve is the one affected, the erup- tion occurs upon the forehead ; if one of the intercostals, then on the side of the chest or abdomen. If on the trunk, the eruption generally begins from behind at the spinous processes of the vertebras, the vesicles arranging themselves in a curved line, passing obliquely downward and forward on the trunk, and approaching the median line in front, beyond which they very rarely extend. Zoster is not contagious, and occurs, as a rule, but once in the same person. Sometimes, in rare cases, papules, bullas, or pustules may appear instead of vesicles. In other cases the neu- ralgia may be intensely severe before, during, and after the eruption; and occasionally the eruption is bilateral. Zoster may occur at any period of life, and the two sexes are equally liable, Fig. 1679.-Vertical Section of a Vesicle, a, One of the larger septa, containing spindle-shaped epithelial cells ; b, smaller septa, containing the same cells; b', spindle-shaped cell; spindle-shaped cell with prolongation; c, epidermis. tween the sixth and ninth ribs. In this case the ganglia at the commencement of the sixth, seventh, and eighth intercostal nerves, as well as a portion of the nerve be- yond, were infiltrated with pus. Barensprung believes that zoster is dependent on affec- tions of the ganglionic nervous system, rather than upon alterations in the peripheral nerves themselves; this lat- ter view is held by Curshmann andEisenlohr,11 and is ap- parently substantiated by the following case: The 'pa- tient had zoster of the forearm and arm ; some small nodules, which were noticed along the branches of the ax- illary and other nerves, were examined microscopically, and showed a perineuritis acuta nodosa, taking origin in the blood-vessels of the nerve sheath and perineural con- nective tissue. The nerve substance itself was intact. At a subsequent post-mortem examination the spinal ganglia were fouqd normal in appearance. Symptoms and Course, - Herpes zoster possesses 646 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Herpes. Herpes. A recurrence of zostex- is exceedingly rare. An inter- esting case of this sort has been reported by Tilbury Fox.12 The patient, a male aged thirty-three, had his first at- tack in June, 1868, the second in the same month in 1869, and the third attack in June, 1870 ; at this latter date he was seen by Dr. Fox. The eruption was an interrupted band of well-marked vesicles crossing from front to back over the point of the right shoulder, and also a crop of vesicles upon the gluteal region of the same side. Ka- posi 13 reports a case in which the eruption appeared five times, within a comparatively short period, always in the same region over the right cervico-brachial plexus ; the sixth time it occurred in the lumbo-sacro-crural re- gion on the right side ; while in the seventh, eighth, and ninth outbreaks the eruption was found in the left cervico- brachial region. Sometimes the eruption does not disappear within two weeks, but continues over the implicated nerve-twig for from three to six weeks. If the patient scratches the af- fected skin, deep ulcers are formed, which, on healing, leave deep and ugly scars. Occasionally ulcers occur without scratching, and in Barensprung's case quite ex- tensive gangrene of the skin took place. This certainly points to the trophic nature of the disease. The nervous symptoms in zoster may be of a motor nature, as in the case reported by Broadbent,14 in which an old woman had a permanent partial paralysis of the arm following zoster, and other observers have seen the same ; these motor dis- turbances are, however, quite rare. We will adopt the following classification : Zoster faci- alis, z. cervicalis, z. brachialis, z. thoracalis, z. abdomi- nalis, z. lumbalis, and z. sacralis. Zoster facialis.-In this variety the fifth cranial nerve is the one affected. Zoster frontalis seu ophthalmicus, is the variety under this group that is most interesting, and Hebra says of it, ' ' that often the eruption appears upon the forehead and scalp in the course of the supra-orbital nerve, passing from the supra-orbital notch upward to the top of the head. In some of these cases the eye is also affected, the vessels of the conjunctiva being injected, severe pain being also complained of, and the mobility of the iris being so much impaired that the disease may simulate iri- tis. " The nerve most frequently affected is the supra-orbi- tal, and next the supra-trochlear, though the latter never suffers alone ; both are often affected without the other branches of the fifth nerve being involved, and when this happens the eye is not so apt to become inflamed. The nasal nerve, a branch of the fifth which finally divides into the infra-trochlear and external branches, and sup- plies the middle and tip of the nose, is said to play an important part in the eye-symptoms of ophthalmic ' ' shin- gles." Mr. Hutchinson,15 of London, says he has never seen the whole side of the nose covered with vesicles without also witnessing inflammation of the eye, and has never seen the eye inflamed from herpes, unless vesicles were also visible on the side of the nose. He considers the nasal nerve the trophic nerve of the eye. This view, advanced nearly twenty years ago, has recently been brought forward again by Badal, who, calling this nerve the trophic nerve of the eyeball, advises stretching of the infra-trochlear, one of its branches, for glaucoma, and also for painful ocular neuralgias. Careful observ- ers have confirmed Hutchinson's views. I have, how- ever, frequently seen the eye inflamed when the eruption did not occur over the course of the nasal nerve. The following brief history of a case may serve to give a cliilical picture of the disease : The patient, a man aged thirty-four, came under my notice in 1880, having for two weeks previously complained of severe pain on the left side of the forehead, nose, and scalp, as far back as the frontal suture. When first seen there was great swelling of both upper and lower eyelids, but mostly the upper, severe conjunctivitis with chemosis, pupil irregu- lar, and some superficial keratitis ; the eye symptoms were most marked at the time of the greatest eruption of vesi- cles. The cornea was anaesthetic, and the keratitis was of the neuro-paralytic variety. The eye symptoms were very severe, and sight was lost in consequence of the ex- tensive changes which took place in the cornea. The eruption of vesicles followed the course of the supra- orbital and nasal nerves. The eruption is always limited to one side, and never crosses the median line of the forehead or nose ; it sel- dom affects the cheek, although there may be some oedema of the part, produced by the surrounding in- flammation. It invariably leaves deep scars, by the ar- rangement of which it is usually easy to recognize a case years after its occurrence. If the eye becomes inflamed when the eruption first appears, the organ is generally very severely affected, but the inflammation is of a mild type if it occur toward the termination of the attack. When the disease has subsided the eyeball is left some- what anaesthetic, and the skin is often complained of as being numb and stiff, like parchment. Occasionally the eye is lost by general inflammation of the globe (panophthalmitis). Zoster Cervicalis is that variety of zona which is found distributed upon the portions of skin supplied by the superior cervical nerves. Their points of emergence are near the middle lateral portions of the neck. It is an un- usual form. Zoster Brachialis generally begins in the median line posteriorly, in the region of the first dorsal nerve ; a few vesicles may appear upon the median line, then some along the course of the circumflex nerve, and when very extensive, it may appear upon the forearm and hand. • Zoster Thoracalis is the most common variety, and the one from which the name zoster seems to have origina- ted. The dorsal, intercostal, and thoracic nerves are the ones affected. The widest part of the eruptive zone is in the dorsal region ; the anterior part of the zone may oc- cupy the mammary region, or may extend to the um- bilicus. In sixty-five observed cases-thirty-nine males and twenty-six females-the right and left sides were equally affected. The pain which precedes the eruption in this variety may be often mistaken fox' acute inflammation of the pleura, the pain being more severe in this form by reason of the respiratory act. The eruption is usually unilateral, though it may occur on both sides at once. Zoster Abdominalis.-Here the eruption follows the course of the perforating thoracic nerves and the cutane- ous branches of some of the lumbar plexus. The eruptive zone occupies the region of the umbilicus. Zoster Lumbalis.-The eruption here is distributed along the branches of the lumbar, crural, external femo- ral, and internal saphenous nerves. The vesicles occur- upon the genital organs and inner surface of the thigh. Zoster Sacralis.-The eruption is distributed along the cutaneous branches of the sacral and sciatic nerves, and the vesicles may extend as far down as the heel. This form is of rare occurrence, and the pain may at first be taken for sciatica. Prognosis.-The prognosis of ordinary uncomplicated zoster is favorable, and no danger is to be apprehended. The severe pain that frequently follows the healing of the vesicles generally ceases in a few weeks. When the dis- ease occurs in old and cachectic persons, in whom gan- grene of the skin has been a complication, the prognosis is more grave and the disease is apt to terminate fatally. There is a vulgar but erroneous notion that the disease proves fatal when the eruption surrounds the body or trunk. This idea is as old as the time of Pliixy. In ophthalmic " shingles " the eye often suffers serious damage, the cornea being the seat of deep ulceration, and permanent impairment of vision sometimes results. Treatment.-The treatment consists in local and in- ternal medication, and is mostly of the expectant charac- ter. Local treatment is directed especially to the protec- tion of the vesicles from irritation by the clothing ; this is best done by anointing the parts with carbolic oint- ment or vaseline. Painting the parts with collodion makes a very good protective agent for the vesicles ; in some cases, however, it temporarily increases the pain by contracting the skin in the vicinity. Hypodermatic in- jections of cocaine hydrochlorate over the nerve supply- 647 Herpes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hip-Joint. ing the painful area will be of immense service. Oint- ments containing cocaine and morphine may also be applied to the vesicular patches. For the painful neuralgias occurring after the healing of the vesicles, oleic acid containing some drug, such as morphine, cocaine, atropine, or daturine, may be used as an inunction. Static electricity 16 has also been found ex- tremely useful in allaying the severe pain, applied both over the course of the nerve and at its origin. In ophthalmic shingles the eye symptoms are treated in the usual way. Internally, quinine and iron are the principal remedies used. William Oliver Moore. 1 New York Medical Journal, vol. xxxix., No. 24. 2 Journ. de Physiolog., 1859. 3 Allgem. Wien. Med. Zeitung, 1866, No. 48. 4 Affections Cutanees, Paris, 1860. 6 Medical Times and Gazette, 1868, 1869. 6 Concours Med., February 2, 1884. 7 Duchenne : Localized Electrization. 8 Ueber Blasenbildung bei einigen Hautkrankheiten, von Dr. D. L. Haight, aus New York, 1868. 9 Danielssen und Boeck: Recueils d'Observations sur les Maladies de la Peau, Schmidt's Jahrbiicher, 1857, Bd. xcv. 10 Beitriige zur Kenntniss des Herpes Zoster, Charite-Annalen, 1863. 11 Deutsches Archiv f. klin. Med., Bd. 34, Hft. 4, 1884. 12 British Medical Journal, August 6. 1870. 13 Wien. med. Wochenschr., 1874, 1875, to 1877. 14 British Medical Journal, 1860. 15 Ophth. Hosp. Reports, 1866. 16 Personal Communication by Dr. F. B. Carpenter, New York City. cessive laughing or crying ; from over-eating ; from chok- ing in rapid eating ; from fright. 2. As a continued disturbance without well-marked lesion or disease, in persons of neurotic or hysterical tem- perament ; in such cases it sometimes becomes a habit, and it appears to be of central origin. It is also observed as a local chorea of the diaphragm and larynx. When of cerebral origin it is more frequently associated with conditions of exhaustion than of excitement. A case has been reported by Romberg which resulted from fright, and which alternated with spasms of the glottis. 3. As a continued disturbance due to definite lesions which excite direct irritation of the phrenic nerves or dia- phragm. Such lesions are in the neck or thoracic re- gion. Examples are : mediastinal tumors pressing upon the phrenic nerves, inflammations (especially gouty) of the serous surfaces lying in contact with the diaphragm, an- eurisms, pneumonia, pleurisy of the mediastinal pleural surface, fractured ribs, etc. Two interesting cases have been reported by Bright of lesions of the phrenic nerve itself, which gave rise to no hiccough (!) 4. As a disturbance due to more or less remote reflex action ; for example, irritations excited by disturbances of any portion of the alimentary tract or the liver. The passage of renal or biliary calculi; more rarely, affec- tions of the prostate, uterus, etc., strangulated hernia, affections of the pharynx and larynx. It also may occur in malarial disorders. • 5. As a symptom in advanced fatal disease, especially among the aged, when it is of very serious import. For example, in uraemia, cholera, severe dysentery, extensive haemorrhages, and gangrene. When the hiccough is per- sistent and violent it may cause considerable pain and sore- ness in the abdominal and thoracic muscles, for they also may participate in the spasmodic movement. There are sometimes dyspnoea, embarrassment of speech, and vomit- ing. The hiccough may recur as frequently as forty or even fifty-five times per minute, and very exceptionally nearly all the muscles of the trunk become involved. In the worst cases the patient cannot swallow food easily, or the food is eructated, and emaciation ensues, the pulse becomes feeble, sleep is interfered with, and a most de- plorable condition results. Hiccough differs from cough in that it is an inspiratory, not an expiratory, act. It differs from sobbing in that it is unaccompanied by lachrymation or emotional phe- nomena, and by the long expirations; moreover, the sound is usually higher pitched in hiccough. It differs from laryngismus stridulus in that the diaphragm is more distinctly affected in hiccough, and in laryngismus stridu- lus the spasmodic closure of the glottis is complete, relatively long-continued, and the resulting dyspnoea is extreme. The treatment naturally depends upon the etiology. If transient the affection will soon stop of itself. If necessary, various simple domestic remedies may be em- ployed ; such are: distracting the attention by excitement of any sort, or by an unexpected loud noise, swallowing ice or a glass of cold water, acid drinks, cold douches, friction over the neck and epigastrium, firm compression of the base of the thorax accompanied by forced flexion of the head for a few minutes, which is said to relax the diaphragm, hot mustard water, or infusion of pepper, pouring a large quantity of water down the throat so as to compel swallowing, etc. In, prolonged cases, if the exciting cause cannot be de- termined and removed, those remedies which have proved most useful are : opium and antispasmodics, belladonna, camphor, oil of amber, cannabis indica, assafoetida, and chloral. Musk is said to be almost a specific. Ether and chloroform are used internally, and in severe cases also by inhalation. Both the galvanic and faradic currents are used. One pole is applied over a phrenic nerve in the neck, and the other over the region of the diaphragm. The galvanic current is advised for sthenic, the faradic for asthenic cases (Jones). Stimulation of the superior laryngeal nerve by blisters, etc., may be of service. Hy- podermatic injections of morphine and of atropine cure HEU ST RICH. A bathing-place and milk-cure, situ- ated a short distance south of the Thuner See, Germany, in a valley at an altitude of 2,100 feet. It owes its prom- inence chiefly to its mineral spring. One pint of the water contains : Grains. Sodium chloride 0.070 Sodium sulphate 1.539 Potassium sulphate 0.049 Sodium bicarbonate 5.IM Magnesium bicarbonate 0.058 Calcium bicarbonate 0.087 Other solid constituents, chiefly compounds of sulphur. 0.488 Total 7.444 Grain. Sulphuretted hydrogen About 1.129 Temperature, 42.5° F. The spring has received great credit for the activity of the sulphur which it holds in solution, the narcotic effect of the sulphuretted hydrogen being very apparent when large quantities of the water are taken. Indications.-The clinical investigations of this water by a number of authorities indicate its applicability to the treatment of chronic catarrhs of the respiratory or- gans, the larynx, the intestinal tract, and the urinary bladder. It is used also as a gargle, or in the form of spray, in throat affections. J. M. F. HICCOUGH. Synonyms.-The synonyms are many, but the commonest are Hiccup, Singultus, Lygmus, Schleuchzen (Ger.), Singultueux (Fr.). Definition.-Hiccough is a clonic spasm of the dia- phragm, accompanied by a quick inspiratory effort, in- terrupted by closure of the glottis, which gives rise to a characteristic sound ; a short expiration then follows. By some observers the closure of the glottis is said to be complete, and the sound is produced by the impact of the entering column of air which strikes against the vocal cords. By others the closure is said to be partial. It is a difficult matter to determine by laryngoscopic examina- tion, but the variety in pitch of the sound produced would seem to indicate that the cords were not uniformly tightly closed. Etiology.-Hiccough may occur : 1, as the result of direct local irritation of the phrenic nerves or diaphragm ; 2, from reflex irritation; 3, from central irritation orig- inating in the nerve-centres of the upper cervical part of the cord and the medulla. Mild hiccough is sometimes controlled by the will, and it may be imitated volun- tarily. Hiccough may occur: 1. As a transient neurotic disturbance, when it is more common among children than adults; as a result of ex- 648 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Herpes. Hip-Joint. some cases. Not infrequently cases occur which resist almost every remedy. This is particularly true of hysteri- cal cases, of those which are due to pressure from tumors, and to advanced fatal disease. Additional remedies which have occasionally proved successful are quinine in large doses in malarial cases, iodoform, bismuth in large doses, amyl nitrite, etc. In several obstinate hysterical cases, one of which had lasted for over six months, the writer employed wet packs and the Paquelin cautery with suc- cess. The firm support of the diaphragm made by an assistant, by pressing the fingers deeply and firmly up un- der the margins of the lower ribs for an hour at a time, has cured some very intractable cases. The diet usually requires careful supervision, and carbo-hydrates or other foods liable to produce irritant fermentation, with pro- duction of gases in excess, should be withheld. In many continued cases tonics, such as mix vomica and iron, are beneficial, combined with proper hygienic measures, exer- cise, cold bathing, etc. Therapeutic Properties.-According to the above analysis these are alkaline and carbonated waters of re- markable strength, and should be as valuable as their more renowned prototypes, those of Vichy and Ems. These springs are situated near the head of the fertile Big Valley of Lake County, at an elevation of seventeen hundred feet above the sea. The Mayacamas Mountains, thirty-three hundred feet in height, surround the valley on three sides and shelter it from the coast -winds and fogs. There are twenty-five springs in this group, each pos- sessing individual medicinal properties. The " Dutch Spring " is said to be similar to the " Ems Spring," Ger- many. The hotel and cottages, open all the year, will accommodate one hundred. Late improvements to the property include facilities for baths of various kinds. Good hunting and fishing is found in the neighborhood. Geo. B. Fowler. HIP-JOINT. The development of the pelvic limbs into organs for support and propulsion has given to the joints by which they are articulated with the trunk a pe- culiar character of strength and solidity. While move- ment is free in every direction, and the femur can be cir- cumducted as well as rotated, yet these movements are C. H. Jones : Functional Nervous Disorders, pp. 646-648. Erb: Electro-Therapeutics, in Wood's Med. Library, pp. 271, 272. Rosenthal : Diseases of the Nerv. Syst., in Wood's Med. Library, vol. ii., pp. 225, 226. William Gilman Thompson. Bibliography. HIGHGATE SPRINGS. Location and Post-office, High- gate Springs, Franklin County, Vt. Access.-By Central Vermont or Boston & Lowell (Vermont Division) Railroad to Swanton, three miles from the springs. Analysis.-One pint contains : Champlain Spring. A. A. Hayes. P. Sterry Hunt. Grains. Grains. Carbonate of potassa 0.459 Carbonate of soda 0.153 1.713 Carbonate of magnesia 0.152 0.729 Carbonate of lime 0.127 0.175 Carbonate of ammonia trace Chloride of potassium 0.093 Chloride of sodium 0.021 2.930 Sulphate of soda 0.306 Protoxide of iron 0.004 Potassa and boracic acid Crenic acid 0.112 Silicic acid 0.102 Total 1.223 5.853 Therapeutic Properties.-This is a feeble sulphur- water of local repute. The springs are situated on the Missisquoi River, about nine miles north of St. Albans, near the shore of Lake Champlain, amid the beautiful scenery of Northwestern Vermont. G. B. F. HIGHLAND SPRINGS. Location and Post-office, High- land Springs, Lake County, Cal. Access.-By Central Pacific Railroad to Calistoga, thence by stage to Kelseyville, forty miles, thence by car- riage to springs, four miles ; or by San Francisco & Northern Railroad to Cloverdale, thence by stage to springs. Analysis (Professor W. B. Rising).-One gallon con- tains : Fig. 1681.-Front View of the Hip-Joint. (From Sappey.) 1, Tendon of rectus femoris, cut; 2, its attachment to tile antero-inferior iliac spine ; 3, reflected portion of the tendon ; 4, tubercle of the trochanter major; 5, tendon of the gluteus minimus ; 6, the attachment of the ilio-femoral ligaments to the antero-inferior iliac spine; 7, fibrous union of the capsule with the tendon of the gluteus minimus; 8, supe- rior ilio-femoral ligament; 9, section of a very thin fibrous lamella which covers over and crosses the ligament obliquely ; 10, 10, thinner portion of the capsule between the two ilio-femoral bands; 11, anterior ilio-femoral ligament; 12, 13, thin portion of the capsule arising from the ilio-pectineal eminence, and from the horizontal ramus; 14, orifice in the capsule communicating with the bursa beneath the tendon of the ilio-psoas ; 15, pubo-femoral ligament; 16, 17, 18, 19, fibrous bands re- lating to the obturator membrane ; 20, the obturator foramen or sub- pubic canal; 21, lesser trochanter; 22, antero-superior iliac spine; 23, postero-superior iliac spine ; 24, postero-inferior iliac spine, 25, ilio- pectineal line ; 26, ilio-pectineal eminence. Seltzer. 64.8° F. Dutch. 70.5° F. Magic. 82.4° F. Grains. Grains. Grains. Chloride of sodium 0.723 1.862 1.290 Bicarbonate of soda 12.796 18.348 21.763 Bicarbonate of potash 0.489 0.770 0 544 Bicarbonate of lime 52.045 57.302 50.411 Bicarbonate of magnesia 34.872 67.634 70.213 Bicarbonate of iron 1.267 1.341 1 087 Bicarbonate of manganese Silica 5.245 7.126 7.398 Alumina 1.565 0.117 0.169 Organic matter Free carbonic acid 100.250 87.822 •74.462 Total 209.252 242.322 227.337 much less extensive than at the shoulder. The head of the distal bone is more completely enclosed, and the cap- sular ligament is stronger and narrower at its distal in- sertion, so as to offer a resistance to luxations. Besides this, certain modifications have been caused by the strain and pressure occasioned by the erect position. It would 649 Hip-Joint. Hip-Joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. naturally be supposed that in a ball-and-socket joint the surfaces of contact would be perfectly spherical, and, in- deed, the head of the femur is usually described as pre- senting from two-thirds to three-fourths of the surface of a sphere fitting closely the acetabular cavity. Aeby1 and Schmid2 have, however, shown that this is not quite correct, as there is a slight flattening of the surfaces and a thickening of their encrusting cartilages where they are subjected to the greatest pressure. This is more marked in the adult. The liability of the articulation to disease and injury is considerable, both on account of its size and of the press- ure upon the surfaces. It is therefore important to de- termine its precise position and relations-and this is by no means easy, as it lies buried under thick masses of muscle. In front is the reflected tendon of the ilio-psoas, a bursa (B. subiliaca), which sometimes communicates with the joint-cavity, intervening. Above, the reflected tendon of the rectus femoris and the gluteus minimus are firmly united with the capsule (see Fig. 1681). Internal- ly lies the pectineus above, also united with the capsule, and the obturator externus below. The tendon of this latter muscle also lies posteriorly, together with the ob- the adductor longus which starts up. Joining these two points is Poupart's ligament, which may easily be felt. The muscular prominence on the outer side of the leg is caused by the tensor vaginae femoris, on the inner by the adductor muscles, and the triangular interval between, which reminds one distantly of the axillary space, is the fossa subinguinalis, or Scarpa's triangle. It is through the middle of this that the great vessels pass down the thigh, and the beating of the femoral artery, which lies nearest the joint, may be felt by pressing just below Pou- part's ligament. The joint is about half an inch external to this, and in a very lean person (easier in cadaver) the head of the femur may be felt rolling under the fingers by pressing deeply here while an assistant extends and rotates the limb. This is impossible, however, when the subject is even moderately fat. A fulness and tenderness here are noted in the early stages of hip disease, when there is effusion into the joint. Pus forming around the joint is always confined, and burrows extensively along the lines of fascia above mentioned. An abscess pointing below Poupart's ligament, and external to the vessels, usually comes from the joint. Two other bony points should be noted. First, the tuberosity of the ischium, which is the part upon which the weight of the body rests in sitting. In the erect post- ure it is concealed by the gluteal fold behind, but readily made out by palpation. Second, the great trochanter, which is situated on the outer part of the upper thigh, about four inches below and behind the anterior superior iliac spine. The top of it is on a level with the pubic spine, and about three-fourths of an inch below the head of the femur. When the leg is abducted the trochanter will be found at the bottom of a depression ; when adducted and rotated inward it makes a prominence. The anterior superior iliac spine, the tuberosity of the ischium, and the pubic spine are all about equally distant from the bottom of the acetabulum. A line con- necting the first two is known as Nelaton's line. It grazes the great trochanter and passes directly over the middle of the acetab- ulum when the thigh is slightly flexed. By noting the extent of displacement of the tro- chanter with reference to this line, much can be made out as to dislocation or fracture. Upon rotating the femur the trochanter will be seen to describe the arc of a circle, with a radius equal to the length of the head and neck; in case of fracture the arc is much less, the bone rotating merely upon the axis of the shaft. The patient being in the recumbent position, a fracture of the neck may also be detected by noting the displacement of the trochanter toward a line dropped vertically from the anterior superior spine of the ilium (Bryant). Of the articular surfaces the acetabulum is the more lia- ble to disease, because it is composed of a greater variety of elements. The three primitive bones, the ilium, ischi- um, and pubes, which unite to make the innominate bone, all participate in the formation of the cavity. Up to the age of puberty the component bones are separated by a Y-shaped strip of cartilage. It is probably on account of the unusual activity required by the osteogenic process here that the joint is so prone to disease in childhood, hip disease rarely occurring after ossification is completed. The primitive divisions of the cavity are still indicated in the adult by notches on the edge of the acetabulum. The lower part of the cavity is not covered with cartilage, but offers a rough depression filled in with fat and processes from the synovial membrane, in which vessels pass to sup- ply the joint (Haversian gland) (Fig. 1682). It results from this that the part of the joint covered with cartilage has somewhat of a horse-shoe shape. The lower part, both because of its vascularity and its want of protection by cartilage, is usually the first attacked by inflammatory processes. It is also in this situation that the walls are thinnest, as it is necessary to buttress above against the thrust of the femur in the erect position. The thinness Fig. 1682.-The Hip-Joint Opened. (From Sappey.) 1,1, Transverse section of the capsu- lar ligament, showing its variations in thickness; 2, section at the situation where it is strengthened by the ilio-femoral bands ; 3, 3, free edge of the cotyloid ligament; 4, 5, 6, semilunar interspaces which separate that ligament from the capsule ; 7, 7, pad of fat at the bottom of the acetabulum ; 8,9, the ligamentum teres ; 10, the umbo, or depression on the head of the femur; 11, 11, head of the femur; 12, farthest extent of the articular surface behind ; 13, 13, that portion of the neck behind that is invested with synovial membrane; 14, 14, oblique line where the synovial membrane is reflected : 15, that por- tion of the neck behind that remains without the capsule ; 16, great trochanter ; 17, digi- tal fossa; 18, lesser trochanter ; 19, posterior intertrochanteric line. turator internus, the gemelli, the pyriformis, and the quadratus femoris. All these form an immediate investment for the joint, and are themselves partially covered by a second mass composed of the tensor vaginae femoris, the gluteus max- imus and medius behind and externally, the biceps group behind, and the adductor group internally. Over these muscles there stretches the fascia belonging to the different groups, and in several situations this no- tably strengthens the joint-capsule, especially where the iliac fascia comes down from the ilio-psoas, where the pec- tineal fascia passes outward upon the capsule from the pectineus, and, externally, where a strong process passes inward between the tensor vaginae femoris and the rectus femoris. , The depth at which the articulation lies makes it diffi- cult to obtain any positive knowledge as to the condition of the joint by direct manipulation, but a fairly accurate notion of its situation may be had by noting the surface forms and bony points of the region. As to the bones, note first the anterior superior spine of the ilium, always marked even in the fattest subjects ; then the spine of the pubes, which can easily be found by abducting the thigh and then running the finger along the strong tendon of 650 Hi p-J oiut. Hip-Joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. here explains the ease with which inflammatory processes may be propagated, an arthritis giving rise to a pelvic cellulitis, and a pelvic abscess occasioning inflammation of the joint. Perforation of the acetabulum is not very common, as the pressure is but slight. Within the pelvic cavity the situation corresponding to the acetabulum is covered in part by the obturator inter- ims. When the perforation occurs it must therefore be in one of three positions-either upon the muscle, behind it, or in front of it. In the first instance the pus passes out with the tendon of the muscle at the lesser sciatic notch, and points upon the nates. When behind, it goes into the ischio-rectal fossa, and discharges through the perineum or into the rectum. When in front, it passes upward along the sheath of the obturator vessels, and makes its appearance in the groin.3 The acetabular cavity is not quite an inch in diame- ter, and does not comprise an entire hemisphere. This deficiency is made up by fitting to the rim an elastic structure of fibro-cartilage called the cotyloid ligament. This is triangular on section, and spans over the notch at the bottom of the cavity, being there known as the transverse ligament. The cavity, thus deepened, is some- what more than a hemisphere. The cotyloid ligament is applied closely to the surface of the femur, and helps to retain it in position-acting, however, as a valve, as it is easily stretched sufficiently to disarticu- late the bones. Both the head and the neck of the fe- An apparatus connected with the synovial membrane of the joint is the so-called ligamentum teres, or round ligament-which is not round, nor, properly speaking, a ligament, being a flattened band quite similar to the syno- vial processes with which it is united at both ends (see Fig. 1682). It passes from the fossa at the bottom of the acetabulum to the umbo upon the. head of the femur. It does not, like interosseous ligaments, extend in the shortest direction from one bone to the other, but is in a manner rolled around the lower part of the head (Fig. 1683). It is composed of loose connective tissue and con- tains vessels. Various surmises have been made as to its use. It was formerly held to be for the purpose of limiting out- ward rotation and adduction during flexion.6 It has been shown, however, that if the capsule is left intact, these motions are more closely limited than when it is severed, and the strain comes alone upon the ligamentum teres. Tillaux4 thinks that it tends to break shocks de- livered by the femur upon the top of the acetabular cav- ity in jumping, etc. Sappey8 supposes that its principal function is the protection and conveyance of vessels to nourish the head of the femur; but Hyrtl9 finds that, upon careful injection of the arteries, only the round liga- ment and the fatty cushion at the bottom of the acetabu- lum become reddened, and that at the insertion of the round ligament upon the femoral head the capillary ar- teries loop back and unite w ith veins. An injection of the superior nutrient artery, on the contrary, fills the cap- illaries of the cancellous tissue of the head. This explains the well-knowm pathological fact that an intracapsular fracture of the femoral neck is likely to be followed by non-union of the fragments, notwithstanding that the ligamentum teres may be left intact. Langer,10 however, finds that, in young subjects, vessels of considerable size pass through directly into the proximal epiphysis of the femur, and suggests that its function is connected with the nourishment of that epiphysis. When this becomes united, its vascular system is connected with that of the nutrient artery, and the branches received through the ligament gradually atrophy, until in old age they are al- most entirely wanting. Weicker11 has made a careful examination of this liga- ment in the animal series, as well as in human embryos, and considers it a process of synovial membrane originat- ing as a fold at the side of the articular surface, and grad- ually detached by the twisting of the limbs. In some animals quite near man, as the orang (occasionally also in man), it is wanting, but it may be said to be generally present when there is much differentiation of the hind limbs. In the tapir it is reduced to a process attached only at the side, a condition occasionally found in the human shoulder-joint. One of the most interesting views as to the nature of this puzzling structure is that of Sutton,'2 wdio thinks it a vestige of a tendon, probably a former attachment of the pectineus. The ambiens muscle of ostriches, homol- ogous with the pectineus, carries its tendon into the joint to the head of the femur. In the lizard, Sphenodon, the pectineus has twro heads, one going to the femur, the other to the pubic bone, reminding one of the biceps brachialis. In the horse the ligamentum teres has two parts, one of which is continuous with the pectineus. The capsule of the joint is much stronger and thicker than that at the shoulder, and confines the bones more closely. It is united above just beyond the base of the outer edge of the cotyloid ligament, and to the transverse ligament. Upon the femur it passes considerably beyond the articular surface, taking in a portion of the neck. In front it reaches to the anterior intertrochanteric line, while behind, because of the numerous muscles coming to be inserted into the trochanter, it does not reach the posterior line, but covers only about the inner two-thirds of the neck. It follows from this that all fractures of the neck are intracapsular in front, that they are intra- capsular in front and behind when situated at the inter- nal half, but when at the external half they may be intra- capsular in front and extracapsular behind. Tillaux4 notes that the synovial membrane is reflected within the Fig. 1083.-Section through the Left Hip-Joint. mur should be considered as taking part in the articu- lation, the first by actual contact, the second by its inclu- sion in the capsule. The articulating surface of the head has been estimated at nine and a half square inches, and when to this is added the surface of the acetabulum and capsule, there are about twenty square inches of synovial surface subject to inflammation.3 It is not, therefore, surprising that the joint should be susceptible to injury. The cartilaginous covering extends farther from front to back than from side to side, indicating the direction of the greatest excursion of the articular surface. A short distance below the summit of the head, and a little nearer the posterior than the anterior surface, there is a slight depression, termed the umbo, for the insertion of the ligamentum teres (see Figs. 1682 and 1683). The neck is obliquely set upon the shaft at an angle which varies according to the age of the individual, but not as much as is generally supposed, being about an average of 131° for the child and adult, and 128° for the aged.4 Individual variations are more pronounced, lying be- tween 121° and 144°, or more. The angle is less in fe- males than in males. These facts explain the greater frequency in women and aged people of fracture from shocks delivered u^on the neck in a vertical direction, as the nearer the angle between the neck and the shaft is to a right angle the greater would be the shearing stress under such circumstances. The compact tissue is mainly at the lower part, where the most bracing is required. Caries, therefore, works much more rapidly upon the up- per surface.3 651 Hip-Joint. Hip-Joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. capsule somewhat in advance of the fibres of the capsule, and shows that a fracture might be intracapsular and still not involve the synovial membrane. He therefore pro- poses that the fractures of the neck be divided into intra- and extra-articular. The innermost layer of the capsule, not including the synovial membrane, is a thin layer of circular fibres. These become more apparent behind and at the lower part, where they are known as the zona orbicularis. This is the weakest part of the capsule, and, consequently, the point where pus usually bursts through, and where spon- taneous dislocation takes place in hip disease. A blow on the great trochanter forcing the head of the bone downward and backward is apt to occasion dislocation, especially when the thigh is flexed so as to make the head of the femur press against this weak part. The circular fibres are not confined to this spot, but are found inter- mingling with others in all parts of the capsule. They undoubtedly exercise a restraining influence against dis- location of the bone by constricting the capsule at its femoral insertion. In those situations where special stress occurs, longitu- dinal bundles of considerable strength have been formed upon the surface of the capsule. These form four tol- erably distinct bands. Two of these are caused by the necessity of supporting the trunk in the erect position. They pass from the anterior inferior spine of the ilium downward, diverging from each other like the branches of an inverted Y (a), one going to the base of the trochanter major, the other to just above the trochanter minor. They have been usually described collectively as the ilio-femoral ligament, ligament of Bertin, or Y ligament of Bigelow. Weicker 11 has, however, suggested that, as the two bands are distinct and perform different physiological func- tions, they should receive separate names, and proposes to call them the superior and anterior ilio-femoral liga- ments. They are both exceedingly strong. It is because of this that, in the barbarous punishment of "drawing" a criminal, by means of four horses attached to his limbs and proceeding in opposite directions, the separation at the hip-joint had usually to be completed with a knife, the ligaments resisting after several hours of trial-as was the case at the execution of Ravaillac, the assassin of Henry IV., and of Damiens, who attempted the life of Louis XV. The superior ligament is perhaps the strongest ligament in the body, being from one-fourth to one-half an inch thick (7 to 14 mm., Weicker), and stronger than the tendo Achillis. Its action is to limit the extension of the femur upon the pelvis. In the erect position the weight of the body falls behind the hip, and the pelvis is accord- ingly tilted backward, putting this band on the stretch, and it then sustains the whole weight of the trunk, head, and arms, a great economy of muscular force being thus effected. It also limits outward rotation and adduction. The anterior ligament is also very strong, being nearly one-fourth of an inch thick (4 to 5 mm.), and the longest strengthening band of the capsule. It assists the superior ligament in limiting extension, but not in the same plane, the plane of limitation for the superior ligament being nearly parallel to the axis of the femoral neck, that of the anterior with the axis of the shaft. The two ligaments are but slightly developed before the erect position is attained. Indications of them are found early, but they increase with the growth. In animals that can stand partially erect, such as apes and some marsupi- als (kangaroo), the ligaments are strong ; in others slight.13 They have an important influence in determining the deformity which results from dislocations of the femur, and may be used as a fulcrum in reducing them.14 Thus, it is the superior ligament which holds the neck fixed, and hence causes the inward turning of the toes in dislocation backward. In thyroid dislocation the anterior ligament causes in a similar way an eversion of the toes. Another strengthening band of the capsule is the pubo- femoral ligament, which stretches from the pectineal eminence of the pubic bone to the lesser trochanter. It is from two to three millimetres thick, and limits abduc- tion. The ischio-femoral band is of about the same size, and stretches in a similar way from the tuberosity of the ischium to the digital fossa of the great trochanter, along the line of the tendon of the obturator internus, with which it is somewhat blended. It limits rotation inward. It is sometimes described as ending upon the capsule, and therefore called ischio-capsular (Henle); but Weicker and others find the arrangement described the usual one. The action of these four bands is such that in passing from the flexed to the extended position they wind around the neck in such a way as to shorten the capsule, which, being closely united with the zona orbicularis, is drawn up against the edge of the acetabular cavity and sur- rounds the lower part of the head as with a ring. It may be said that the contraction is such that dislocation is impossible in the extended position. The brothers Weber made the discovery that the head of the femur is held in position by atmospheric pressure, the amount of weight thus lifted being somewhat great- er than that of the limb. This greatly economizes the muscular force required for walking. The closely fitting cotyloid ligament assists this greatly, and dislocation is very unusual, if not entirely impossible, without injury to it. Men and animals that ascend mountains to a height where the air becomes sufficiently rarefied to be of less effect in upholding the weight of the limbs suffer from weakness in the joints. Hyrtl9 states also that moun- taineers, who have trained their muscles by long use in a rarefied atmosphere, are somewhat inexpert in the use of their legs when theydescend to the valleys. The arterial supply to the joint is, as has been stated, through the notch in the lower part of the acetabulum, some collateral circulation being imperfectly effected by means of capillary branches from the nutrient artery of the femur. The capsular ligament is remarkable for the number of vessels and nerves which ramify in it. The joint is usually said to be supplied with nerves from the sciatic and from the obturator trunks, but re- cently the nervous supply has been carefully reinvesti- gated by Chandelux, who finds it to be as follows : In front, a twig from the musculo-cutaneous branch of the anterior crural is given off a short distance from the point where the nerve is lost in the pectineus. This passes be- hind the sheath of the femoral vessels, and reaches the capsule at its antero-internal portion. It supplies the in- ternal half of the anterior part of the capsule. Behind there is a branch of somewhat variable origin, but always emanating either directly or indirectly from the sacral plexus. It descends upon the posterior part of the ar- ticulation, reaches the capsule behind and above, and is distributed to the internal half of the posterior portion. No nerve was found from the obturator trunk. It is believed that this distribution explains certain phenomena connected with coxalgia. In certain forms the propulsion of the head against the acetabular cavity by percussion upon the knee is hardly felt, although a direct pressure upon the internal part of the femoral head in front is very painful, as are also forced move- ments of outward rotation. In this case it is supposed that there is a coxalgia of capsular origin. Again, the characteristic attitude is also explained. Often adduction of the leg is accompanied by inward rotation, but in some patients outward rotation occurs. As the anterior articular nerve is only a bifurcation of the branch going to supply the pectineus, it may easily be imagined that a neuritis, arising perhaps from the syno- vial membrane, affects the pectineal branch and causes the muscle to act. The pain in the knee, which is an almost constant symptom in hip disease, has usually been considered as caused by the reflex action through the articular branch from the obturator nerve. It may, however, be caused by a neuritis extending to the internal saphenous nerve, or, as is more likely, by the pressure which the effusion into the joint makes upon the obturatoi; nerve where it lies upon the anterior part of the capsule.8 Bibliography. 1 Aeby, Chr.: Spha/oidgelenke am Extremitatengurtel, Zeitschr. f. rat. Med., iii., R„ xvii. Ibid.: Die Gestalt des Femurkopfes, Med. Jahrb., pp, 75, 564, Wien, 1877. 652 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hip-Joint. Hip- Joint. 2 Schmid, Fr.: Ueber Form und Mechanik des Hiiftgelenkes, Deutsch. Zeitschr. f. Chir., v., 1, Leipzig, 1874-75. Albert E.: Zur Mechanik des Hiiftgelenkes, Med. Jahrb., p. 105, 1876: p. 291, 1877 ; Wien. 3 Clippingdale, S. D.: An Essay upon Hip-joint Disease, Med. Press and Ciro., xxxiv., 436, London, 1882. 4 Tillaux : Anatomie Topographique. 6 Struthers: On the True Function of the Round Ligament of the Hip-joint, Lancet, February, 1863. 6 Savory, W. S.: On the Use of the Ligamentum Teres of the Hip- joint, Jour. Anat, and Physiol., viii., 291, London, 1873-74. 7 Morris, H.: The Ligamentum Teres and its Uses in Man and Ani- mals, Brit. Med. Jour., ii., 1036, London, 1882. 8 Sappey, Ph.: Anatomie Descriptive. 9 Hyrtl, J.: Topographische Anatomie. 10 Langer, C.: Lehrbuch der systematischen und topographischen Anatomie. 11 Weicker, H.: Ueber das Hiiftgelenk, Zeitschr. f. Anat, und Ent- wickgsch., i., 41; ii., 98, 231; Leipzig, 1875-76. 12 Sutton, J. B.: The Ligamentum Teres, Jour. Anat, et Physiol., xvii., 191, London, 1882-83. 13 Arens, F.: Beitrag zur Anatomie des Ligamentum ileo-femorale. Greifswald, 1878. 14 Bigelow, H. J.: The Mechanism of Dislocation and Fracture of the Hip. Philadelphia, 1869. 15 Chandelux, A.: Sur les nerfs de 1'articulation coxo-femorale, Lyon Medical, li., 551, 1886. Frank Baker. head of the femur would be far more apt to cause a sepa- ration of the epiphysis. It is not unlikely that many cases of so-called congenital dislocation, due to traumatic causes, are in reality diastases, as we shall see in speaking of the diagnosis. According to Carnochan, dislocation is caused by muscular spasm, dependent upon " a perverted condition of the excito-motor apparatus of the medulla spinalis." Such spasm must be transitory, since no traces of it are discoverable in later life, and did it occur, the re- sult would be a diastasis rather than a dislocation. Morel- Lavallee believes the cause to exist in an intra-uterine coxitis, synovitis serosa, inducing a condition similar to the spontaneous dislocation of hip disease. But no traces of this inflammatory state are discoverable after birth, and, furthermore, the so-called spontaneous dislocation is of very doubtful occurrence in the early stages of morbus coxarius. Dupuytren regards the condition as dependent upon a defect of the germ, and thinks that hereditary in- fluences play an important part. lie cites a remarkable in- stance in which numerous members of different branches of a family for several generations were thus afflicted. Breschet thinks that there is an arrest of development in the pelvis. Saint-Germain considers the malformation to reside in the femur ; the head, he says, is small and flat- tened, and the neck is short and set at nearly a right angle with the shaft. He also considers heredity to be an impor- tant factor. Guerin asserts that there is often a condition of paresis and atrophy of the pelvi-trochanteric muscles, notably of the glutsei, which permits the head of the femur to leave the acetabulum. Finally, Tillmann relates a case in which the dislocation was apparently due to an abnormal length of the round ligament, by which the head of the bone was pushed out of its socket. It is more probable that the conditions were reversed, and that the displaced head of the femur was the cause of the lengthening of the lig- amentum teres. A theory that has been adopted by some is that the luxation is produced by external violence act- ing through the abdominal wall of the mother upon the foetus in utero. This is frequently put forth as the cause by the parents of the child, but the number of children born with dislocation of the hip bears a very small pro- portion to that of pregnant women who have received blows of greater or less severity upon the abdomen, and this is probably an insignificant factor in the production of congenital luxation. Opportunities for examining the hip-joint in this affec- tion do not often present themselves, and those which have been seen were chiefly in the adult subject. The changes there found are such as one would expect to And in old unreduced dislocations of non-congenital origin. The acetabulum is usually partly filled up with a soft, imperfectly formed osseous tissue. It is commonly small, of a somewhat oval shape, sometimes triangular, and without any remains of the joint-structures. In some cases of incomplete luxation the cotyloid cavity is of an elongated oval, or of an hour-glass shape. In such cases the ligamentum teres is elongated and flattened, the capsular ligament stretched, but intact, resembling a long, narrow bag, and the interior of the joint is pro- vided with normal synovial membrane. In complete dis- locations the capsule is usually ruptured, allowing the head of the bone to escape, or it may be converted into a fibrous cord, narrowed in the middle, and expanding at either end to embrace the head of the femur and the ace- tabulum. There are usually changes also in the femur. Not infrequently the head is completely absorbed, to- gether with the neck, or, it may be, these parts were congenitally absent. In all cases the articular extremity of the femur is atrophied, if present, and its texture is altered, so that, instead of presenting the hardness of normal bone, it is brittle and can be easily crushed or broken. In certain cases, when the head of the bone has been extruded from the capsule, a new articular depres- sion is formed on the dorsum ilii. The pressure of the head of the bone causes an absorption of the periosteum in one point, and then in time a cup-shaped depression is formed, producing a new, though usually shallow, ace- tabulum. An imperfect capsule may even be formed, whereby the head of the femur is retained in its new HIP-JOINT, CONGENITAL DISLOCATION OF. Syn. : Fr., Luxation Congenitale de la Handle; Ger., Angeborene Verrenkung der Hufte. Dislocations have been observed at birth in almost all the joints ; but, with the exception of the hip, they are extremely rare, and, as a rule, are met with only in monstrosities. A few cases have been recorded of dis- locations at the shoulder, and at the knee, in otherwise well-formed infants, but they may be regarded rather as curiosities than as conditions which, from the frequency of their occurrence or the difficulty of diagnosis, require a detailed description. It is otherwise, however, with con- genital dislocation of the hip-joint. This affection is by no means an uncommon one, and yet it not seldom es- capes recognition ; the awkward gait is referred by the physician to habit or weakness, and the parents are assured that their child will outgrow the trouble. For this reason it has been deemed advisable to devote somewhat more space than is customary to this troublesome deformity. Congenital dislocations of the hip may be complete or incomplete. Of the former, three varieties are usually described, according as the head, of the femur lies above and anterior to the cotyloid cavity, below and anterior, or above and posterior. There is one case on record in which the head of the bone was found just above the an- terior superior spine of the ilium. By far the most com- mon is dislocation upward and backward, the femoral head resting on the dorsum ilii, and it is this form to which the following description will apply unless mention is made to the contrary. Congenital luxation may exist in one or both hips. Most authorities agree in describ- ing the double form as the more common, but this has not been the writer's experience. Of 25 consecutive cases of true congenital dislocation presenting at the New York Orthoptedic Dispensary, 10 were of the left, 5 of the right, and 10 of both hips. Boyer met with 13 double dislocations, and 12 single ; Pravaz with only 4 double, and 15 single. The deformity occurs much more fre- quently in girls than in boys. Dupuytren and Pravaz met with only 7 or 8 males in 45 cases. According to Volk- mann, Behrend saw but 1 male in upward of 100 cases. Of the 25 cases above referred to, 23 were females and but 2 males. The cause of this remarkable disproportion in the sexes has received, as yet, no satisfactory explanation. The etiology of congenital dislocation is obscure. Nu- merous hypotheses have been advanced to account for the condition, but none of them is entirely satisfactory, and none will account for all cases. It is most probable that intra-uterine luxation may occur from a variety of causes, among which, however, traumatism is the least frequent. Brodhurst believes that the condition is produced at the time of birth, and results from injury due to extractive measures in breech presentations. It is certain, however, that all infants born with dislocated femora do not pre- sent by the breech, and, furthermore, as pointed out by Hueter, an amount of violence sufficeut to dislocate the 653 Hip-Joint. Hip-Joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. position. The new joint may, or may not, be provided with synovial membrane; sometimes the surface of the cavity is formed of eburnated bone. The round liga- ment, in most cases, is ruptured, though sometimes it is found unbroken and degenerated into a mere cord; its vessels are, however, obliterated. It is mainly because of this cutting off of its blood-supply that the head of the bone atrophies and becomes changed in texture. The epiphysis is sometimes unabsorbed, but detached from the rest of the bone. The pelvi-trochanteric muscles are relaxed, and in time become contracted and the seat of fatty degeneration. The symptoms of congenital dislocation of the hip vary according as the misplacement exists in one or both hips. In the double deformity the first thing that strikes the eye, when the child is stripped, is the great breadth of the hips. The normal joint-outlines are obliterated, the slight projections formed by the trochanters are absent, and the nates are flattened below, while above, at the level of the iliac crests, the hips are flaring. The thighs are separated from each other above, and the perineum has a square appearance, so that there is a triangular interval, having the perineum for its base and the apex of which is formed by the approximation of the inner borders of the thighs below. The femora being thus obliquely placed, the child seems to be knock-kneed. Owing to the abnor- mal position of the femoral heads, posterior to the ace- tabula, the centre of gravity is shifted anteriorly, and the pelvis is tilted, so that in order to maintain the erect posi- tion the lumbar spine is strongly lordosed. The lower ex- test is often of value in confirming the diagnosis. A line drawn from the anterior superior spine of the ilium to the tuberosity of the ischium (Nelaton's or Roser's line) is found to pass directly over the great trochanter of the femur when this is in its normal position, but in disloca- tion of the hip the trochanter may be from one to two and a half inches above it. All the motions of the hip are free (adduction and inward rotation abnormally so) with the exception of abduction and outward rotation, in which directions motion is somewhat restricted, unless the head and neck be absorbed or greatly atrophied. Pain is, as a rule, absent, though fatigue is a very promi- nent symptom, and occurs after even moderate walking. In unilateral dislocation inspection shows one hip to present the appearance described above, while the other is normal in outline. The lordosis of the spine, while present, is less marked than in the case of bilateral lux- ation ; but now the pelvis is tilted laterally as well as antero-posteriorly, and is slightly rotated, and the result is a lateral curve of the spine in the lumbar region, "with the convexity toward the affected side. There is a very marked limp, which usually varies in degree according to the age of the patient. In a young child the foot is placed flat on the ground, and the body sinks far down on this side with every step. But when the patient is old enough to care for appearances, she seeks to hide the de- formity as far as possible by extending the foot so that the toes only rest on the ground. She succeeds in mak- ing her lameness less apparent, but the continued exten- sion of the foot results in a contracture of the muscles of the calf and the production of a true talipes equinus. The limp of unilateral congenital dislocation is very charac- teristic ; it seems never to stop. When the condition is one merely of unequal length of the two limbs, the body sinks to one side until the foot touches the ground ; then it ceases, and the patient stands firmly on that leg until the next step is taken. But in dislocation, after the foot touches the ground motion begins at the ilio-femoral junction, and the body continues to sink until the sup- port is transferred to the sound side. When the patient is placed in the recumbent position, the secondary de- formity of the spine disappears. It may not entirely do so in older patients, as in them the long-continued mal-position often induces a permanent lateral curvature. The two extremities are of unequal length, measured from the iliac spines to the malleoli, but traction on the luxated side will always, in young subjects, materially reduce the difference, though it seldom happens that the dislocated limb can be brought down so as to equal in length its fellow. The great trochanter lies above Nela- ton's line, except in the rare instances of subcotyloid dis- location, when it is below this point. In every case of congenital dislocation there is the history of a limp or awkward gait from the time that the child began to walk, and, unless the parents are unusually stupid and unob- serving, the absence of this history is a very strong point against the congenital nature of the affection. There are several conditions simulating congenital dis- location at the hip-joint, only a few of which, however, present any difficulty in diagnosis after a careful study of the symptoms. In discriminating between congenital and traumatic dislocations, it should be borne in mind that the latter condition is of extreme rarity ; a few cases have been reported by competent observers, but a trau- matism sufficient to cause dislocation of the hip in a young child is far more likely to result in a separation of the epiphyseal end, and it is probable that the majority of the reported cases have been of this condition. When a diastasis exists, there is almosts always a history of an injury followed by pain and a limp. In congenital dis- location the parents will state that the child walked lame from the first. If either of the parents or near relations have congenital luxation, this will add weight to the sup- position that the same condition exists in the child. In diastasis in the early stage, on pulling down the limb until it nearly equals its fellow in length, a slight crepitus may be detected. In congenital dislocation, faint crepitation may be obtained by rotating the femur, but it is softer and smoother than that felt in epiphyseal separation. Figs. 1684 and 1685.-Representing the Normal Outline of the Hips, and the Deformity Presented in Double Congenital Dislocation. (From Hueter.) tremities seem to be much shorter than normal, and out of all proportion to the length of the body or of the upper ex - tremities. This picture of wide hips, short legs, lordosed spine and protruded belly, and square, flat perineum is very characteristic of double congenital dislocation of the hips, and when once seen may always be recognized. Figs. 1684 and 1685 represent the difference of outline between normal and dislocated hips. In some cases, when the head and neck are undeveloped or have been absorbed, the thighs, instead of being wide apart, are more closely in contact than normal, and may even with difficulty be separated. The child's walk is unsteady, the gait being best described as waddling, the body being swayed from side to side, as with each step the child endeavors to balance the side of the pelvis upon the slid- ing head of the femur. This awkwardness is less appar- ent in running or other rapid movements, as then the body rests but an instant upon each femur, and there is less necessity for obtaining an equilibrium. When the child lies down the most marked of these symptoms dis- appear ; the spine straightens, and the breadth of the hips is diminished. If traction be made upon the limb, it can usually be lengthened an inch or more as measured from the anterior superior spine of the ilium to the inner mal- leolus. In cases in which the head has escaped from the capsule, and has formed a new socket for itself on the dorsum ilii, this lengthening is not so apparent. The head of the femur, when not absorbed, may sometimes be felt by making deep pressure in the gluteal region behind the trochanter with the fingers of one hand, while rotation of the femur is made with the other hand. Nelaton's 654 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hip-Joint. Hip-Joint. Hip disease may be mistaken for congenital dislocation ; but in the former, pain and restricted motion are promi- nent symptoms which are absent in dislocation. There is sometimes a curve in the upper part of the femur in rachitis which may be mistaken for the deformity of congenital luxation. The character of the walk, the inability to lengthen the limb by traction, and the evidences of rick- ets in other parts of the body, will suffice to determine the nature of this condition. Congenital shortening of the femur, paralysis of the gluteal muscles, or relaxation of the joint-ligaments from any cause, may lead to an in- correct diagnosis, but a moderate amount of attention to the symptoms presented will serve to prevent error. This affection cannot be fatal in itself, and there is no reason why its subjects should not enjoy as long a lease of life as other children whose hips are normal. But the prognosis, as regards a cure of the deformity, is very unfavorable. If the treatment be begun early enough, and unremittingly persevered in for a long time-months, and may be years-a cure may possibly be obtained. But such a result presupposes not only the employment of the proper means on the part of the surgeon, and a consider- able degree of intelligence on the part of the parents, but also an amount of patience and perseverance on the part of both surgeon and parents which is seldom met with. As the child grows older attachments form between the head of the femur and the ilium, so as to steady the limbs during progression, and the awkward gait becomes there- by much less noticeable. The treatment, as stated above, in order to be effectual, must be unremittent and long continued. It consists in gradually drawing down the head of the bone by constant traction until it reaches the acetabulum, where it is to be steadily maintained for months, until it will remain in the socket without any external retentive force. When the dislocation is bilateral, this can only be accomplished by keeping the child on its back in an immovable apparatus while traction is exerted upon the thighs. This is the plan proposed by Pravaz, of Lyons, who claimed to have obtained a perfect cure in a number of cases of this de- formity. While traction is being made, and until the head of the bone is brought down opposite the cotyloid cavity, the thighs should be kept flexed at an angle of about one hundred and fifty degrees with the trunk. After the femoral heads have been maintained for three or four months or longer in apposition to the acetabula, and have become so fixed in that position that they will remain there when the traction force is relaxed, it is time to begin passive motion. This should be attempted very gradually and always combined with traction, as any un- due violence may in one moment undo the labor of months. The child may now be allowed to get up, wear- ing a modified Davis' apparatus, such as is used in the treatment of coxitis by the traction method, and move about in a wheel-crutch. As a further precaution, Du- puytren's trochanteric support should be used. This consists in a wide, closely fitting, well-padded leather belt encircling the pelvis below the iliac crests. A piece of strong elastic webbing is to be set into a notch made on either side of the belt to receive the trochanters. After from six months to a year the extension apparatus may be removed at night, the trochanteric belt being still re- tained and prevented from slipping up by padded straps fastened before and behind and passing beneath the peri- neum. The subcutaneous division of tendons and con- tracted muscles, as usually recommended, is in most cases unnecessary, for steady and continuous traction is generally sufficient to elongate the muscles to any re- quired extent. Buckminster Brown, of Boston, has re- ported, in the Boston Medical and Surgical Journal, a case of bilateral dislocation successfully treated by trac- tion. which well illustrates the value of this method when intelligently and perseveringly carried out. In older children and adolescents little hope can be en- tertained of restoring the femora to their normal position by means of traction, and it will be better, if nature has not already made a new joint on the dorsum of the ilium, to assist her in so doing. The periosteum, at the point on the ilium where the caput femoris rests, is to be scarified by a subcutaneous operation, so as to excite an adhesive inflammation about the head of the bone. Passive move- ments of the thigh must be made subsequently, when the new adhesions have become sufficiently strong to prevent displacement. When the dislocation is unilateral the lameness may be overcome to a great extent by a high- soled shoe worn on the affected side. Dupuytren recom- mends affusions of cold water, and claims that they exert a local as well as general tonic effect. In cases in which it is not deemed advisable to resort to any operative measures, great relief may be obtained by the steady use of the trochanteric support. Not only do the patients ex- press themselves as feeling much better for the firm sup- port which the belt gives them, but their walk is much improved and the deformity rendered less noticeable. Within a few years some attempts at a cure of this con- dition by operative measures have been made. E. Rose performed resection of the articular extremity of the fe- mur, in a case of congenital dislocation, in 1874, and since then Reyher, Heusner, Margary, and others have written in support of active interference in these cases. Margary opens the joint by means of a straight incision, passing from the great trochanter to the posterior superior spine of the ilium, the thigh being adducted and flexed to an angle of forty-five degrees. If the capsular ligament is not freely opened by the primary incision, the aper- ture is enlarged upward by a probe-pointed bistoury, and downward to the upper margin of the neck by a straight resection knife. The round ligament is then divided, and, the soft parts being protected by blunt hooks, the head of the bone is severed from the neck by an Adams saw. A drainage-tube being inserted, the wound is then closed by sutures, and the dressing applied with antiseptic pre- cautions. Immediate extension is now made upon the limb by the weight and pulley, beginning usually with about seven pounds. The results in two cases, reported by the operator in the Archivio di Ortopedia, Fasc. 5 and 6, 1884, were excellent. The patients were able to walk well with the aid of a cane, and in one case, twenty-two months after operation, the boy had discarded the stick and walked with a scarcely perceptible limp. The defor- mity was also markedly lessened ; the trochanters were no longer prominent, and the lordosis had disappeared. There was also considerable joint-motion possible. Another operation which Margary performed, in 1882, upon a boy aged fifteen, would seem to be preferable in many cases to exse.ction, although in the reported instance death occurred. It consisted simply in opening the joint by means of a T-shaped incision, and chiselling out the acetabulum to a depth sufficient to receive a little over half of the head of the femur. The luxation was then reduced, and the capsular ligament was strengthened by a strip of periosteum removed from the posterior superior margin of the acetabulum toward the iliac fossa. The boy died on the eleventh day from pyaemia, caused ap- parently by septic catgut, since suppuration was found to have occurred at each point of suture. Heusner op- erated in a similar way upon a young woman aged twenty, resecting, however, the articular end of the fe- mur as well as deepening the acetabulum. The following are some of the treatises and shorter ar- ticles which may be consulted in the study of congenital dislocations: Bouvier, H.: Lejons Cliniques sur les Maladies Chroniques de L'Ap- pareil Locomoteur. Brodhurst, B. : Lectures on Orthopaedic Surgery. Carnochan, J.: Etiology, Pathology, and Treatment of Congenital Dis- locations of the Head of the Femur. Dubreuil, A.: Elements d'Orthopedie. Davis, H. G. : Conservative Surgery. Guerin, J.: Recherches sur les Luxations Congenitales. Hamilton, Frank H.: A Practical Treatise on Fractures and Dislocations. Hueter, C.: Klinik der Gelenkkrankheiten. Morel-La vallde: De la Coxalgie chez le Foetus et de son Role dans la Luxation Congenitale du Femur, Bulletin de l'Academie de Medicine de Paris, April 25, 1854. Pravaz : Traite Theorique et Pratique des Luxations Cong6nitales du Femur. Saint-Germain, L. A.: Chirurgie Orthopedique. Sayre, Lewis A.: Orthopaedic Surgery and Diseases of the Joints. Margary, F.: Archivio di Ortopedia, Fasc. 5 and 6, 1884. Brown, Buckminster: Boston Medical and Surgical Journal, June 4, 1885. Thomas L. Sledman. 655 Hirsuties. Hirsuties. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. HIRSUTIES, or hypertrichosis, is a condition of abnor- mal hair growth, whether occurring in localities where no marked appearance of hair is usual or consisting simply of an extreme development of hair in localities where this is usually found. Recent writers have classified hirsuties under the fol- lowing heads (Michelson): I. Hirsuties dependent upon heredity or upon some in- fluence exerted during intra-uterine life (Hypertrichosis indoles hereditaria). (a) Hirsuties universalis: 1, The so-called hairy men, homines Sylvestres, homines pilosi s. hirsuti; 2, general extreme hairiness of the human body. (d) Hirsuties localis : 1, Abnormal growths of hair oc- curring upon localities where the skin is apparently un- altered ; 2, abnormal growths of hair occurring upon pigmented and thickened (hypertrophic) patches of skin. II. Abnormal growths of hair occurring in extra-uter- ine life. Hirsuties acquisita s. transitoria : 1, Occurring through neurotic influences (hirsuties neurotica); 2, occurring as the result of irritation or stimulation of the skin (hirsuties irritativa). It may be here remarked that there are certain localities which never present any growth of hair, even of lanugo, and that these are never af- fected by any of the forms of hirsu- ties above mentioned. These locali- ties are the palms of the hands and soles of the feet, the terminal pha- langes of the fingers and toes, the inner surface of the prepuce, the glans penis, tlie vermilion bor- der of the lips, and the upper eyelids. That variety of hirsu- ties which is at the same time one of the rarest and one of the most ex- traordinary is the type represented by the "Rus- sian dog - man " (Fig. 1686), who has been on exhibition in various parts of this country for some time past, and whose case has been de- scribed by Ecker. In all cases of this class there is a general hairiness of the whole body, with the exception of the parts above mentioned, al- though this hairiness dif- fers in degree in differ- ent localities, being usually most striking upon the face, and giving the individual a certain resemblance to a wild animal. It has been shown by Eschricht and Voigt that the thick coating of hair with which the foetus is covered during the fifth and sixth months of intra-uterine life is arranged in lines and whorls over the various parts of the body, this arrangement being constant, with slight variations in individuals. This arrangement is also ob- served in the form of hirsuties at present under consid- eration. Moreover, the hair is fine and silky, resembling lanugo rather than fully developed hairs. For these rea- sons Ecker has supposed that hirsuties universalis is a condition of arrest of development, with persistence and further production of the embryonal hairy covering. The hereditary character of hirsuties universalis has been proved by observation, notably in the case of the hairy family kept by King Thebaw at Mandalay. The grandfather of this family was seen and pictured by Crawford about 1826 ; the mother and child by Youle in 1855, and by Houghton in 1868. The surviving mem- bers of this family, three in number, are now (June, 1886) in London, and it is said that they will soon be brought to this country for exhibition. A curious fact in connection with this family of hairy men, and others, is that they show a certain defect in the teeth. In one case, three of the four canines and twenty of the back teeth were wanting, even the alveolar process being absent. The hairy descendants of this in- dividual, so far as known, show a similar deformity. The ' ' Russian dog-man " shows the same peculiar de- fect in a somewhat different manner, while his son is sim- ilarly lacking in some of the teeth. It is a curious fact that in congenital alopecia a defect in the teeth is also ob- served. In some families excessive hairiness in certain locali- ties, as the face, chest, back, dorsal surface of the ex- tremities, etc., is hereditary, and constitutes a less fully developed grade of hirsuties congenita. In these cases, also, the lines and wdiorls pointed out by Eschricht and Voigt are followed out, and the recent investigations of Michelson show that defective teeth are likewise frequently present. A typical variety of hirsuties lo- calis is that presented in " bearded women." Bartels divides these cases into three kinds : 1. An exaggeration of the normal slight downy growth on the upper lip, or, less frequently, of that on the region over the masse- ter muscle and under the chin. This is seen in young women. 2. An ex- cess of growth in those parts where hair is commonly found in the male. Women who present this peculiar- ity have usually passed the climacteric, having shown no indications of such grow'th in early years. Many of these show other signs of an inclination toward the virile type in more robust build, deeper voice, etc. But there are many ex- ceptions to this rule. The writer, in fact, believes it to be by no means constant. In these cases the individual hairs are strong and bristly, and not very closely set to- gether. 3. The true bearded woman, in whom a full hirsute growth up- on the face is observed, of which Duhring's case is perhaps the most re- markable on record (Fig. 1687). This case, which was also seen by the waiter, was one of a married woman, twenty- three years of age, of delicate frame and feminine charac- teristics, the mother of two children. The history of the case showed the growth on the face to have commenced about the age of ten, and to have progressed steadily, without being influenced one way or the other by the de- velopment of puberty, until the woman was eighteen years of age, and then to have remained stationary. The hair of the scalp at the time of examination was short and quite thin, the eyebrows and lashes were nor- mal, while the upper lip, cheeks, chin, and submaxillary region were the seat of hair in the form of full mustache and beard which involved exactly the same regions as in the male. The hair was flue and black in color, and viewed in its entirety the beard would be termed full, thick, and handsome, and wTas such as is not infrequently met with in men who have never shaved. Extending from shoulder to shoulder, over the back, there existed sufficient hair to constitute a diffused hairy patch about the width of a hand. The whole of the back on either side, from the scapula downward, Fig. 1686.-The Russian Dog-Man. (After Michelson.) 656 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hirsuties. Hirsuties. was covered sparsely with hair, starting from either side of the spinal column and taking a course downward and forward around the sides of the thorax, covering the lat- eral portions of the trunk. The thighs and legs wrere slightly hairy, and the arms from the shoulders dowm were decidedly so. The axilla) and pubic region showed no unusual amount of hairiness. Belonging also to this form of hirsuties are those cases of precocious development of hair in localities where this would naturally appear at a later stage of development- e.g., Beigel's case of a six-year-old girl w ho showed the hairy development about the genitalia usually observed in a woman twenty years of age, and also the cases of boys with mustache, beard, etc. Circumscribed hirsuties over a limited region of un- altered skin, where the hair is not usually developed to a marked degree, is apt to be met with over the sacral re- gion and the .loins. In the latter locality it not infre- quently occurs with spina bifida. A somewhat strange peculiarity among those presented by hereditary hirsuties is shown in the form known as hirsuties senilis, where an increased growth of hair occurs rotica. Erb and Schiefferdecker describe cases in which excessive growth of hair has followed upon spinal paraly- sis. The latter also observed soldiers suffering from nu- merous trophic disturbances following gunshot wounds who almost invariably showed accompanying excessive growth of hair. Cases in which excessive growth of hair has followed upon local irritation, as that described by Gueterbock, where hair grew on a porter's shoulder at the spot where the burdens rested, or as Rayer's case, where the repeated application of blisters, continued for months, was fol- lowed by local hirsuties, are not very numerous, and have never been critically examined into. The treatment of hirsuties is only a matter of practical interest when the hairy growth occupies such a position as to make it a conspicuous deformity. Hairy moles may sometimes be removed by the knife when favorably sit- uated and not too large. Circumscribed or diffuse growths of hair, occurring chiefly about the face and in females, are best removed by electrolysis. In former times epila- tion, shaving, and the application of caustic depilatories formed the only modes of treatment, and these were highly unsatisfactory, as only in part removing the disfigure- ment, and at the same time requiring frequent repetition. In fact, epilation by means of forceps is said, and prob- ably with truth, to stimu- late the growth of new hair in the neighborhood. To Michel and to Harda way, of St. Louis, we are indebted for a safe, easy, and effectual method of re- moving superfluous hairs by electrolysis. Though electrolysis had been sug- gested at a somewhat ear- lier date by Piffard, as a means of destroying the hairs in hairy naevi, the method was first employed systematically by Michel in trichiasis, and was adapted to general dermatological use by Hardaway, who read a paper upon the sub- ject before the American Dermatological Association in 1878. The operation, as described by Hardaway, is performed as follows : A No. 13 cambric-needle is attached to any con- venient handle, which latter is connected with the nega- tive wire of a galvanic battery ; a moistened sponge-elec- trode is connected with the positive pole. Under a strong lens, held in the left hand (or without this if the operator has very good eyesight), the patient being seated in a re- clining chair, facing a good light, the needle is entered, as near as possible, into the hair-follicle ; after this has been accomplished, and not till then, the patient is told to bring the sponge (positive) electrode in contact with the palm of the hand. The needle is not withdrawn until a slight frothing is observed around the stem, showing that the electrolytic action has been fully developed ; but to avoid shock the sponge-electrode is first released by the patient, the needle being removed subsequently, this order being exactly the reverse of the initial steps. The hair should always be left in situ, and not ex- tracted before the needle* is introduced, as it is a guide for the introduction of the latter, the instrument being passed in alongside of it. Besides this, it is an immediate Fig. 1688.-Extensive Growth of Hair on the Back and Arm. (Af- ter Paget and Smith.) Fig. 1687 -The Bearded Woman. (After Duhring.) in elderly people in the beard, eyebrows, upon the cheeks and nose, and particularly within the nostrils and ears. A not very uncommon variety of inherited hirsuties is that which is usually known as hairy mole, or hairy naevus, where the excessive growth of hair occurs upon a pigmented, more or less rugous, hypertrophic patch of skin, and not infrequently in connection with the growths of molluscum fibrosum (Fig. 1688). The cause or causes which produce the varieties of inherited hirsuties above described are practically un- known. An arrest of development in the first form and a " neurotic influence " in the latter form are all that can be suggested. The fact that hairy naevi are frequently, in fact almost always, so situated as to be referred to the distribution of some nerve gives grounds for supposing a nervous influence as'the cause of the abnormality. The second class of hirsuties cases, those included under the designation hirsuties acquisita or transitoria, includes those in which the abnormal hairiness is due to some pathological influence acting during extra-uterine life. The first variety of this class is known as hirsuties neu- 657 HUtoETeclinique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. guarantee of the success of the operation ; for if the hair comes away with the very gentlest traction of the depi- lating forceps, a point always to be tested, at once we know that the papilla has been destroyed; but if force is re- quired for its extraction, it is a sign that the follicle has not been properly entered. In this case the needle is re- introduced, or, better, it is not removed at all, repeated attempts being made from time to time to withdraw the hair until finally it is loosened. Eight cells of a freshly charged galvanic battery will usually suffice. A greater or less number, however, may be required in one case or another. The operation is a painful one, and but few hairs can usually be removed at a sitting. The needle should be as fine as can be procured, even finer than a No. 13 cambric if such is procurable. An expert mechanician can grind an ordinary needle down to the finest diameter. Some operators prefer an irido- platinum needle ; others a watchmaker's very fine steel wire. It must be remembered that the larger the needle the longer it must be retained in situ, and the stronger the battery-power the more rapidly and thoroughly can the hairs be removed. But if either of these conditions overstep the proper limits, abscess and scars are apt to follow, and much unnecessary pain is caused. In any case, thirty or forty per cent, of the hairs remain (or appear to remain, for the growth of neigh- boring fine hairs seems to be stimu- lated by the use of the electricity), and the operation must almost al- ways be repeated once, or several times. Some ex- pert operators claim a re- turn of only five to ten per cent, of hairs operated upon, but for the majority of operators the percentage above stated will be found safer to reckon upon. When the operation is carefully performed not much scarring results, and most ladies who suffer from the growth of a mustache or beard would prefer the scars. vation, the larva-holder of Schulzer (Fig. 1689) will be found very convenient. The head of the animal is placed under the edge, a, the tail is spread out on the bevelled plate, b, and covered with a cover-glass. The cell holds sufficient water to cover the animal. To keep the animal quiet, wrap it loosely in a piece of cloth, leaving the gills free, or add a few drops of ether to the water. If the observations are to be continued for any length of time, provision must be made for the renewal of the water. This can be accomplished by any of the usual methods of irrigation. For observations on the frog, it is necessary to para- lyze the animal with curara. A slight nick is made in the skin over the posterior part of the head, and two to three drops of a one-twentieth per cent, solution of cu- rara * is injected into the dorsal lymph-sac by means of a long, slender pipette introduced through the above nick. The exact amount of curare to be used will depend upon its quality and the size of the animal, and can only be de- termined by experiment. In the course of a few hours the animal will become completely paralyzed, while the vegetative functions continue, the necessary amount of oxygen being supplied by cutaneous respiration. Fig. 1690.-Thoma's Frog-plates. We utilize for these observations : 1. The Web.-The advantage of this part of the animal is that we do not inflict any injury, consequently we are not likely to meet with any disturbances of the vital pro- cesses ; but, on account of it not being very transparent, it is inferior to other parts. A frog poor in pigment should be selected, and after being wrapped in a moist cloth it is laid on an oblong sheet of cork, in one end of which a hole, at least fifteen millimetres in diameter, is made, at the edges of which four or five pins are stuck, to which bits of soft string attached to the toes are tied, spreading the web out over the hole. The cork is now placed on the stage of the microscope, and the web moist- ened at intervals to prevent its drying. 2. The Tongue.-For observations on this and other organs of this animal, Professor Thoma has invented a series of frog-plates, which are shown in Fig. 1690. The centre one of the figures is for the tongue; that on the left for the mesentery ; that on the right for the lung and bladder. These plates consist of a bed-plate, a, of brass, covered by a thin sheet of hard rubber. At B is an opening, which varies in the different plates, cov- ered with a thick glass plate on which the organ to be examined is placed. At some distance from this plate runs the brass rim, c, c, c, seven millimetres high, which by a proper inclination conveys the irrigating fluid, as it flows off the organ, to the tubes, d, d, to which are attached rubber tubes leading to a vessel for receiving the waste-fluid. The supports, t, are for holding the ir- rigating cannula, g. They are pivoted to the plate, and move on a perpendicular axis; to the upper end is at- tached a short split tube, which is tightened by a small screw; this is connected with the support by a hinged A. Ecker: Ueber Abnorme Behaarung der Menschen, inbes. Ueber die Sog. Haarmenschen. Braunschweig, 1878. Eschricht : Mtiller's Arch. f. Anat., Phys., etc., Jahrg, 1837, p. 37 ft'. Voigt: Abhandlung fiber die Richtung der Haare am Menschlichen Kbrper, Denkschrift d. Wien. Acad. d. Wissens. (Math. Naturw. KI.), Bd. 13, 1857. H. Beigel : The Human Hair. London. 1869. Idem.: Ueber Abnorme Haarentwickelung beim Menschen, Virchow's Archiv, Bd. 44, s. 418, 1868. Max Bartels : Zeitschr. f. Ethnolog., Bd. 8, 1876. Duhring : Case of a Bearded Woman Archives of Dermatology, vol. iii., p. 193, 1876-77. Erb: Ziemssen's Handbuch, Bd. xi., 2. Schiefferdecker : Ziemssen's Handbuch, Bd. xi., p. 163. Idem.: Berlin Klin. Wochens., s. 160, 1871. Michelson : Zum Capital dir Hypertrichosis, Virchow Archiv, Bd. 100, p. 66. Slocum : Case of Hirsuties Gestationis, New York Medical Record, July 10, 1875. A. McLane Hamilton: On the Significance of Facial Hairy Growths among Insane Women. New York Medical Record, March 12, 1881. Hardaway : The Permanent Removal of Hairs by Electricity, Philadel- phia Medical Times, vol. x., p. 247, 1879-80. Arthur Van Harlingen. Bibliography. HISTOLOGICAL TECHNIQUE. Methods of Study- ing Living and Fresh Tissue.-For observations on liv- ing tissue, we now make use of the cold-blooded animals Fig. 1689.-Schulzer's Larva-holder. almost exclusively ; and, on account of the convenience, use the tails of amphibian larvae, and small fishes and frogs. For holding these small animals, while under obser- * S. H. Gage recommends the following solution : Curara, two-tenths of a gram ; ninety-five-per-cent, alcohol, 20 c.c.: water, 20 c.c. Grind up the curara in a mortar with the water and alcohol. Do not filter. 658 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Silwl?Technique. joint, allowing it to be moved on a horizontal axis. In this tube is placed the glass irrigation cannula, g. It will be noticed that in the tongue and mesentery plates two supports are provided. This is to allow of the use of two cannulse, one for irrigating the upper, and the other the under, surface of the organ. At e is a perpendicular rod for supporting the ring holding the cover-glass. At each side of the plates (in the tongue plate it is at the end) is a notched support, k, for holding the rubber tube attached to the cannulae introduced into the different organs for gating cannula should be by drops, at short intervals, and is regulated by the pressure in the bottle, the size of the opening in the point of the cannula, and, if necessary, by a spring-clip placed on the rubber supply-tube. Fresh tissues are to be examined in the fluid that bathes them during life, or in a fluid that will change them but little if at all. Such fluids are known as indif- ferent fluids, and resemble in composition the natural fluids of the body. They are as follows : Aqueous Humor of the Eye.-Obtained by puncturing the cornea of a recently killed animal, and allowing the aqueous humor to es- cape. Blood-serum.-The blood of a recent- ly killed animal is poured into a tall, glass cylinder and allowed to coagu- late. After coagulation has taken place, separate the upper margin of the clot from the sides of the vessel, to permit it to sink; allow the vessel to stand for twenty-four hours; then draw off the clear serum with a siphon, taking care not to disturb the clot. Iodized Serum.-Prepared by adding to every 1,000 cubic centimetres of blood-serum, obtained as above, 10 cubic centimetres of tincture of iodine. This fluid alters the tissues slightly and stains them yel- low. Instead of blood-serum, amniotic or pericardial fluid may be used, but it must be absolutely fresh. Artificial Serum.-This is only to be used when the natural serous fluids cannot be obtained. It is prepared by dissolving 2 grams of sodium chloride and 28 grams of egg-albumen in 250 cubic centimetres of distilled water, and adding 2.3 cubic centimetres of tincture of iodine ; then filter. Salt Solution (three-fourths per cent.).-Dissolve 7.5 grams of perfectly dry sodium chloride in 1,000 cubic centimetres of distilled water. This solution alters fresh tis- sues but slightly. Fresh, thin membranes can be examined in one of the above solutions without any previous preparation. Bits Fig. 1691.-Inflation Cannula?. inflation, etc. Between the rim, c, c, c, and the plate, B, bits of cork are wedged for pinning out the organs. For examining the tongue, the animal is placed on the plate belly down, and the nose is brought close to the edge of the glass plate; the tongue is drawn out over the plate, and fastened to the bits of cork by pins which are cut off short. 3. The Mesentery.-Male frogs are to be used, so that the examiner may not be embarrassed with the ovaries. An incision is made through the skin, on the side, from the pelvis nearly to the axilla. After all haemorrhage has ceased, the abdominal cavity is opened by an incision of ten to twenty millimetres in length ; a coil of intestine is drawn out carefully over the glass plate so that it will fall upon the bits of cork, to which it is pinned, leaving the mesentery spread out in a thin layer on the glass plate. 4. The Bladder.-A glass cannula (B, Fig. 1691) is filled with a three-fourths per cent, salt solution, and the rubber tube closed with a bit of glass rod. The cannula is now inserted into the cloaca, and directed forward into the bladder ; it is held in place by a thread passed through the skin over the sacrum and tied around the cannula. An incision, similar to the one for the mesentery, is made in the side of the animal. The glass rod is removed from the rubber tube, the latter raised slightly so as to cause the fluid to flow into the bladder, distending it. The ani- mal is now placed on the frog-plate, and by gentle ma- nipulation with the handle of a scalpel the distended or- gan is brought upon the glass plate and further distended if necessary ; the glass rod is now replaced in the rubber tube, and the latter fixed in the support (k, Fig. 1690). The animal is covered with a bit of moistened filter paper, and the frog-plate is placed on the microscope. 5. The Lung.-The cannula (A, Fig. 1691) is introduced through the epiglottis, and held in place by a thread passed through the nose and tied around the constriction of the cannula. An incision, carried well into the axilla, is made through the skin on the side of the anknal, and when all haemorrhage has ceased the thoracic cavity is opened. The operator should now remove the bit of glass rod from the end of the rubber tube attached to the cannula, and gently blow into the same, when the distended lung will be forced through the incision. The animal is placed on the frog-plate, and the distended lung brought upon the plate B. In Fig. 1692 is shown the arrangement of the frog-plate on the microscope, and the irrigating bottle. The stage of the microscope is to be inclined so as to cause the irrigating fluid to flow away. The bottle attached to the ring-stand, filled with a three-fourths per cent, salt solution, is closed tightly with a rubber cork, through which pass two glass tubes. To one is attached a rubber tube which is connected with the glass cannula (g, Fig. 1690), and conveys the irrigating fluid. The other is for regulating the pressure, which can be varied by raising or lowering the tube. The flow from the end of the irri- Fig. 1692.-Frog-plate and Irrigating Apparatus. of organs, fibres, etc., are to be teased on a slide, in a drop of one of the indifferent solutions, or sections can be made by the freezing microtome. In observations on fresh tissue it is necessary to pre- vent evaporation, and, in most cases, pressure. The first can be prevented by painting a ring around the cover with oil or vaselin ; the latter by placing a hair between the cover and slide ; or we may use the moist chamber. 659 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. A simple form of moist chamber is shown in Fig. 1693. A glass ring (b), 5 mm. high, is cemented to a glass slide (a). A few drops of water are placed at the inner edge of the ring with a brush. The specimen is placed in the centre of a round cover-glass (c), inverted, and placed on the ring. In Fig. 1694 is shown another form of moist chamber. In the centre of a thick glass slide is cut a cavity, around gas-generator, and connects the gas to the chamber ; the other, a1, serves for its exit. Application of Heat.-A simple warm stage for roughly heating specimens can be made of an oblong copper plate, two inches long by one inch wide, from one side of which a rod of the same material projects. This plate is to be cemented to an ordinary glass slide. A large-sized cover- glass, on which the specimen is placed, is laid over the hole in the plate, and covered with a smaller cover-glass. The rod is heated by an alcohol-lamp, and the heat is conducted to the plate by the rod, and from it transmitted to the specimen. The position of the lamp is so adjusted that the temperature of the copper plate will be the circumference of which is a groove (rr). The latter is filled with water ; the specimen is placed on the cover- glass (o'), or in the middle of the cavity. Methods of Applying Reagents.-Application of Fluids, Irrigation.-A drop of the reagent is placed on the slide in contact with the edge of the cover-glass, and on the opposite side of the cover a bit of filter paper. The latter sucks out the fluid, which is replaced by the re- agent flowing in on the other side. This process of irri- Fig. 1693.-Simple Moist Chamber. Fig. 1696.-Simple Warm Stage. about that of the body. This is roughly determined by the melting of a bit of a mixture of cacao-butter and wax Fig. 1694.-Moist Chamber. gation can be continued for any length of time, if the re- agent be renewed as it becomes exhausted, and the filter paper as it becomes saturated. Application of Vapors and Gases.-A simple way of ap- plying a volatile reagent to a specimen is to put a drop of such reagent in a cell on a slide, and invert a cover- glass, on which the specimen has been placed, over it. For gases it is necessary to use a gas-chamber. Such a piece of apparatus is shown in Fig. 1695. It consists of a thick glass slide, in the upper surface of which is ground out a circular cavity. Two glass (the melting point of which is about 30° C.) placed close to the specimen. The arrangement of this apparatus on the microscope is shown in Fig. 1696. A more accurate warm stage is shown in Fig. 1697. It consists of an ebonite plate, o, o, with the cen- tral opening C. In the upper face of the plate is imbedded the bulb of a thermom- eter, which is covered by a metal shell, k, k, k, to which is fastened the project- ing rod k', and on this the heating rod 9, q, is slipped. The dotted line, t, t, t, represents the posi- tion of the thermometer-tube. The specimen is placed on a cover-glass, covered with a smaller one, painted around with a ring of oil to prevent evapora- tion, and placed on the copper ring. The flame of the lamp is applied to the extremity of q, and gradu- ally brought closer to the slide until the desired tempera- ture is reached. Stricker has also constructed a slide in which hot water or steam can be used for heating, or which by the use of Fig. 1697.-Stricker's Warm Stage. Fig. 1695.-Stricker's Gas-chamber. tubes are cemented into the two half-canals. The tube a, is connected by an india-rubber tube, a2, with the 660 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. ice-water may also be converted into a refrigerating slide. It consists of a hollow, rectangular box of metal, with a little tube in the top of d is pierced with a small opening, to allow a constant passage of gas. In Fig. 1700 is shown a combined warm stage and gas-chamber. It consists of a rectangular piece of ebonite, E, E, fixed to a brass plate that rests on the stage of the microscope. On the upper surface of the ebonite is a brass plate, P, with an opening in the centre, C, leading into a brass tube, closed below by a piece of glass. For heating, the copper wire is placed on the tube a, the temperature of the plate being indicated by the thermometer t. The gas is conducted into the chamber by the tube a', while a serves as an exit. Application of Electricity.-For the application of the electric current to specimens, the slide shown in Fig. 1701 will answer as well as a more complicated piece of apparatus. Take a glass slide 27 x 127 nun., and cover the sur- face with gold size ; press the moist surface firmly down Fig. 1698.-Stricker's Hot-water Slide. central opening (C, Fig. 1698) which permits the passage of light. At each end of the slide a small tube, a, is in- serted, by means of which it is connected with a vessel of water. For supplying a current of hot water, Schafer has de- vised the apparatus shown in Fig. 1699. The vessel / is filled with water, which has been boiled to expel the air, and is heated at g by a small gas-flame. The warmed Fig. 1701.-Gold-leaf Electrodes. on gold-leaf or tin-foil; allow to dry ; scrape away the metal so as to leave the two triangles e, d, leaving an in- terval, a, between their apices, of about five millimetres for the object. The specimen is placed at a, and covered with a cover-glass. For transmitting the current the ends of the slide are clamped by the clips c, d, to which the wires leading from the battery are attached. In Fig. 1702 is represented a combined moist chamber and electric slide. The slide, s, is covered with tin-foil, /, on its upper and lower surface, the foil on the upper surface being carried to the upper edge of the glass cell, c, which is cemented to the slide. The slide is placed on the copper supports, k,k, that are attached to the stage, p, if it be a glass one ; if not, they must be insulated by strips of hard rubber. Two small strips of foil are cement- ed to the cover-glass, leaving a space of five millimetres water rises through the tube c to the box a, and descends through the tube c' to the vessel f, thus keeping up a constant circulation. The bulbed tube d is filled with mercury and serves to regu- late the flow of gas, so that the temperature may be kept at any desired point. This is effected by turning the screw e, when the point has been reached, so as to raise the mercury in the glass tube until it closes the lower end of the tube fixed in the upper end of the tube d. If the temperature rises in the bulb/, the mercury will expand and reduce the sup- ply of gas, and thus reduce the flame ; as the temperature Fig, 1699.-Schafer's Apparatus for Supplying a Current of Warm Water. Fig. 1702.-Electric Slide and Moist Chamber. between the ends. The bottom of the cell is filled with a few drops of water ; the specimen is placed on the cover- glass, in contact with the tin-foil, and the cover inverted and placed on the cell, c, so that the foil comes in contact with that covering the cell. The electric current is con- ducted to the specimen through the metal supports by wires placed in the holes in their ends. Methods of Fixing, Hardening, and Preserving. -By the term " fixing " is meant the rapid killing of the Fig. 1700.-Stricker's Warm Stage and Gag-chamber. falls, the mercury will contract, and the flame will again rise. To raise or lower the temperature, screw in or out the screw e, which controls the height of the column of mercury. To prevent the extinction of the flame, the 661 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tissue elements, so that they are preserved in the same con- dition, as regards form and structure, that they had during life. The process of fixing also partially hardens the tissue, so that it is not injured by the subsequent manipulations. A perfect fixing agent should meet the following re- quirements : It should kill rapidly, without having any injurious action on the tissue ; it should not dehydrate, as the withdrawal of water causes shrinking; it should not render the tissue brittle ; it should not interfere with the subsequent staining. Of the numerous reagents used for this purpose, there is but one that meets all these requirements, and that is the vapor of osmic acid. This, on account of its feeble penetrating power, can only be employed on small bits of tissue or on thin membranes. All the other fixing agents fail to meet one or more of the above requirements. By combinations of one or more of these agents the faults of one may be counter- balanced by those of another. The following general rules should be observed in the use of fixing agents : The size of the specimen should be small and the quantity of the fluid large, as much as a hundred-fold. The specimen should be removed from the fluid as soon as fixed. This depends on the fixing agent used, and on the size and density of the specimen. Osmic and acetic acids act quickly ; chromic acid requires considerable length of time ; picric acid comes between the two. The blood-vessels of organs should be injected with the fluid, and after a few hours the entire organ is im- mersed in the same fluid. After the specimen has been fixed it is to be well washed in water, to remove all traces of acid, and the hardening completed in alcohol. Osmic Acid is a very volatile substance, its vapor be- ing extremely irritating to the conjunctiva and nostrils. It is found in commerce in glass tubes, each containing one gram or one-half gram of the crystals. It is used in aqueous solutions of the strength of 0.1 to 2.0 per cent., or in combination with other acids in the propor- tion of 1 to 10,000. For making a solution, a bottle is thoroughly washed with sulphuric acid, then with distilled water, that all traces of organic matter may be removed ; then remove the label from the tube, and wash the tube in sulphuric acid and distilled water ; break off the two extremities of the tube and put it into the bottle ; add the proper amount of distilled water to make a solution of the required per- centage. The solution is to be kept in a well-stoppered bottle protected from the light. This reagent is more valuable as a fixing than as a hardening agent, having the property of preserving the most delicate tissues in a condition the same as in life. It prevents all granular coagulation and post-mortem struct- ural changes. Its power of penetration is very slight, its action being confined to the superficial parts. The vapor has a much greater penetrating power. Tissues to be submitted to the action of the vapor are pinned out on a cork, fitted to a wide-mouthed bottle, in which there are a few cubic centimetres of a one per cent, solution of the acid, and allowed to remain until they become of a brownish color. They are then washed in water and preserved in alcohol. When placed in the solu- tion, the specimen should not be allowed to remain over twenty-four hours. Specimens submitted to the action of this acid should be protected from the light while such action is going on. If specimens, after being removed from osmic acid, be not well washed, they are apt to become over-black in time. This over-blackening may be removed by Mayer's calcium-chloride method, which is as follows : 'Place the specimen in seventy- or ninety-per-cent, alcohol, and add enough crystals of calcium chloride to cover the bottom of the bottle ; then add a few drops of hydric chloride, and mix by shaking the bottle as soon as the green color of the chloride appears. Large specimens may be bleached in half a day. This process has no bad effect on the tissue. The blackening may also be checked by the use of Merkel's fluid. Osmic acid stains fat black. Osmic and Chromic Acids.-Flesch 1 recommends the following mixture : One per cent, solution of osmic acid, 10 parts ; one per cent, solution of chromic acid, 25 parts ; water, 65 parts. Specimens remain in this mixture for twenty-four to thirty-six hours. Complete the hardening in alcohol and preserve in the same. Osmic, Chromic, and Acetic Acids (Flemming's Mixture2). -This mixture was employed by Flemming in his inves- tigations on the intra-nuclear network and cell division. Its composition is as follows: One per cent, solution of osmic acid, 10 parts ; one per cent, solution of chromic acid, 25 parts ; two per cent, solution of hydric acetate, 5 parts ; water, 60 parts. The best results are obtained when this mixture is al- lowed to act for half an hour only. Fol3 recommends the following modification of the above: One per cent, solution of osmic acid, 2 parts ; one per cent, solution of chromic acid, 25 parts ; two per cent, solution of hydric acetate, 5 parts ; water, 68 parts. Chromic and Acetic Acids.-One per cent, solution of chromic acid, 20 to 25 c.c. ; one per cent, solution of hydric acetate, 10 c.c. ; water, 70 c.c. This solution is recommended by Flemming4 for after-staining of the specimen with haematoxylin. Preparations do not stain well with aniline dyes. Osmic Acid, Chromic Acid, and Alcohol.-One-fifth per cent, solution of chromic acid, 500 c.c. ; one per cent, solution of osmic acid, 50 c.c. ; alcohol, 95 per cent., 500 c.c. This mixture is employed by Professor Delafield for the kidney. The blood-vessels are first washed out with one-fifth per cent, solution of chromic acid, and then about 500 c.c. of the above mixture slowly injected under a pressure of 50 mm. of mercury, the renal vein having been previously ligated. Preserve in alcohol. Alcohol.-As a fixing agent, alcohol is generally em- ployed in the strength of thirty-three and one-third per cent. " Alcohol au tiers " of Ranvier. Tissues are placed in this alcohol for twenty-four hours ; then stained with an alcoholic staining medium. They should never be treated with water or aqueous liquid, except picro-carmine, alum-carmine, or methyl-green. As a hardening and preserving agent, strong alcohol is the most useful of all these agents. It acts by the ex- traction of water and the coagulation of albumen; be- sides, it dissolves fat and extractive matter. It cannot be used for the central nervous system, as it dissolves the fatty matter of the nerve-fibres. The pieces of tissue should be small, and should be placed in ten or twelve times their volume of dilute alco- hol (alcohol 2 parts, water 1 part) for twenty-four hours, then in strong alcohol (90 to 95 per cent.), where they can remain indefinitely. Alcohol and Sodium Hydrate.-Beale5 recommends a mixture of 2 c.c. of solution of caustic soda (U. S. Ph.) to each 100 c.c. of alcohol. This mixture hardens, and at the same time renders tissues transparent. It is especially adapted for investigations on the ossification process in early embryos. The soft tissues become perfectly trans- parent, while the earthy matter of the bone is not affected. If a foetus be soaked in this fluid for a few days and then preserved in dilute alcohol, all the ossific points are beau- tifully brought out. Chromic Acid.- Used in aqueous solutions of one- tenth to one per cent, as a fixing agent, and allowed to act for a few hours only. For fixing nerve-tissue, solutions of one-fiftieth to one-eighth per cent, are used. The pieces of tissue should be small, and after removal from the fluid should be well washed in water and preserved in alcohol. As a hardening agent, it is used in aqueous solutions of one-sixth to one-half per cent. It is very slow in its ac- tion, taking weeks, and even months, if the specimen be large. As a rule, the pieces of tissue must be small, two to three centimetres on a side, and the quantity of fluid large, two hundred cubic centimetres for each cubic cen- timetre of tissue. The fluid must be renewed at the end of the first, third, and fifth day. After the hardening 662 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. is completed the specimen is placed in water for a day or two, to remove all traces of the acid, and then preserved in alcohol. After partial hardening in chromic acid, the action can be completed in alcohol, care being taken to thoroughly wash out the former before placing the speci- men in the latter. Two or three weeks' immersion in the acid will be sufficient if the hardening is to be completed in alcohol. The action of chromic acid seems to be analogous to that of tanning. The acid enters into combination with the tissues, rendering them tough like leather. A pro- longed action of the acid will render them brittle. Chromic acid has the property of softening bone, and is often used as a decalcifying agent. This acid is an ex- cellent hardening agent for central nervous system, nerve- tissue, glandular tissue, and epithelium. When the crystals of chromic acid are exposed to the air, they quickly absorb moisture and undergo a chemi- cal change. For this reason it is better not to keep the crystals in an undissolved state ; but to make a stock solu- tion of ten per cent., and by dilution of this with water make solutions of the required percentage. Chromic Acid and Alcohol.-Klein used a mixture of two parts of a one-sixth per cent, solution of chromic acid and one part of alcohol for his investigations on cells, and claims that it gave better results than the ordinary re- agents, even osmic acid. Chromic and Picric Acids.-A mixture of ten parts of a saturated solution of picric acid, twenty-five parts of a one per cent, solution of chromic acid, and sixty-five parts of water makes an excellent hardening fluid. Its action is slow. Chromic Acid and Platinum Chloride (Merkel's Solu- tion6).-This is recommended by its originator as an excel- lent fixing agent, especially for the retina. Take equal parts of a one-fourth per cent, solution of chromic acid and a one-fourth per cent, solution of platinum chloride. Place the specimen in this fluid for from two to three hours ; then preserve in alcohol. Eisig allows specimens to remain three or four hours in this fluid, and then pre- serves them in seventy-per-cent, alcohol. Specimens stain well with almost any stain. Chromic and Nitric Acids (Perenyi's Solution6).-This mixture was used by its originator for fixing ova. Its composition is as follows : Ten per cent, solution of ni- tric acid, 4 parts; alcohol, 3 parts ; one-half per cent, solution of chromic acid, 3 parts. After a short time this mixture becomes violet-colored. Specimens are placed in the fluid for four or five hours ; then in seventy-per-cent, alcohol for twenty-four hours ; then in strong alcohol. Staining solutions may be com- bined with this fluid. Fuchsin may be dissolved directly in the solution. Eosin, purpurin, anilin-violet, must be dissolved in three parts of alcohol, and then shaken into the fluid. The addition of picro-carmine and alum-car- mine causes a precipitate ; this is to be filtered off before using the fluid. Potassium Bichromate.-The action of this salt is sim- ilar to chromic acid. It is used in aqueous solutions of one to two per cent, for fixing, and two to five per cent, for hardening. Its action is slow, and it has the advan- tage of never rendering the tissues brittle. Muller's Fluid.-This fluid was first introduced by H. Muller for hardening the retina. It is an excellent hard- ening fluid for the majority of tissues, especially for the central nervous system. Its action is slow, but its pene- trating power great. It requires a month to six weeks to complete the hardening of a spinal cord. If the temperature of the fluid is kept at 30° to 40° C., the time is reduced to eight to ten days (Weigert). The composition of the fluid is as follows : Potassium bichromate, 2 to 2.5 parts ; sodium sulphate, 1 part; wa- ter, 100 parts. It should be used in large quantities, re- newed at the end of twelve hours, then every third day until the hardening is completed. Then wash well in water and preserve in alcohol. Erlicki's Fluid.-This is also an excellent hardening fluid for the central nervous system. It consists of potas- sium bichromate, 2.5 parts; cupric sulphate, 0.5 parts; water, 100 parts. At a temperature of 30° to 40° C. it hardens the spinal cord in four days. Ammonium Bichromate.-This is used in one to two per cent, solutions in water, in place of the previous salt, for hardening the central nervous system. If one cubic centimetre of ammonia be added to each one hundred cubic centimetres of potassium bichromate solution, the color changes to a bright yellow, and its power of pene- tration is increased. Ammonium Chromate (Neutral Chromate).-As a fixing agent this salt is used in five per cent, solution, and allowed to act for twenty-four hours. The specimen should after- ward be washed well in water and preserved in alcohol. Picric Acid.-Used in cold saturated solution in water. The bits of tissue must be small-one to two centimetres on a side for each one hundred cubic centimetres of fluid. The solution must always be in a state of satura- tion ; to accomplish this a quantity of picric-acid crystals are placed in the bottle, and the latter shaken occasionally. This reagent acts by gradually transposing the albu- men into an insoluble compound, so that tissues harden in it entirely without shrinking. As the tissues become less solid than with other reagents, it is necessary to com- plete the hardening in alcohol. The majority of tissues are stained yellow, but the color is withdrawn by alcohol, water, glycerine, etc. This acid is also used as a decalci- fying agent. Cupric Sulphate.-Besides being used in combination with potassium bichromate in Erlicki's fluid, this salt is used in combination with hydric acetate. Remak recom- mends the following solution : Two per cent, aqueous so- lution of cupric sulphate, 50 c.c.; twenty-five-per-cent, alcohol, 50 c.c.; rectified pyroligneous acid, 35 drops. Palladium Chloride.-Employed by Waldeyer in one- thousandth per cent, aqueous solution, with the addition of a few drops of hydric chloride to aid in the solution, for softening the cochlea. The specimen is placed in this solution for twenty-four hours, and then in absolute al- cohol for the same length of time. F. E. Schulze1 uses this salt in 0.01 to 0.2 per cent, so- lutions. As the penetrating power is slight, small pieces of tissue are to be used-a piece the size of a bean to thirty cubic centimetres of the solution. The hardening is com- pleted at the end of thirty-six to forty-eight hours, but the specimen may remain in the fluid for months without harm. This solution stains protoplasm dark yellow, stri- ated muscle brownish yellow, smooth muscle straw yel- low, medullated nerves black. Hyaline membranes and elastic fibres stain slight yellow and remain transparent. Interstitial substance of connective tissue remains color- less, and will stain deeply with carmine and other stains, while the tissue colored by the palladium remains un- stained. Sections are to be well washed in water and mounted in glycerine. Mercuric Chloride (Corrosive Sublimate).-An excellent fixing agent. It kills rapidly, and does not interfere with the subsequent staining. It is used in cold, saturated, aqueous solution, and the tissues are allowed to remain in the fluid until thoroughly permeated ; then washed'in water for half an hour; then in dilute alcohol for twenty- four hours, and finally hardened in strong alcohol. In all manipulations with this reagent metal instruments must be discarded, and wooden or glass ones used. After remaining in alcohol for some time, the specimens are apt to become brittle. Wickersheimer's Fluid.-This is employed chiefly for the preservation of museum specimens. The author claims that the natural color of the specimen is retained in this fluid, but in my opinion this claim is only par- tially sustained, as the color fades more or less. He gives two formulae : For injecting. For immersing. Arsenious acid 12 gm. Sodium chloride 80 60 Potassium sulphate 200 150 Potassium carbonate 20 15 Potassium nitrate 25 18 Glj-cerine 4,000 c.c. 4,000 c.c. Wood-naphtha 750 750 Water 10,000 10,000 663 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Methods of Decalcifying.-Hydrochloric Acid.- One part of strong hydrochloric acid is mixed with ten parts of water, and then ten per cent, of sodium chloride added. Without the addition of the latter the acid will cause some tissues to swell. The specimen of bone is placed in a large quantity of this fluid, and a little fresh acid added, day by day, until the bone has become soft. Then wash in water until all traces of acid are removed, and preserve in alcohol. Nitric Acid.-This acid is highly recommended by Busch.8 He employs a ten per cent, solution for adult bones, and a one per cent, solution for fcetal bones. Fresh bones are placed for three days in ninety-five-per-cent, alcohol; then placed in the nitric-acid solution, which is changed daily until decalcification is complete. This re- quires eight to ten days. They are then washed in running water for two hours ; and finally placed in ninety-five-per- cent. alcohol, which is renewed at the end of three days. Foetal bones are first placed in a mixture of one per cent, potassium bichromate and one-tenth per cent, of chromic acid for one or two days; then decalcified in one per cent, nitric acid. When thoroughly decalcified they are washed in water and preserved in alcohol. Sections of bone treated by this method stain well with eosin, but staining with haematoxylin is seldom successful. Chromic Acid.-This acid is employed in solutions of one-tenth to one per cent. It is better to commence with a weak solution, one-sixth per cent.; at the end of two days increase the strength to one-fourth percent.; and at the end of two days again increase the strength to one-half per cent., or even one per cent. This process will require from two to three weeks, but it may be shortened by the addition of a little nitric acid (one cubic centimetre for each one hundred cubic centimetres of chromic-acid solu- tion) at the end of the first week. After decalcification has taken place, which is ascertained by passing a needle into the specimen, the specimen is soaked in water for twenty-four to forty-eight hours, then preserved in alco- hol. Chromic acid often leaves the specimen in a cloudy condition. Picric Acid.-This is used in saturated aqueous solution. It is slow in its action. The specimen should be small, and be suspended in a large quantity of the fluid. The latter must be kept in a saturated condition by the addi- tion of fresh crystals of the acid and frequent agitation. Palladium Chloride and Hydrochloric Acid.-Wal- deyer9 employs a one-thousandth per cent, solution of palladium chloride with one-tenth of its volume of hydro- chloric acid for softening the cochlea. Small pieces of bone are placed in this fluid for twenty-four hours. If not softened at the end of this time the fluid is renewed, and they are allowed to remain another twenty-four hours, when, as a rule, they will be found completely softened. The specimens are then washed in alcohol, which is re- newed at the end of twenty-four hours. This fluid does not cause the tissues to swell, nor does it interfere with the staining. Methods of Dissociation.- Mechanical.- Scraping and Teasing. Which of these methods is to be employed depends upon the nature of the tissue. Epithelium can be easily scraped off in large flakes by a knife, while fibrous parts are to be teased apart with needles. Scrap- ing is performed as follows : A small bit of the tissue is placed on a slide, with the epithelial surface uppermost, one end fixed with a needle, and the surface lightly scraped with the blade of a scalpel, the result of the scrap- ing diffused in a drop of water, salt solution, or glyce- rine on a slide and examined. For teasing we employ needles mounted in handles. Various forms of the latter are supplied by instrument- makers, but a needle forced into the end of an ordinary penholder will answer every purpose. In order to suc- cessfully tease a specimen, it is necessary to have some idea of its structure, whether its elements are arranged in parallel fibres or interlaced. In tissues arranged in paral- lel fibres, apply the needles to one extremity and sepa- rate it into two parts ; select one of these, repeat the oper- ation, and so on until it is impossible to separate them any more. In other tissues a small bit is fixed by one needle, and with the other, commencing at one edge, the teasing is carried on in a deliberate manner until the tissue is reduced to the required degree of fineness. The opera- tion of teasing is performed on a slide in a small drop of fluid. Unstained material is placed on a black back- ground, stained on a white background. Brushing.-This operation is performed under water by gently brushing the surface with a camel's-hair brush. Shaking.-Thin sections of tissue are shaken in a test- tube with a suitable fluid, then the contents of the tube are poured into a dish of water, the section being floated on a slide. Compression.-By making pressure on the cover-glass, especially after maceration of the specimen, one is often able to separate the elements. This pressure can be made with the handle of a teasing-needle, but it is apt to be unequal, and there is danger of breaking the cover and thus destroying the specimen. It is better to use an in- strument called a compressorium, constructed especially for this purpose. In Fig. 1703 is shown one of the latest form, invented by H. Jung, of Darmstadt. The plate A is attached to the stage of the microscope by the catch n and the two screws s, s. On this plate is a double lever, one arm of which has a movable ring, II, and adjusting screw, St, and the knob K. The two levers are so connected with the bent piece C that when K is pressed down the ring 11 is also pressed toward the Fiq. 1703.-Jung's Compressorium. stage-plate. Conversely, an upward movement of the knob, produced by the spring F, raises the ring. For use as a compressor the screw 6'1 is loosened, and St screwed down until the desired degree of pressure is ob- tained. This apparatus can also be employed for another useful purpose, viz., beating. The process of beating is often resorted to for the purpose of isolating cells, tissue, etc. In using the instrument for this purpose the screw St is so adjusted that the ring 7? lies close to a large and thick cover-glass covering the specimen, and S\ is turned so that the lever can move but slightly. By quick and continuous movement of the lever, and the changing pressure on the cover-glass thus produced, tissues (after maceration) can be easily dissociated. When the cells are isolated they can be made, by a slower movement of the lever, to move about in all directions, so that they can be observed from all sides. Interstitial Injection, or Artificial (Edema.-A hypoder- mic syringe is filled with salt solution or a warm solution of gelatine, the needle is inserted into the tissue-the sub- cutaneous tissue of a freshly turned-up flap of skin- and the fluid forced out. The fluid does not immedi- ately diffuse itself, but forms a bulla covered with a thin film of tissue. A bit of this film is snipped off with scis- sors and examined. If gelatine be used, it soon solidi- fies, when thin sections are made with a razor. Chemical Dissociation.-By submitting tissues to the action of different chemical solutions certain parts be- 664 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. IliMtoloKical Techniq tie. come dissolved or softened, while others remain unal- tered. Consequently certain elements can be easily iso- lated by one of the mechanical methods. The reagents used for this purpose are as follows : Dilute Alcohol, " Alcohol au tiers" of Ranvier.-Alco- hol of ninety per cent, is diluted with two parts of water. Bits of tissue are placed in this fluid for twenty-four hours ; if at the end of this time the tissue is not suffi- ciently softened, the fluid is renewed and the action con- tinued for twenty-four hours longer. Recommended highly by Ranvier for isolating epithelial cells. Osmic Acid of the strength of one-tenth per cent, is recommended by Rindfleisch for the cerebral cortex. Small pieces of the cortex are placed in a considerable quantity of the fluid for a week or ten days, then in glyc- erine. Chromic Acid is employed in the strength of two to three parts to one thousand of water. Recommended es- pecially for nerve-tissue and smooth muscle. The amount of fluid should be ten times greater than the piece of tis- sue. After macerating for twenty-four hours, the tissues are easily dissociated. Potassium Bichromate employed in the same strength as chromic acid, its action being similar. Muller's fluid, diluted with an equal volume of water, is also employed as a macerating fluid. It requires from twenty-four hours to a week. Potassium and Ammonium Sulpho-cyanate.-A ten per cent, solution of either salt is recommended by Stirling10 as a dissociating medium for epithelium. After macer- ating for twenty-four to forty-eight hours, the tissue is lightly scraped with a scalpel. Potassium Hydrate.-Used in twenty to forty per cent, solutions in water. It acts very quickly on fresh tissues, and is used mostly for isolating the cells of nails, hairs, and epidermis. Sodium hydrate may be used in its place, but in more dilute solutions. Preparations by this method cannot be permanently preserved. Sodium Chloride.-Used in ten per cent, solution in water for isolating white fibrous tissue. It requires from two to three days for its action. Sodium Hypochloride.-A solution of eight drops of the officinal solution (U. S. Ph.) in one hundred cubic centimetres of water will, after twenty-four hours' action, macerate nerve- and muscle-fibres so that they can be separated by simply shaking the vessel. Barium Hydrate.-Used in saturated aqueous solution for nerve-, muscle-, and tendon-fibres. It requires from eight to twenty-four hours for its action. Nitric Acid.-Used in twenty per cent, solution for muscle-fibres. After acting for twenty-four hours, the fibres are easily isolated by shaking the specimen in a test-tube with water. Schwalbe uses a twenty per cent, solution for isolating nerve-fibres for measurement. He macerates the nerve-trunk in the above solution at a temperature of 40° C. for twenty-four hours, and then ■washes in water. The fibres retain their normal diam- eter, but become very brittle. Nitric Acid and Potassium Chlorate.-A piece of stri- ated muscle is buried in crystals of potassium chlorate placed in the bottom of a vessel, and four times the vol- ume of the crystals of nitric acid is poured on and al- lowed to act half au hour ; the muscle is then shaken in a test-tube with water, when it will break up into isolated fibres. Hydrochloric Acid is used mixed with an equal vol- ume of alcohol for isolating the tubules of the kidney. A small bit of fresh kidney is placed in this mixture for twelve hours; then soaked in water for a few hours to remove the acid, and preserved in glycerine. The acid partially dissolves the intertubular tissue, so that by very careful teasing the tubules can be isolated. It is also em- ployed in the strength of 1 to 250 of water for cleaving striated muscle into disks. Boiling.-Small pieces of tissue are boiled in water or salt solution for one to three hours, when they fall to pieces. Gelatinous and extractive matters are dissolved, horny substances softened, and albuminous ones coagu- lated. As water causes structural changes, Cudereau uses a mixture of 300 c.c. of Muller's fluid, 600 c.c. of water, and 35 grams of potassium nitrate. He recom- mends this mixture highly for isolating gland-elements. Artificial Digestion.-For the purpose of artificial digestion we make use of either pepsin or trypsin, stom- ach or pancreatic extract. The stomach extract is prepared as follows : The mu- cous membrane from the fundus of the pig's stomach is cut into small pieces and digested with a 1 to 1,000 solu- tion of hydrochloric acid, at a temperature of 38° C. for one hour, and then filtered. An artificial digestive fluid can also be made by adding 1 Gm. of scale pepsin to 500 c.c. of distilled water acidulated with 1 c.c. of pure hy- drochloric acid, heating the mixture to 38° C. for two hours, and then filtering. The pancreatic extract is prepared as follows (Kuhne11): The pancreas of a freshly killed beef is chopped fine, and four to five volumes of absolute alcohol added ; it is al- lowed to stand for three days, is drained, and the mass extracted with ether ; it is then dried quickly in the air. To each 5 Gm. of this mass 50 c.c. of a one per cent, solution of salicylic acid is to be added ; it is then digested on a water-bath, at a temperature of 37° C. for four hours, and filtered ; and to the filtrate is added twenty-five one- hundredths per cent sodium bicarbonate. It is well to add one per cent, of thymol to the fluid to prevent putre- faction. The pancreatic fluid can also be made by dis- solving six to seven per cent, of trypsin in water con- taining one per cent, of salicylic acid. Pieces of tissue may be first digested in these fluids and then sections cut, or the sections may be first cut and then submitted to the action of the fluids. The digestive pro- cess is to be carried on at a temperature of 37° to 38° C., either in an incubator or on a warm stage on the micro- scope. Pepsin very quickly dissolves connective tissue, mus- cle, most cellular elements, etc., but not elastic tissue or nerve-fibres. Trypsin, on the other hand, dissolves elas- tic fibres and neuroglia, while connective tissue is not acted upon. Corrosion.-Altmann's12 method is founded on the fact that most animal tissues are quickly destroyed by eau de Javelle, while fats that have been hardened by osmic acid resist its action for a long time. If a fat is intro- duced into a tissue and hardened with osmic acid, and the tissue destroyed by the action of eau de Javelle, a cor- rect mould of the space filled by the fat is obtained. He employs two processes, injection and impregnation. For injection he uses olive-oil, which is injected into the blood-vessels. The injected tissue, if thin, is placed in a one per cent, solution of osmic acid for twenty-four hours. Organs and thick specimens must be frozen, cut into thin sections, and then placed in the acid. The speci- mens are then placed in eau de Javelle, contained in shal- low dishes, in order that the progress of the corrosion can be watched, for a few moments to twenty-four hours. When the corrosion is completed the specimen is care- fully floated on a platinum spatula, the excess of fluid absorbed with filter paper, and the specimen placed in glycerine. For impregnation he mixes one volume of olive-oil with one-half a volume of absolute alcohol and an equal vol- ume of ether. If small bits of tissue be soaked in this mixture, all the constituents of the tissue that are soluble in the mixture-water, fatty and nervous matter-will be taken up by it, and the oil-mixture will replace them. Now, if the tissue be placed in water, the alcohol and ether will be removed, and the fat precipitated. This is hardened by exposing the tissue to the action of a one per cent, solution of osmic acid, and then corroded by eau de Javelle. In place of the above mixture he also uses a solution of two parts of castor-oil in one part of alcohol. Fresh tissue should always be employed. Small bits are soaked in the oil-mixture for five to eight days, then placed in water to precipitate the oil, then in one per cent, solution of osmic acid for twenty-four hours, and finally corroded with eau de Javelle and mounted in glyc- erine. Schiefferdecker13 uses a solution of celloidin in ether, 665 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. colored with asphalt, as an injection mass. Digest pul- verized asphalt with ether in a covered vessel for twenty- four hours. Pour off the brown-colored ether, and add shreds of celloidin until a solution that flows like heavy oil is obtained. This gives a transparent mass. For an opaque mass, mix cinnabar or Berlin blue into a paste with absolute alcohol, and mix this with a solution of celloidin, using as little color as possible, or the mass will become brittle. Inject this mass as quickly as possi- ble into the vessels, as the mass, in coming in contact with tissue, hardens. After injecting, suspend the speci- Sections of Fresh, Tissue.-Sections of fresh tissue are best made with the freezing microtome, though fair sec- tions can be obtained with Valentine's knife (Fig. 1704). This consists of two parallel blades attached to each other at their lower end by a hinge. At a is a screw sliding in the slot, by means of which the blades are approximated. For use, the knife is forced into the organ ; then the blades opened by sliding back the screw a, when a sec- tion, the thickness depending upon the distance between the blades, will be found attached to one of the blades. This is floated off into salt solution, and examined as usual. There are two forms of freezing micro- tome. One in which a mixture of ice and salt is used as the freezing medium ; in the second, the ether spray. In Fig. 1705 is represented one of the ice- freezing forms (Rutherford's). The box C (Fig. 1705) is tilled with alternate layers of snow or finely powdered ice and salt, and well packed around the well. A cork is placed in the tube II, and only re- moved when the freezing box becomes filled with wa- ter. Gum solution is poured into the well, and the tis- sue introduced after a layer of ice has formed around the interior of the well. The mouth of the well is covered with a thin sheet of gutta percha, and a flat lead weight placed on it. The whole instrument is now enveloped Fig. 1704.-Valentine's Knife. men in a vessel containing concentrated hydrochloric acid until the tissue is dissolved. Then wash carefully in running water until all the gummy matter is washed away. It is a good plan to leave the preparation in wa- ter for a week, so that all bits of tissue that are apt to cling to the vessels may macerate off. Preserve in a mixture of equal parts of glycerine, alcohol, and water. Hoyer14 places a large quantity of shellac in eighty- per-cent. alcohol; allows it to stand for twenty-four hours, and then warms on a water-bath until the solution is com- plete. When cold he dilutes it with alcohol to the con- sistency of thin syrup, and strains through muslin. For coloring he uses cinnabar or Berlin blue. The coloring- matter is rubbed up with water, and alcohol added ; after allowing the mixture to settle, he pours off the dilute alco- hol and adds strong. He then shakes it in a flask, by means of which the coarser particles are brought to the bottom, and at this moment pours off the supernatant fluid con- taining the finer particles; adds this to the shellac, and strains through muslin. As the shellac mass is apt to be brittle, he adds five per cent, of a filtered, alcoholic Fig. 170G.-Rutherford's Ether-freezing Microtome. in flannel until the freezing is complete. The specimen is raised by the micrometer-screw D, which works on a brass plug fitted into the bottom of the well. This micro- tome can also be used for specimens imbedded in paraffin and similar substances. Rutherford has lately adapted an ether-freezing appa- ratus to this microtome. It consists of a zinc box (Z, Fig. 1706), on which the specimen to be frozen is placed. Ether is blown from the bottle 0, by the elastic bellows jV, against the under surface of the zinc plate. The con- densed ether flows down through the tube P, and is col- lected in a bottle. The zinc box is insulated from the plug, upon which the micrometer-screw works, by vul- canite. To convert the ice-freezing microtome into this form, place the zinc box Z in the well, and the supports Jf, J/' on the plate B, and screw down the glass plate L. Introduce the spray-tubes T into the slot under Z, and the instrument is ready for use. In cutting sections, the knife is pushed on the glass plate at a right angle ; the section is removed with a camel's-hair brush, and placed in water to remove the gum. solution of Venetian turpentine. For corroding he uses strong, fuming hydrochloric acid, washes as above, and mounts in glycerine. Methods of Making Sections.-Sections of Hard Tis- sues.-Sections of unsoftened bone, teeth, etc., are made by grinding, after cutting thin plates by means of a tine saw or an iron disk, on a lathe fed with flour of emery and water. These plates are to be ground on a metal plate charged with flour of emery and water until trans- parent, polished on a Turkey hone, washed in water, and dried in the air. Spongy bone should be imbedded in copal, according to Von Koch's method,15 and then ground. Fig. 1705.-Rutherford's Freezing Microtome. 666 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. HiMtological Technique. Thoma's ether-freezing microtome, which is shown in vertical section in Fig. 1707, consists of a cast iron-frame tissue may be made by free-hand cutting, or by the mi- crotome. For free-hand cutting, the first requisite is a good razor or knife. An ordinary hollow-ground razor, with the lower side ground flat, will answer ; but if one practises free-hand cutting to any extent, it is better to be provided with a larger and heavier one.* For cut- ting large sections free-hand, Thanhoffer's irrigation knife (Fig. 1708) will be found very convenient. This knife has a wedge-shaped blade, 11 ctm. long and 1| ctm. broad, with a tube, a, for supplying water or alcohol to the blade. This tube is attached to the back of the blade, and is pierced with a row of fine holes ; it also extends through the handle and terminates at the butt end in a stopcock, b, to which an India-rubber tube is attached. This tube is also connected with a feeding bottle, placed at a higher level than the knife. The irri- gating fluid flows from the holes in small drops ; these, flowing together, cover the blade with a layer of fluid along its whole length. The knife should be held in a slightly inclined position, so as to cause the fluid to flow over the blade. The section-cutting is performed as follows: A shal- low dish is partially filled with alcohol, with which the specimen and razor-blade are to be constantly flooded, the blade being dipped into the alcohol. The specimen is held firmly between the fingers and thumb of the left hand (Fig. 1709), and the razor lightly with the right, the handle resting on the fingers, the thumb being used for changing the direction of the edge of the razor. The section is cut by drawing the razor-blade diagonally through the specimen, from heel to point, and then floated off into a dish of alcohol. After cutting every third or fourth section the razor should be stropped, so as to keep the edge in the best possible condition. Thoma's sliding microtome (Fig. 1710) consists of a stand of cast-iron, on which slide two carriers. The section-knife is attached to one of these, a, which slides horizontally. The other, b, holds the specimen to be cut, and moves on an inclined plane. Professor Thoma found that a carrier moving on five points between two plane surfaces, will slide without difficulty between these planes even if they are not ab- solutely geomet- rical planes, or if the angle included is not everywhere the same. Such a carrier will always take the same course, and conse- quently the knife will cut a series of perfectly parallel sections through an object which is successively raised to a higher plane after each cut. A cross-section of the instrument is shown in Fig. 1711. On the lower surface of the carrier a are shown three points, which give the geometrical projection of the five points of the carrier. The inclination of the plane upon which the carrier b (Figs. 1710, 1711) slides is one Fig. 1707.-Section of Thoma's Ether-freezing Microtome. which is fastened to the table by the screw S. At the lower part is a micrometer-screw, AI, connected with the revolv- Fig. 1708.-Thanhoffer's Irrigation Knife. ing plate N by the rod B. The circumference of the upper surface of this plate is divided into one hundred equal parts, and the revolu- tions of the screw are read from the fixed point I. The micrometer-screw works on the end of the rod R, which supports the reser- voir for receiving, the condensed ether, which in turn supports the corrugated zinc plate Z by the rod A. The top of the frame is covered with a glass plate, P, P, 5 mm. thick, with the circular aperture C, 49 mm. in diameter. The tube T is con- nected with a bottle for receiving the con- densed ether. The specimen to be frozen is placed in the centre of the plate Z, and a spray of ether directed on its under surface. In about three minutes the specimen will be frozen hard enough to cut. The plate Z is raised by the micrometer-screw, and the surface of the specimen cut smooth ; the plate is again raised sufficiently to give a section of the required thickness. In cutting sections, the knife is held at nearly a right angle to the surface of the plate and forced through the specimen like a plane. After cutting, the sections are placed in salt solution to thaw. Sections of Hardened Tissue. - Sections of hardened in twenty ; consequently, if the carrier b is moved one millimetre on this plane it will raise the surface of the Fig. 1709.-Section cutting. * A razor well adapted for this work is made by W. F. Ford, of Cas- well, Hazard & Co., New York. 667 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. specimen one-twentieth of a millimetre. A scale of milli- metres, e, with a vernier, d (Fig. 1710), allows the opera- tions to be easily regulated, and will be found sufficient for sections of 0.015 mm. in thickness. When sections tions cut by this instrument have been 0.002 mm. in thickness. In Fig. 1712 is shown an enlarged view of the clamp. The two metal plates d, d' are fixed, the plate g is mov- Fig. 1710.-Thoma's Sliding Microtome. of greater delicacy are required the micrometer-screw g, g (Fig. 1710) is to be used, as it allows of the greatest exac- titude in the management of the carrier b. The carrier d slides on the same plane as the carrier b. In all positions of the latter it is possible to bring the point of the mi- crometer-screw g, g in contact with the polished plate of able and slides on the rods e, e'. The cork on which the specimen is mounted is placed between the plates g and d', and fixed by turning the screw f. The specimen can be rotated on two horizontal axes. The axis which is parallel to the long diameter of the microtome is fixed by the screw h. The screw h' frees the axis which is ver- tical to the former. Mayer has invented an object-holder especially for paraffin-imbedded specimens, which is shown in Fig. 1713. It is movable in three directions. It is raised vertically and turned on its vertical axis by the hand ; in the other two axes it is moved by rack and pinions. The specimen is imbedded in the cylinder C, which is Fig. 1713.-Mayer's Paraffin Clamp. Fig. 1714.-Knife-holder. filled with paraffin. This cylinder can be pushed up and down in the block A, and by means of six holes beneath and a small metal rod can be turned in it. It is fixed by the screw i. The turning of the block in the frame 2?, around the horizontal axis, is effected by the milled head F', and is fixed by the small screw d', which presses one bearing of the block against its axis. The frame B is turned on its long axis by the milled head F, and is fixed by the screw d. G is the agate plate for the micrometer-screw to work on. In using the microtome, it is placed on a table before the operator, the sliding surfaces freely oiled and the Fig. 1711.-Vertical Section, Thoma's Microtome. agate, f, fixed on b. When in this position, d should be firmly fixed to the stand of the microtome by the screw d. Every revolution of the micrometer-screw g, g will then push the carrier b 0.3 mm., giving a thickness of section equal to 0.015 mm. The periphery of the drum, s, attached to the screw g, g is divided into fifteen equal parts ; consequently, each division corresponds to a thick- ness of section equivalent to 0.001 mm. The finest sec- Fig. 1712.-Specimen Clamp. knife flooded with alcohol. Some specimens (kidney, liver, etc.) can be fastened directly in the clamp, but in Fig. 1715.-Knife-holder in First Position. 668 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. the majority of cases it is better to mount the specimen on a cork and fasten this in the clamp. The clamp is then the cutting edge of the knife, five and one-half inches. The knife-carrier slides on eight ivory points-four on each side-and the slides do not require lubrication. At each end of the main slide there is a stop, with rubber cushions, to prevent the carrier passing over the end. The upper surface of the knife-carrier is made adjusta- ble, so the knife can be made to cut at whatever inclina- tion is found best. The screw for elevating the specimen clamp is graduated to o mm., and has a spring-clip for registering ; this may be turned aside when not required. Fig. 1716.-Knife-holder in Second Position. fixed in a position as near the knife-carrier a as possi- ble, The knife is so adjusted that it will be drawn obliquely through the specimen from heel to point. The sections, after being cut, are re- moved from the knife with a camel's-hair brush, and placed in a dish of alcohol. In cutting sections of hard substances-aorta, cartilage-it often happens that the sections, instead of being even, are thicker at one point than at another ; or that the sections are striped, Iheir thickness varying at different points. Professor Thoma has found that this is due to the fact that hard substances bend the edge of the ordinary knife. For preventing this he has introduced knives with stronger edges and shorter blades. These knives are attached to the knife-carrier of the microtome by the new holder (Fig. 1714). This knife-holder has two forks, 0 and 0', by which Fig. 1718.-Weigert's Immersion Microtome. The specimen clamp has universal motion, so that the specimen can be adjusted to cut at any plane. An ether- freezing attachment is also supplied. The microtome figured in Fig. 1718 and 1719 is an adaptation by Weigert 16 of Altmann's modification of Schanze's, for cutting sections under a fluid. The microtome is fastened to an iron plate (Fig. 1718) by hinges, to which also is attached a tin vessel for hold- ing the fluid. The specimen is fastened to a large piece of cork and the latter clamped in the microtome. The instrument is then turned so that the clamp is immersed in the fluid contained in the tin vessel (Fig. 1719). As an immersion fluid he used ordinary alcohol, and the vessel is filled with this so that the upper side of the specimen is covered. The sections when cut fall nearly perpen- dicularly, and by placing a sufficiently large and deep dish in the bottom of the vessel directly under the speci- men they will fall into this. In Fig. 1720 is shown the latest form of the Thoma mi- crotome. The principle of construction is the same as in the earlier instruments, only its dimensions are larger, Fig. 1717.-Bullock's Microtome. it can be fastened to the carrier 0 (Fig. 1715), and is clamped by S, the knife being fixed in the holder by the screw N (Fig. 1714) acting on G and the wedge V, which is forced against the back of the knife. Fig. 1715 shows the position of the holder when the whole length of the edge of the knife is to be used (fastened by the fork O'), and Fig. 1716 when it is to be used more transversely to the long axis of the microtome (fastened by the fork 0) for par- affin specimens. Z is an attachment to fasten the knife in a handle when stropping. In Fig. 1717 is shown a microtome constructed by W. H. Bullock, of Chicago.* He has taken for his model the Schanze microtome, and adapted to it various modern improvements. The slide for the knife-carrier is ten and one-half inches long; height, to Fig. 1719.-Weigert's Immersion Microtome Instrument in Position for Cutting. * Both the Thoma and Bullock microtomes can be obtained from Mey- rowitz Bros., Twenty-third Street and Fourth Avenue, New York City. and it will cut sections of preparations nine centimetres in diameter. For stiffening the knife a stay, 4, has been provided. 669 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. This is fastened to the knife-carrier 1 by the screw 3, and is arranged parallel to the back of the knife. The catch 6 is pressed down lightly, until it touches the back of the knife, and is then fastened by the screw 5. For keeping the knife flooded with alcohol an irrigat- ing apparatus is now supplied. It consists of a vessel, 30, for holding the alcohol, which turns on an axis in the column 20. To this axis is fastened the horizontal arm 29, through the end of which the pin 22 passes. On the end of this pin is a bridge carrying two rollers, 24, 25, which play upon the raised ridge, 19,19, of the knife- stay. The whole apparatus is so adjusted with the thumb-screws, 21, 21, 21, that the rollers, 24, 25, will play upon the ridge, 19, 19, with as little friction as possible. The chamber, 30, is filled with alcohol by removing the cap, 18. Through this cap runs a siphon, which is con nected with the cannula 26 by a rubber tube. The object, 8, is fastened in the clamp by the screw 12. It can be raised to a higher plane by the milled head M, and is fixed by the levers 16, 16. By loosen- fluid, gently raises it, and transfers it to a second vessel of fluid or to a slide. When sections are transferred from alcohol to water, they spin about in a lively manner and finally spread out into thin laminae. This is caused by the rapid diffusion of the alcohol. Sections can be preserved indefinitely in eighty- to eighty-five-per-cent, alcohol. Methods of Imbedding.-This process is divided into two classes : simple imbedding, when the specimen, being small, cannot be held conveniently in the hand or Fig. 1721.-Spatula. clamped in the microtome, and is simply surrounded with an imbedding mass to give it bulk ; interstitial imbed- ding, or impregnation, when the specimen is permeated with the imbedding mass. The latter process is used when we have a specimen that lacks the necessary con- sistency for cutting (lung, etc.); or when the specimen contains cavities, the contents of which we wish to retain in their normal condition and position ; or when the specimen is so brittle that it would be destroyed in the process of cutting. Simple Imbedding: Imbedding in Liver.-Fresh liver, or that which has been hardened in seventy-per-cent, alcohol, is to be used. A cavity, slightly larger than the specimen, is scooped out of the side of a piece of tins liver, the specimen placed in this, covered with a second piece of liver, the whole tied Fig. 1720.-Thoma's Sliding Microtome, No. 0. ing the lever 11, it can be turned on an axis parallel to the long axis of the instrument. The milled head 13 turns it on an axis at right angles to the instrument, and it is fixed by the lever 7. For convenience in moving the knife-carrier, an axle, 27, with the drum 26, is fastened to the end of the instru- ment ; around the drum is wound a flat band, on the end of which is a hook, which is fastened into an eye on the knife-carrier. By turning the axle the band is wound up on the drum, and the knife-carrier drawn, with a steady motion, to the end of the instrument. After the sections are cut they are removed from the microtome-knife with a camel's-hair brush and placed in a dish of fluid. For sections of fresh tissue and frozen sections, use salt solution and immerse the sections in it; for sections of alcoholic specimens, use alcohol or water. In the further manipulation of the sections great care must be taken, or they will be destroyed. For transfer- ring them from the different reagents, stains, etc., a needle, camel's-hair brush, or nickel-plated steel spatula (Fig. 1721) must be used. In the majority of cases the latter instrument will be found most convenient. It is placed cautiously under the section, floating in the round with a piece of thread and placed in strong alco- hol. The latter causes the liver to contract around the specimen, holding it firmly. The block of liver can be clamped in the microtome. Elder-Pith.-A cylinder of elder-pith is cut in two, longitudinally. The inner face of one-half is kneaded with the handle of a scalpel into a cavity, into which the specimen is placed and covered with the other half. The cylinder is tied round with a thread and immersed in water, which causes the pith to swell and hold the specimen firmly. Melted Masses.-Simple imbedding in a melted mass, as wax and oil, is performed as follows : A small box is placed on a cork, the specimen placed in it and fixed in position by means of pins. The box is now filled with the melted mass and allowed to cool-when the pins and paper are removed, leaving the specimen enclosed in a solid block of the imbedding material. Or a block of the imbedding mass is taken, and a hole, a little larger than the specimen, is scooped out of one face ; the speci- men is washed in the melted mass and placed in the cavity, which is then filled. The imbedding-boxes are made of paper or capsule 670 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. metal (thick tin-foil). A piece of paper or metal is folded, as is shown by the dotted lines in Fig. 1722, the diago- nal lines being scored with a blunt-pointed instrument. These corners are then pinched up between the tliumb In manipulating with melted imbedding masses, it is necessary to have a constant and comparatively low tem- perature, as in many cases the specimen has to be soaked in the melted mass for a considerable length of time (im- pregnation method). In Fig. 1725 is shown a water-bath, devised by Professor Mayer, of the Naples Zoological Station, which will be found very convenient for melted imbedding masses. It consists of a copper box (Fig. 1725), 18 ctm. long, 8 ctm. high, and 9 ctm. wide. Water is intro- duced through the tube A, which is closed with a cork provided with a glass tube bent in the form of a siphon, to prevent the admission of dust and to allow the escape of steam. An oven, O, 0.7 ctm. high and 12 ctm. long, passes through the box and serves for warming-slides. The two ba- sin-like pits P, 5 ctm. in di- ameter and 4 ctm. deep, re- ceive two tin dishes for melt- ing the imbedding masses. There are six tubular pits, one for the thermometer, T, the others for test-tubes. The bath is to be heated by an alcohol- lamp or Bunsen's burner. In Fig. 1726 is shown the imbedding-cup of S. II. Gage, for melted imbedding masses. Into the top of the water-bath A is soldered the imbedding- cup C, which has a wire bas- ket, B, suspended by a wire, for holding the specimen. The apparatus can be heated on a stove, or over a gas or alcohol flame. Impregnation Imbedding.-In this process the specimen is soaked in the imbedding mass until it is thoroughly permeated with it. The proceeding is then like simple imbedding in a melted mass. Imbedding Masses : Gum.-A syrupy solution of gum acacia in water is used. The specimen is soaked in water for a few hours to remove the alcohol, and then placed in the gum solution until it is thoroughly perme- ated ; this requires from a few hours to a day or more, ac- cording to the size and density of the specimen. For speci- m e n s containing large cavities, Bloch- man uses a thin solu- tion of gum, and al- lows it to become of a syrupy consistency by evaporation. The evaporation is hast- ened by placing the vessel containing the mass under a bell-jar with fused calcium chloride. The latter absorbs the moisture rapidly. When the specimen has become thoroughly perme- ated, it is removed from the gum, placed on a cork, and allowed to dry in the air for a short time; then a fresh supply of gum solution is placed on it, and this allowed to partially dry ; and then the specimen is placed in alco- hol until hard. Sections are cut with a knife wet with alcohol, and placed in water to remove the gum. Sometimes the gum Fig. 1722.-Outlines for Imbedding-box. and finger, bent around so as to be applied to the end of the oblong, and fixed by turning down the flaps (Fig. 1723). Another plan, which I have found very conveni- ent, is to have a series of wooden blocks, the faces of which correspond to the sizes of the boxes to be made. One of these blocks is taken, and the paper or metal folded over the face corresponding to the sized box wished for. In folding, the material follows the lines shown in Fig. 1722, and we have a box without the trouble of any measurements. In Fig. 1724 is shown an adjustable imbedding-box of Fig. 1725.-Mayer's Water-bath. Fig. 1723.-Paper Imbedding-box. metal. It consists of two pieces, having the form of a carpenter's square-the long arm being 7 ctm. the short 3 ctm. in length, by 7 mm. high. On the outer side of the short arm is a block of metal, on the top of which is a spring (a, Fig. 1724), which curves over and presses against the long arm, thus holding the two pieces firmly together. The area of the box will vary with the po- sition of the pieces. The area of the box having been fixed, it is placed on a glass plate, moistened with glyce- rine, and a thin layer of the melted mass poured in. When it has cooled, the specimen, which has been washed Fig. 1726.-Gage's Imbedding-cup. in the mass, is fixed in position and the box filled up. When the imbedding mass has cooled the box is removed, and the specimen will be found imbedded in a solid block of the imbedding material. Fig. 1724.-Adjustable Imbedding-box. 671 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. becomes so hard by the action of the alcohol that it is difficult to cut the sections. This fault may be remedied by moistening the specimen from time to time with a lit- tle water, which partially softens the gum. Gum and Glycerine.-Hertwig uses for delicate tissues a mixture of gum and glycerine. He places the speci- men, previously soaked in water, in a dilute mixture of gum-solution and glycerine, and allows it to stand in the air until it has dried to a syrupy consistency ; then the specimen, with a quantity of the mixture, is placed be- tween two pieces of hardened liver, and the whole placed in alcohol until hard. The quantity of glycerine to be added to the mixture depends on the consistency wanted ; as a rule, not more than one-quarter of the volume of the gum-solution is to be added. Gelatine and Glycerine.-Kaiser recommends the fol- lowing mixture: One part of gelatine, six parts of wa- ter, seven parts of glycerine. The gelatine is soaked in the water until soft; then melted on a water-bath and the glycerine added ; then one cubic centimetre of carbolic acid is added to each thousand cubic centimetres of the mixture to preserve it, and the whole is filtered through flannel. The specimen, previously soaked in water, is placed in the mixture, and allowed to remain until per- meated, the mixture being kept at the melting-point on a water-bath. It is then placed in a box, fixed in position, and the box filled with the mass. After cooling, the box is placed in alcohol until the mass becomes hard. The sections are mounted in glycerine, or the imbedding-mass can be dissolved out in warm water and the sections mounted in other media. Egg Emulsion.-Calberla's method : The white of sev- eral eggs is separated from the yolk, the chalaza; removed, The specimens having been prepared by one of the above methods, the block is placed in a box and fluid mass poured on to the height of one to two centimetres above the block. The whole is now submitted to the ac- tion of alcoholic steam to harden, care being taken not to raise the temperature above 30° C., or innumerable air- bubbles will form in the emulsion. In Fig. 1727 is shown a piece of apparatus for harden- ing the emulsion. A shallow water-bath, a, stands on a tripod, b, and is heated by the flame c. The water-bath is covered by a glass plate, d, upon which is placed a small glass vessel, e, filled with alcohol and covered with a perforated disk of tin, f, upon which the boxes contain- ing the specimens are placed and the whole covered with a bell-jar. After one-half to one hour the mass will be- come coagulated. The boxes are then placed in ninety per cent, alcohol, which is changed at the end of twenty- four hours. After twenty-four hours more the specimen will be ready for cutting. The fluid mass may be pre- served for several days by placing a lump of camphor or thymol in it. Specimens imbedded by this method should have been previously stained in toto, as the mass itself stains strongly. Albumen.-Selenke uses the pure white of egg. The specimen, free from alcohol, is soaked for several hours in the white of egg ; then placed in a paper box which is filled with white of egg, and placed in the alcoholic steam-bath (Fig. 1727) for twenty minutes, and then placed in strong alcohol until hard. The advantage of this method is that the block of albumen can be rendered transparent by soaking in oil of cloves, the position of the specimen located, and the cutting regulated accordingly. Celloidin*-This is a pure pyroxylin, free from all for- eign constituents, and makes a clear solution free from sediment. It is soluble in a mixture of equal volumes of alcohol and ether, and the degree of concentration can be varied to suit any particular case. For use, a saturated solution of celloidin is made in al- cohol and ether, and a portion of this is diluted with a mixture of equal parts of alcohol and ether, so as to ob- tain a very dilute solution. The specimen is soaked in alcohol and ether over nightthen in the dilute celloidin for at least twelve hours ; then in a saturated solution for one to eight days, according to the size and density of the specimen. When the specimen has become thor- oughly permeated it is to be imbedded by one of the fol- lowing ways : (a) Cover the smooth surface of a cork with a thick layer of celloidin solution and allow it to dry. Then place the specimen, which has been soaked in celloidin, on this and cover it, layer by layer, with a solution of celloidin, allowing each layer to partially dry before ap- plying another. When the specimen is completely cov- ered allow it to stand in the air for half an hour, and then immerse in eighty per cent, alcohol for twenty-four hours, when it will be ready for cutting. (b) Imbed in a paper box in the usual way, and allow to stand, until a pedicle forms on the surface ; then im- merse in eighty per cent, alcohol for twenty-four hours. (c) A box is made by wrapping a strip of paper around a cork, allowing the paper to project an inch or an inch and a half above the surface of the cork, the paper being fastened by placing a rubber band around it. Pour into this box a small quantity of celloidin solution, and allow it to dry. These boxes can be made in quantities, on different sized corks, and kept in stock. The speci- men, having been soaked in celloidin, is placed in a box, adjusted as to position, and allowed to dry for five or ten minutes, so as to fix it; then the box is filled with celloi- din solution, and as soon as a pedicle has formed, is placed in eighty per cent, alcohol for twenty-four hours. To prevent the corks floating on the surface of the alcohol, Blochman fastens a bullet to the bottom of the cork with a needle, as is shown in Fig. 1728. I have found that when this method is adopted the air-bubbles formed in Fig. 1727.-Alcoholic Steam-bath. and the white cut up with a pair of scissors. To each fif- teen parts of white add one part of a ten-per-cent, solu- tion of sodium carbonate (ten parts of calcined sodium carbonate to one hundred parts of water). To this solu- tion add the well-shaken yolks and again shake w'ell. Pour the mixture into a deep vessel, allow' to settle, re- move the scum, and the mass is ready for use. The speci- mens, after being well washed in water, are placed in this mass until permeated. They are then fastened, with pins, to the freshly-cut surface of a piece of hardened mass. If the specimens are small, they are placed in a few drops of the fluid mass on a piece of hardened mass, and al- lowed to dry in the air for a few* moments. Very delicate specimens and thin membranes are fastened as follows : Thin slices of the hardened mass are soaked in the fluid mass for ten to twenty minutes. The specimen, having been soaked in the fluid mass, is arranged on the freshly- cut surface of a piece of hardened mass, covered with one of the pieces prepared as above, and fastened down with pins. * Celloidin is manufactured by E. Schering, of Berlin, and may be ob- tained of Bachrach & Broother, Baltimore, Md., or of Meyrowitz Broth- ers, Twenty-third Street and Fourth Avenue, New York City. 672 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Tech nique. the imbedding mass have a tendency to go to the surface, and if a thick layer of celloidin is placed over the speci- men, they will collect in it, leaving the specimen im- bedded in a mass free from holes. Viallanes uses chloroform for hardening the celloidin. He has found that this reagent coagulates the celloidin into a mass of the consistency of wax, but very elastic and perfectly transparent. He places specimens, previously soaked in ether, in a test-tube and covers them with a so- lution of celloidin. As soon as a film has formed on the celloidin, the tube is filled up with anhydrous chloro- form and left for two to three days, when the mass will be hardened and somewhat shrunken, so that it can be shaken out of the tube. It is then placed in fresh chloro- form for six days, when it will be ready for cutting. A. B. Lee found that a few hours' immersion in the chloro- form gave the required consistence, and in no case was more than three days required. The celloidin frequently becomes opaque on being put into the chloroform, but becomes transparent after a time. Sections are cut with a knife wet with alcohol, and may be stained with the usual staining agents. Some of the aniline dyes stain the celloidin intensely, and are not removed by alcohol. If sections are to be mounted in Canada balsam, they are dehydrated in ninety-five per cent, alcohol-absolute alcohol dissolves celloidin- cleared in oil of bergamot, sandalwood, or origanum, as oil of cedar or cloves dissolves celloidin. Wax and Oil.-Stricker uses equal parts of white wax and olive-oil, and melts on a water-bath. The specimens are dehydrated in alcohol, cleared in oil of cloves, and im- mersed in the warm mass until permeated. They are then imbedded in a paper box. Foster and Balfour use three parts of wax to one of oil. Cacao-butter.-The specimens are dehy- drated in alcohol, cleared in oil of cloves, placed in melted cacao-butter on a water- bath for a few hours, the temperature of the mass being kept just above the melting- point, and are then imbedded in a paper box. Sections are cut with a knife wet with alco- hol, the imbedding mass dissolved out with oil of cloves, the latter by alcohol, and this by water, when they can be stained by the usual methods. Kleinenberg uses a mixture of four parts spermaceti, one part cacao-butter, and one part olive-oil. The specimens, dehydrated in alcohol, are placed in oil of bergamot, and then into the melted mass. Sections are cut with a knife wet with olive-oil. The imbedding mass is dis- solved out with a mixture of four parts of turpentine and one part creasote. Strasser uses four parts of sperma- ceti, one part of castor-oil, and three to four parts of tal- low. This mass is fluid at a temperature of 45° C. Paraffin.-For imbedding, two kinds of paraffin are used, one melting at 45°, and the other at 54° C. By mixing these two in various proportions, masses may be obtained whose melting-point will range between these two. Paraffin should be chosen of a melting-point suit- able to the temperature of the laboratory. As a rule, a laboratory temperature of 18° C. requires a paraffin whose melting-point is 48° C. The specimen to be imbedded is placed, from alcohol, in chloroform until the alcohol is replaced by the latter ; this takes place quickly. The specimen is then removed to a dish containing fresh chloroform and shavings of paraffin added, so that after the evaporation of the chloro- form the specimen will remain covered by the paraffin. The vessel is now placed in a warm chamber, at the tem- perature of the melting-point of the paraffin, for one-half to one hour. The paraffin melts very quickly, and the specimen, from the evaporation of the chloroform, is bathed in a concentrated solution of paraffin in chloro- form, which soon penetrates the specimen, filling up all cavities. It is essential that all the chloroform should be driven off. When this has taken place, imbed in a box in the usual manner and allow to cool. After cooling, trim the block and clamp in the microtome, or mount it on a cork with a little melted paraffin. A. B. Lee recommends that the specimens be soaked in oil of cedar. This clears them rapidly, and the paraffin penetrates quickly and thoroughly. Sections are to be cut dry. If they have a tendency to roll, they can be held down by a camel's-hair brush, or by attaching a section-smoother to the knife. After cut- ting, the imbedding mass is to be dissolved out before staining. For this purpose, of the many solvents recom- mended, turpentine, naphtha, and xylol are the best. Transparent Soap.-Flemming uses a transparent soap free from glycerine, and dissolves it, by the aid of heat, in one-third to one-half its volume of ordinary alcohol, and filters. The specimen is placed in this warm mass, from alcohol, and when thoroughly permeated, imbedded in a paper box and allowed to stand in the air until dry. The sections are cut with a dry knife, and the imbedding mass washed out with warm water. Flemming recom- mends this mass for osmic acid preparations that have been hardened in alcohol. Kadyi makes a solution of any soda soap in alcohol. Twenty-five grammes of soap are dissolved in one hundred cubic centimetres of ninety-six per cent, alcohol on a water-bath and filtered. Water is added until a drop of the mass upon cooling no longer remains white, but is transparent. Specimens arc to be imbedded as in the above method. Sections are cut with a knife wet with alcohol, and the imbedding mass dissolved out with ninety-six per cent, alcohol with the aid of gentle heat. Wash in fresh alcohol and stain as usual. Copal.-This substance, introduced by von Koch, is recommended for spongy bone. A thin solution of chloro- form and copal is made by rubbing up small bits of co- pal in a mortar with fine sand, pouring chloroform on this fine powder, and filtering. The specimen is placed in an evaporating dish filled with solution, and the chloro- form driven off by heating gently. As soon as the solu- tion is concentrated enough to be drawn out into threads that become brittle upon cooling, the specimen is re- moved, placed on a tile, and allowed to dry for a day or two. When the mass becomes so hard that it cannot be indented with the finger-nail, sections are cut with a fine saw, and cemented to a slide with copal solution or Can- ada balsam. The slide is allowed to dry for a day or two on a warm tile, and when the cement is perfectly hard, the sections are ground down to the required degree of thinness and polished. The copal is dissolved out with chloroform, and the sections mounted in hard balsam. Methods of Staining.-As a rule, the sections to be stained are placed in the staining fluid from water, and Fig. 1728. Fig. 1729.-Syracuse Solid Watch-glass. allowed to remain in the former for various lengths of time-from a few seconds to twenty-four or forty-eight hours. The time depends on the nature of the stain and the result to be accomplished, and will be noted under the various stains. After the staining is complete, the sec- tions are to be washed in water, to remove all the excess of the staining fluid, mounted directly in glycerine, or, after dehydrating and clearing, in balsam. For holding the stains and for the operations of wash- ing, dehydrating, etc., we use small dishes1 of porcelain or glass, watch-glasses, etc. The Syracuse solid watch- glass (Fig. 1729) will be found very convenient. For transferring the sections, the spatula, or lifter (Fig. 1721), needles, camel's-hair brushes, glass rods, etc., are used. 673 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Innumerable substances are used for the purpose of staining, and each year adds a host to the list, many of which are of doubtful value. Only the most important stains will be treated of here. Carmine.-This dye, when first introduced, was used in the form of an ammoniacal solution, and is still em- ployed in this form. Ammonia solutions are not stable ; they undergo various chemical changes upon standing, so that the solution cannot be depended upon. Unless all free ammonia is driven off, the staining is apt to be diffuse. Of late various other solvents have been brought into use with good results. Tissues that are to be stained with carmine must be free from acid. Preparations hardened in chromic acid or so- lutions of chrome salts, must be well washed in water, and then they stain very slowly, requiring days. Ober- steiner hastens the process of staining by heating the fluid to 50° C., and keeping it at that temperature for an hour, when the staining will be completed. I lenle and Merkle soak sections in a one to five hundred aqueous solution of palladium chloride for ten minutes ; then in the carmine fluid for a few moments, when they become stained of a deep-red color. I have found that sections treated with cupric acetate, according to Weigert's method, stain equally as quick. If the stain is diffuse it can be removed by placing the sections in a mixture of one part formic acid and two parts of alcohol for from five to ten hours. This removes the stain, in sections of the central nervous system, from everything except the axis cylinders (Ranvier). Gierke places sections of tissues that have been hard- ened in chromic acid in a one per cent, aqueous solution of uranium nitrate, sulphate, or chloride for twenty-four hours ; then washes well in water and stains in a dilute solution of carmine for twenty-four hours. The sections stain a deep purple, and the nuclei stand out sharper than in the ordinary process. Before mounting, sections stained in carmine should be washed in a one per cent, solution of acetic or formic acid to fix the stain. Carmine stains deeply nuclei, protoplasm, smooth and striated muscle, the basement substance of bone tissue and decalcified bone, the axis-cylinders of nerves, etc. Ammonia Carmine Solutions.-Beal's: Carmine, 1 Gm.; ammonia, 3 c.c.; glycerine, 96 c.c.; distilled water, 96 c.c.; alcohol, ninety-five per cent., 24 c.c. Dissolve the carmine in the ammonia with the aid of heat, boil for a few moments, and allow to cool. After the smell of ammonia has disappeared add the glycerine, water, and alcohol, and filter. If, after standing for some time, the carmine precipitates, add a few drops of ammonia. Ranvier's: Carmine, 1 Gm.; ammonia, 1 c.c.; water, 100 c.c. Rub up the carmine in a mortar with a little water and add the ammonia. When the carmine is all dissolved add the rest of the water. If there is an excess of ammonia heat the solution until the carmine begins to precipitate. Hoyer's: Carmine, 1 Gm.; ammonia, 1-2 c.c.; water, 6-8 c.c. Dissolve the carmine in the ammonia and wa- ter ; heat on a water-bath until the excess of ammonia is driven off; allow to cool and settle ; decant the dark- colored fluid. This fluid is used for staining. For pre- serving add one gramme of chloral hydrate for each ten cubic centimetres of fluid. If this fluid be mixed with four to six times its volume of alcohol, a scarlet-red precipitate is thrown down. This precipitate is filtered off, washed, and dried, or made into a paste as follows : To each gramme of the powder add two cubic centimetres of alcohol, two cubic centimetres of glycerine, and one gramme of chloral hydrate. Both powder and paste can be preserved for a long time. For use dissolve in water. Heidenhain's: Carmine, 1 Gm.; ammonia, 3 c.c.; gly- cerine, 96 c.c.; water, 96 c.c. Dissolve the carmine in the ammonia and add the glycerine and water. Heat on a water-bath until the excess of ammonia is driven off, or neutralize with acetic acid. The sections are placed in a watch-glass of this fluid, and this, with a second watch-glass containing water with a trace of ammonia, is placed under a bell-glass for twenty-four hours. The sections at the end of this time are washed in water and exposed, as above, to the vapor of acetic acid. Mount in glycerine. Borax Carmine.-Thiersch's : Carmine, 1 Gm. ; sodi- um biborate, 4 Gm.; distilled water, 56 c.c. Dissolve the carmine and borax in the water; add 2 volumes of absolute alcohol for each volume of the solution, and filter. This produces a lilac stain well suited to cartilage and bone decalcified in chromic acid. Overstaining can be removed with an alcoholic solution of sodium bibo- rate, or oxalic acid. Woodward's : Dissolve 1 Gm. of carmine and 3.5 Gm. of sodium biborate in a mixture of 150 c.c. of water, and 330 c.c. of alcohol, and filter. The greater part of the car- mine remains on the filter in a crystallized form in com- bination with the borax. These crystals arc dissolved in 236 c.c. of distilled water and the solution evaporated one-half on a water-bath. Sections stain in this fluid in a a few minutes. They are washed in a mixture of hydro- chloric acid 1 part, alcohol 4 parts, until they are of a bright red color. Grenadier's: The author gives two formulae. In the first he dissolves 2 to 3 Gm. of carmine in a solution of 4 Gm. of sodium biborate in 100 c.c. of distilled water and then adds 100 c.c. of alcohol; filters, and after allowing the filtrate to stand a week, filters again. This solution is used chiefly for staining in toto. Pieces of tissue, accord- ing to their size, are placed in the solution for from one hour to three or four days ; then in acidulated alcohol (three to four drops of HC1 to 100 c.c. of seventy-five per cent, alcohol) for from one hour to three or four days. His second formula, known as neutral borax carmine, is as follows: 0.5 to 0.75 Gm. of carmine is boiled in a solu- tion of 2 Gm. of sodium biborate in 100 c.c. of water. The solution is filtered, and acetic acid added to the fil- trate until the purple tint changes to that of ordinary car- mine ; it is then filtered again. Sections stain in this fluid, in from one to three minutes, an intense and diffuse red color ; they are then washed in a mixture of one drop of HC1 to a watch-glass of seventy per cent, alcohol, when the color is withdrawn from everything except the nuclei. Lithium Carmine.-Oth's: Carmine, 2.5 Gm. ; satu- rated solution of lithium carbonate, 100 c.c. After staining, the sections are washed in a mixture of 1 c.c. of HC1, and 100 c.c. of seventy per cent, alcohol, when the coloris withdrawn from all except the nuclei. Piero-carmine.-Ranvier's : Add ammonia carmine to a saturated aqueous solution of picric acid, until a cloudy precipitate begins to appear. Evaporate to one-fifth of its original volume, allow to cool, and filter. Evaporate the filtrate to dryness, when a reddish powder is obtained. This powder is used in one per cent, solutions in water. Gage's: Take equal parts, by weight, of carmine and picric acid. Dissolve the picric acid in one hundred times its weight of distilled water, and the carmine in fifty times its weight of strong ammonia, mix the two solutions, and evaporate three-fourths at a temperature of 40° to 50° C. Allow the fluid to cool, and filter through two thicknesses of paper. Evaporate the filtrate to dry- ness at a temperature of 40° C., and dissolve the residue in one hundred times its weight of water. Make fifty cubic centimetres of such a solution and filter through absorbent cotton packed in the neck of a funnel ; repeat the filtering four or five times, when a clear solution should be obtained. If this is not the case, the remainder of the powder is dissolved in the proportion given above, and allowed to stand for a few days, in a tall glass cylin- der, and the clear fluid decanted. When a clear solution is obtained, add to every one hundred cubic centimetres of the picro-carmine, twenty-five cubic centimetres of strong glycerine, and ten cubic centimetres of alcohol. This solution can be kept clear by filtering once in six months. Weigert's : Soak 2 Gm. of carmine in 4 c.c. of strong ammonia for twTenty-four hours in a closed vessel ; then add 200 c.c. of a saturated solution of picric acid in water, and allow to stand for twenty-four hours. Filter, and add acetic acid to the filtrate, drop by drop, until a slight 674 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. precipitate appears even after stirring. Allow to stand for twenty-four hours, when a precipitate will form which cannot be wholly removed by filtering ; add am- monia, drop by drop, at intervals of twenty-four hours, until a clear fluid is obtained. If the solution stains too yellow, add a few drops of acetic acid ; if too red, a few drops of ammonia. Hoyer's : Dissolve 1 Gm. of carmine powder (see Hoy- er's Carmine) in 5 to 7 c.c. of ammonia and 1 to 5 Gm. of picric acid in 50 c.c. of water. IMix the two solu- tions, and add enough water to make the mixture measure 100 c.c., and add 1 Gm. of chloral hydrate for preserving. If any free ammonia is present, warm on a water-bath until it is driven off. Oth's : Mix one part of Oth's lithium carmine with two to three parts of a cold, saturated solution of picric acid in water. Sections stained in picro-carmine should not be washed long in water, or the picric acid stain will be washed out. They may be mounted in balsam or glycerine ; if mounted in glycerine it should be acidulated with a few drops of acetic or formic acid. Alum Carmine Solutions.-Grenadier's : Boil one-half to one per cent, of carmine in a concentrated solution of ammonia or potash alum for ten to twenty minutes, filter, and add a few drops of carbolic acid to the filtrate. Bal- biani adds a few drops of acetic acid to a watch-glass of this stain with good results. Tizzoni adds a little sodi- um sulphate, thereby increasing its staining power. This fluid stains quickly, and nuclei stronger than other parts. Acid Carmine Solutions.-Schneider's: Boil pulverized carmine in forty-five per cent, acetic acid until no more will dissolve ; filter, and dilute to one per cent for use. Schweigger-Seidel's : Add an excess of acetic acid to ammonia carmine, and filter. Stain sections a few mo- ments and wash in one-half per cent, solution of HC1, which removes the stain from everything, except the nuclei. Mount in glycerine containing one-half per cent, of HC1. Rollet's : Boil pulverized carmine in dilute sulphuric acid ; filter off the red precipitate, and dissolve in water for use. Hamann's : Dissolve 30 Gm. of carmine in 200 c.c. of strong ammonia; add acetic acid, drop by drop, until the fluid becomes neutral or slightly acid ; allow to stand for from two to five weeks, and filter. This solution stains quickly and safely. Over-staining is not to be feared. Bohm's: Mix 4 Gm. of pulverized carmine with 200 c.c. of water ; add ammonia, drop by drop, until the solu- tion becomes cherry-red ; then add acetic acid, drop by drop, until the color changes to brick-red ; filter until per- fectly clear. Stain for twenty-four hours, and remove the over-stain by washing in a mixture of 50 volumes of glyc- erine, 50 volumes of water, and half a volume of HC1. Recommended for karyokinetic figures. Alcoholic Carmine Solutions. - Grenadier's : Boil as much carmine as can be held on the point of the blade of a pocket-knife, in 50 c.c. of eighty per cent, alcohol, acid- ulated with four to five drops of HC1; allow to cool, and filter. If the filtrate is of a yellow color, add a little am- monia. If the fluid stains diffusely, add a little HC1. After staining, sections must be washed in alcohol, as water removes the color. Diffuse staining can be re- moved by washing in alcohol slightly acidulated with HC'l. Mayer's: Dissolve 4 Gm. of carmine in 100 c.c. of eighty per cent, alcohol, acidulated with thirty drops of HC1; heat on a water-bath for half an hour ; filter hot, and neutralize the excess of acid with ammonia. This solution stains rapidly. If a pure nuclei stain is wanted, wash sections in alcohol acidulated with HC1. Hoyer's : Heat carmine in a retort with alcohol, acidu- lated with sulphuric acid, until dissolved ; filter and di- lute largely wuth water. Add to the filtrate lead acetate as long as a rose-red precipitate forms. As soon as a vio- let precipitate appears, filter, and add to the filtrate lead acetate as long as the violet precipitate forms. Filter, wash, and dry the precipitate. Suspend the latter in a small quantity of strong alcohol; add alcohol, strongly acidulated with sulphuric acid, until the violet precipitate has lost its color and the alcohol becomes intensely red. Filter and use the filtrate for staining. Two drops of this fluid to a watch-glass of alcohol makes a strong stain. Cochineal Fluids.-Mayer's: Soak 1 Gm. of pow- dered cochineal in 10 c.c. of seventy per cent, alcohol, for at least three days. Filter, and use the deep-red filtrate for staining. Sections are placed in this fluid from seventy per cent, alcohol, and they stain in a few moments, or it may require several days, the time de- pending on the size and nature of the sections. When stained, wash in seventy per cent, alcohol until no more color comes away ; then mount in the usual media. The results obtained by the use of this fluid varies with the nature of the tissue, and the presence or absence of certain salts-also upon the strength of the alcohol em- ployed for solution. Overstaining may be removed by washing in one-tenth per cent. HC1, or one per cent, acetic acid. Czoker's Alum Cochineal.-Boil 7 Gm. of pulverized cochineal and 7 Gm. of alum in700 c.c. of distilled wa- ter, until the quantity of fluid is reduced to 400 c.c.; cool, add a few drops of carbolic acid, and filter. After stand- ing for a few days, filter again, when the fluid will be ready for use. Martinotti recommends the use of chrome alum in place of ordinary alum, and does not allow the temperature to go above 80° C. This fluid stains nuclei a haematoxylin color, other elements different shades of red. Alcoholic specimens stain quickly, in from three to five minutes ; chromic acid preparations require from three to five hours. After staining, specimens are washed in water and mounted in the usual media. Carminic Acid.-Carminic acid,17 the basis of the color- ing matter of carmine, is soluble in water, while carmine is not, requiring the aid of ammonia, borax, etc., to bring it into solution. By the use of carminic acid we get r.id of the caustic or destructive elements, and obtain an in- nocuous staining fluid. For the preparation of carminic acid Dimmock recom- mends two methods, De la Rue's and Schaller's. De la Rue's method is as follows : Cochineal is ex- hausted in boiling water.' The extract is precipitated with plumbic acetate slightly acidulated with acetic acid, care being taken not to add an excess of the lead. The precipitate is washed with distilled water until the wash- water ceases to give a precipitate with mercuric chloride, then decomposed with hydrogen sulphide ; it is now fil- tered-and the filtrate is evaporated to a syrupy consistence on a water-bath and dried; the dark-purple product is extracted with alcohol, which dissolves out the carminic acid. Schaller precipitates the aqueous extract of cochineal with plumbic acetate, acidulated with acetic acid ; decom- poses the precipitate with hydrogen sulphide, and filters. The filtrate is evaporated to dryness on a water-bath, and the residue dissolved in absolute alcohol; this solution is allowed to evaporate when the crystals of carminic acid separate. These crystals are freed from a yellow coloring matter by washing with cold water, which dissolves only the carminic acid. For use dissolve 0.25 Gm. of carminic acid in 100 c.c. of eighty-five per cent, alcohol. This so- lution stains sections in from two to five minutes. The sections are washed in absolute alcohol, cleared in oil of cloves, and mounted in balsam. Some preparations that were mounted in glycerine lost their color in a few months, while similar preparations mounted in balsam retained their color perfectly. This is also an excellent solution for staining in toto. Sections stained with this dye may have the stain re- moved from all parts except the nuclei by washing with dilute HOI. If sections are treated with an alcoholic solu- tion of mercuric chloride, washed in alcohol, and then stained with alcoholic carminic acid, they take a fine coloration of mercuric carminate. If, after staining, sec- tions are treated with a very dilute solution of plumbic acetate or cobalt nitrate in alcohol, a beautiful purple color is obtained. In some cases the salts contained in the tissue unite with the carminic acid, forming carmi- nates and giving double stains. 675 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tilage. It stains the cartilage cells, leaving the matrix clear. Duval found that it has a selective action on preparations of the spinal cord hardened in ammonium bichromate. Nerve-cells and their processes, axis cylin- ders, and connective-tissue fibres remain unstained ; nu- clei of connective tissue and capillaries stain red. Ranvier's Solution : Dissolve 1 Gm. of either ammonia or potash alum in 200 c.c. of water; add an excess of purpurin and boil. Filter hot into a flask containing 60 c.c. of alcohol. This gives an orange-rose colored fluid of considerable fluorescence. The solution does not keep for more than two weeks. Grenadier's Solution : Dissolve one to three grams of alum in fifty cubic centimetres of glycerine ; add an ex- cess of purpurin and boil. Allow the mixture to stand for two to three days and filter. This makes a stable solution and gives a clear nuclei stain after ten to twenty minutes' action. Ribesin.-The juice of the black currant {Ribes ni- grum). It was introduced by H. Fol, and gives a clear, nuclear stain resembling haematoxylin. It is prepared as follows : The juice of the black currant having been ex- pressed, the skins are boiled for several hours in a ten per cent, solution of alum ; then diluted with water ; al- lowed to stand for twenty-four hours, and filtered. The filtrate is used for staining. Stains similar to Bohmer's haematoxylin, is well suited for alcohol and chromic-acid preparations, but less so for potassium bichromate ones. Myrtillus.-The juice of the common bilberry (Vac- cinium myrtillus'). Express the juice of the fresh berries and mix with two volumes of water, to which one per cent, of alcohol has been added ; heat for a short time and filter warm. Dilute the filtrate with two to three volumes of water for use. Two shades of color are obtained with this tincture, one resembling carmine, the other a lilac color, resembling haematoxylin. The first shade is obtained by staining fresh neutral speci- mens with the fresh acid myrtillus fluid. Specimens hardened in chromic acid or its salts give the same shade. The red shade is not durable. More durable prepara- tions are obtained with the lilac color. Lardowsky stains sections as follows: The sections are stained for one to two minutes in the acid myrtillus solution, washed in water, and placed in a one per cent, solution of lead acetate, until the color becomes of a lilac shade. They are then washed well in water and mounted in glycerine, to which a little lead-acetate solution is added, or are mounted as usual in balsam. This method gives a clear nuclei stain resembling haematoxylin, and brings out karyokiuetic figures well. Red Cabbage.-M. Flesch mixes a concentrated watery extract of red cabbage with a solution of lead acetate ; precipitates the lead with carbonic acid gas, the precipi- tate carrying down the most of the coloring matter. Fil- ters and washes the precipitate with water, and dissolves it in an acid ; neutralizes the solution, decomposes it with hydrogen sulphide, and filters. The filtrate containing the coloring matter is evaporated to dryness on a water- bath. For use an alcoholic or aqueous solution of the powder is made. This fluid stains the nuclei of fresh and hardened preparations green, protoplasm red. Orchella.-Wild drives off the free ammonia of the French extract by heat, and adds this to a mixture of 20 c.c. of absolute alcohol, 5 c.c. of acetic acid, and 40 c.c. of distilled water, until a dark red-colored fluid is obtained, and filters once or twice. Sections to be stained are washed well in water and then placed in this fluid. Protoplasm of cells stain while their nuclei remain clear. Connective-tissue cells stain deeply, the intercellular sub- stance faintly. The basic substance of bone and teeth, ganglionic cells and their processes stain deeply. Indigo-carmine.-1Thiersch makes a saturated solution of indigo-carmine in a solution of oxalic acid of the strength of 1 part to from 22 to 30, and dilutes with alco- hol for use. Nuclei and protoplasm stain deep blue. Overstaining can be washed out with a solution of oxalic acid in alcohol. Norris and Shakespere have used this dye in combina- tion with carmine as a double stain (see double staining). Hematoxylin.-This is one of the coloring substances contained in ordinary logwood. It is found in commerce in the form of reddish-brown crystals. Haematoxylin is not to be confounded with the ordinary crude extract which is sometimes sold under this name. This dye is one of the best nuclei stains that we have, staining both alcoholic and chromic acid specimens deeply and sharply. In chromic acid preparations the color is likely to fade after a time, unless all the acid has been re- moved and the sections thoroughly dehydrated before mounting. Gibbes recommends that sections of chromic acid preparations be treated with a one-per-cent, solution of sodium carbonate for ten to twenty minutes, and then washed well in water before staining. The clearest stainings arc obtained with dilute solu- tions. After staining, the sections are washed well in water and mounted as usual. Bohmer's Solution : Dissolve 0.35 Gm. of haematoxylin crystals in 10 c.c. of alcohol; and 0.1 Gm. of potash ahim in 30 c.c. of distilled water. Allow the first solution to stand in the light for from three to four days and then filter. For use add the first solution, drop by drop, to the second, until a violet-colored fluid is obtained. Kleinenberg's Solutions : 1. Add to a saturated solu- tion of calcium chloride in seventy per cent, alcohol as much potash alum as it will take up. 2. Saturated solu- tion of potash alum in seventy per cent, alcohol. Mix this solution with the first in the proportion of eight to one. 3. Saturated solution of haematoxylin crystals in (a) alcohol or (b) in solution 1. For use one drop of the haematoxylin solution (a) or (b) is add :d to 2. Mayer modifies this solution by adding to the saturated solution of calcium chloride and alum six to eight vol- umes of seventy per cent, alcohol. To this is added a saturated solution of haematoxylin in alcohol until the re- quired degree of concentration for staining is obtained. Dippel mixes as aturated solution of aluminum chloride in alcohol with six to eight volumes of seventy pel' cent, alco- hol, and adds to this an alcoholic solution of haematoxylin. Friedlander's Solution : Haematoxylin crystals, alum, each 2 Gm.; alcohol, glycerine, distilled water, each 100 c.c. Filter before using. Delafield's Solution : Saturated solution of ammonia alum, withan excess of crystals, 100c.c.; to this is added 1 Gm. of haematoxylin crystals dissolvedin 6c.c. of alco- hol. This solution is allowed to stand in an unstoppered bottle in the light for four or five days, and then filtered. Then glycerine, 25 c.c., and wood naphtha, 25 c.c. are added ; this is allowed to stand, as above, for one to two days, and then filtered ; the filtering is to be repeated at intervals, until all sediment ceases to form. Dilute at least one-half with water for use. Alleyer Cook's Solution : 6 Gm. of extract of log- wood, 6 Gm. of alum, 1 Gm. of cupric sulphate, and 40 c.c. of water are rubbed up into a paste in a mortar. This is allowed to stand for two days and then filtered ; a crystal of thymol is added to the filtrate for preserving. Fresh and alcoholic preparations are quickly stained by this fluid ; but for chromic-acid preparations the follow- ing mixture is used : Dilute 8 drops of the stain with 120 drops of water, and add 1 drop of a one-tenth per cent, solution of potassium bichromate just before using. Wash well in water. Heidenhain's Method : Pieces of tissue, hardened in al- cohol, are placed in a one to two per cent, solution of hae- matoxylin crystals in water, for from eight to ten hours ; then in a one to two per cent, solution of potassium bi- chromate for the same length of time. Wash well in water and proceed in the usual way. Sections must be very thin. Nuclei stain black, tissue elements more or less dark-gray or black. In epithelial cells the protoplasm is darker than the other elements. If a one per cent, solution of alum is used in place of the bichromate, a blue color is obtained. Gierke places sections for twenty-four hours in a one- fourth to one-half per cent, aqueous solution of haema- toxylin and then for ten to twenty hours in a one-half per cent, solution of potassium bichromate. Purpurin. - One of the coloring substances of the madder root was first used by Ranvier for staining car- 676 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hiatologieal Technique. Anilin Dyes.*-Fuchsin, Rosanilin Hydrochloride.- Soluble in alcohol and water. Used for staining fresh tissue, blood-cells, and connective-tissue cells. Chiefly used for staining bacteria. Merkle has used it for stain- ing the structureless membrane of the retina. Acid Fuchsin, Rosanilin Sulphonate.-(Fuchsin S, No. 130 of the Baden anilin factory.) Used by Weigert for staining the central nervous system, and by P. Michelson18 for investigations on the skin. Safranin, -An oxidation product of pure toluol. Soluble in alcohol and water. A nuclei stain best suited for chromic acid preparations. Pfitzner dissolves one gram of safranin in one hundred cubic centimetres of absolute alcohol; allows it to stand for two to three days, and then adds two hundred cubic centimetres of distilled water. He washes the sections in water, stains in this fluid for one hour ; washes in water ; dehydrates in absolute alcohol, which removes the most of the color ; clears rapidly in oil of cloves, and mounts in balsam. Flemming dissolves one-tenth to five-tenths per cent, in a mixture of equal parts of alcohol and water. Stains sections for twenty-four hours ; washes in weak alcohol, which frees them from part of the color; then in absolute alcohol, until no more color comes away ; then in oil of cloves only long enough for them to become penetrated, as it extracts the colors ; mounts in balsam. Bouma employs safranin in aqueous solutions of 1 to 2,000, for staining sections of developing bone. After staining, the sections are washed in acidulated water. Bone and connective tissue stain red, cartilage yellow. Babes recommends the following methods : 1. Sections of alcoholic or chromic acid preparations are stained for half an hour in a warm, concentrated aqueous solution of safranin, or in a mixture of equal parts of concentrated aqueous and concentrated alcoholic solutions. They are then washed in absolute alcohol quickly, as it withdraws the stain, cleared in turpentine, and mounted in balsam. 2. For demonstrating the details of cell-structure, and for bacteria. A super-saturated solution of safranin in water is warmed to 60° C. and filtered. After cooling, the solution becomes muddy. A small quantity of this fluid is placed in a watch-glass with the sections, and warmed slightly over an alcohol lamp for a minute, when the fluid will become clear. The sections are then washed in water, cleared in turpentine, and mounted in balsam. 3. For many purposes, especially for tumors of the cen- tral nervous system, the sections are stained for twelve to forty-eight hours, and then handled as in previous meth- ods. 4. Small bits of tissue are placed in a mixture of equal parts of alcoholic solution of safranin and oil of cloves, or oil of origanum, which is placed under a bell-jar of an air-pump, the air exhausted, and allowed to remain for one hour. Sections are now cut and mounted in bal- sam. The staining is diffuse-connective tissue and cells stain rose-red, muscle fibres and elastic tissue yellow. By washing the sections in an alcoholic solution of potassa, all is decolorized except elastic tissue and muscle. These sections are to be preserved in potassium acetate. Safranin staining is especially recommended by the au- thor for pathological work. " Although the sections ap- pear to be unstained, yet they show the following struct- ures: nuclei of white blood cells, granules in the same, and in cells of rapidly proliferating granulation tissue ; filamentous bodies occurring in connection with develop- ing blood-vessels ; nuclei of giant-cells and nucleoli of all large-celled sarcomata and carcinomatous tumors." Safranin is also a good reagent for amyloid substance, staining it orange-yellow, other tissue rose-red. Eosin.-This dye is found in commerce in two forms. One soluble in alcohol (tetrabromofluorescm), the other in water (a potash salt of the first). Fischer, who first introduced the dye, used an aqueous solution of 1 to 20, a few drops of this solution being added to a watch-glass of water, and stained the sections in this fluid for twenty-four hours. Later he precipitated the coloring matter from an aqueous solution with an acid ; filtered and washed the precipitate with water, and then dissolved the precipitate in alcohol. He prefers the alcoholic solution for chromic acid preparations. Eloni dissolves the eosin in glycerine, and after stain- ing, fixes the dye with a saturated solution of alum in glycerine. For general use a one-half to one per cent, solution in alcohol or water, will be found most convenient. Sec- tions are stained for a few moments and mounted in gly- cerine tinged with eosin, as pure glycerine withdraws the color. For mounting in balsam the sections are dehydra- ted in the alcohol eosin and cleared in oil of cloves, with- out any previous washing. This clye, in combination with haematoxylin, is the best for general work, the haematoxylin staining the nuclei of the cells purple, while the cell bodies and inter- cellular substance are stained rose-red. Orange III, Gold-orange. Dimethyl-anilin-azo-p-benzo- sulphate of Ammonia.-Soluble both in alcohol and water. Stains fresh, alcoholic, and chromic acid preparations ; bone orange-red, muscle and cartilage golden, connec- tive tissue reddish. An excellent stain for glandular organs and preparations whose vessels have been injected with blue. Strong solutions are to be used, as alcohol re- moves considerable of the color. Anilin Blue.-Salts of the phenylate rosanilins. Insolu- ble in water, but soluble in alcohol. Employed by Ran- vier for staining hard bone. Bits of bone are placed in a strong alcoholic solution of the dye, and heated on a water- bath for from one to two hours ; then ground down on a smooth stone moistened with a two per cent, solution of sodium chloride ; washed well in the same solution, and mounted in glycerine diluted with an equal volume of the salt solution. Soluble Anilin Blue, Nicholson's Blue.-The sulpho- nates of phenylrosanilins. Generally employed in one per cent, solutions. Sections are stained for a few mo- ments only, washed in water, and mounted in glycerine or balsam. Frey recommends this dye for lymph-glands, spleen, intestines, and central nervous system. It stains the axis-cylinders, nerve-cells, and peptic cells of the stomach deeply. Quinolin Blue, Cyanin. Quinoliniodocyanin.-Ranvier makes a strong alcoholic solution and dilutes this with water for use. After staining, the sections are to be mounted in glycerine. Nuclei stain violet; nerves, gray- blue ; smooth muscle, blue ; protoplasm, blue ; fat, deep- blue. Ranvier found that after the sections had been in glycerine for twenty-four hours, the nuclei became de- colorized , protoplasm and nerves retain the color, but seem to contain granules stained a deep blue. If the sec- tions be treated with a forty per cent, solution of potassa, this reaction takes place immediately. Methyl Blue.-An oxidation product of pure anilin. Soluble in both alcohol and water. Used chiefly for staining bacteria. Sahli has employed it for staining the central nervous system. Methyl Green-The double zinc salt of the base penta- methyltri-p-amidotriphenylcarbinolmethylate. Used in one per cent, aqueous solutions, and is chiefly a nuclei stain. Calberla found that it stained the nuclei of vessels and nerve-sheaths rose-red, cells of the corium and their nu- clei red-violet, and the cells of the rete Malpighii greenish- blue. Carnoy employs it in a concentrated aqueous solution, to which is added one per cent, of acetic acid and one- tenth per cent, of osmic acid for staining fresh tissue. Nuclei stain sharp. The excess of color is washed out with water. Curshmanu recommends this dye as a reagent for amyloid, which it stains violet. Iodine Green, Hoffman's Green.-The hydriodide of te- tramethylrosanilinmethyliodide. Griesbach employs this dye in the strength of one-tenth of a gram to thirty-five * These dyes can be obtained of Meyrowitz Brothers, Twenty-third Street and Fourth Avenue, New York. 677 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cubic centimetres of water. Sections are placed in the dye from water. They stain almost instantly, and fre- quently diffusely. They are then washed in water and mounted in glycerine, or, after dehydrating and clearing, in balsam. Alcohol does not extract the color. Chiefly a nuclear stain, but it has a remarkable selective action for certain tissues, which it stains various hues. Gland- tissue stains dark green ; epithelium, blue ; muscle-fibres, malachite-green ; nuclei, a darker shade. Good stains are also obtained with blood, spermatozoa, and bacteria. On account of the expense of preparation this dye has been superseded by methyl green in commerce. For histological purposes it can be obtained of D. G. Griibler, No. 17 Dufour Strasse, Leipzig. Iodine Violet, Hoffman's Violet (a, Dahlia, bluish tint ; b. Primula, reddish tint).-The pentamethyltriamidotolu- yldiphenylcarbinol. Ehrlich employs a saturated solution in a mixture of five hundred cubic centimetres of alcohol, one hundred cubic centimetres of water, and twelve and a half cubic centimetres of acetic acid. Stains sections for twenty- four hours ; then washes in water acidulated with acetic acid, and mounts as usual. Protoplasm and connective tissue are partially stained; nuclei stain blue-violet. Some- times the fat of fat-cells and goblet-cells stain. Jurgens employs an aqueous solution as a reagent for amyloid, which stains bright red, while the rest of the tissue stains blue-violet. Treitel19 found that this dye stained normal medullary nerve-substance deeply, while degenerated nerve-fibres stained but slightly, and connective tissue not at all. He employed one drop of a one per cent, solution to ten cubic centimetres of water, and stained sections for one min- ute. Tissues hardened in Muller's fluid do not stain. Flemming employs the dye in the same .manner as safranin. Gentian Violet.-Employed chiefly for staining bac- teria. Methyl Violet, Leonard's Tint.-The pentamethyltria- midotriphenylcarbinol. Cornil found that aqueous solutions stained the cells of hyaline cartilage violet, the basement substance red- dish, connective tissue, fibrillated and elastic fascia violet. Baumgarten stains sections of decalcified developing bone in an aqueous solution of this dye for two to ten minutes ; then washes in a mixture of two to three drops of acid to a watch-glass of water, until the blue tint changes to violet; then washes in water and mounts as usual. Cartilage stains light blue to lilac, ossific carti- lage violet to rose, bone reddish (often very slightly or not at all), medullary tissue light blue. This dye is also used as a reagent for amyloid, which it stains red. According to Capparelli20 this reaction is an optical instead of a chemical one. He examined un- stained sections by light transmitted through a thin layer of this dye and found that the amyloid substance ap- peared as if it had been stained. He then examined un- stained sections on glass stained with the colors of the spectrum, and found that in the section on the violet the amyloid substance appeared red, while the normal tissue appeared blue. His conclusion was that the amyloid substance permits the red rays to pass, but stops the violet. This dye is also used in staining bacteria. Anilin Blue-black, Nigrosin.-The chloride or sulpho- nate of the base, Ci8Hi6N3. Two forms of this dye are found in commerce-one soluble in water, the other in alcohol. The one soluble in water is to be employed. This dye was first used by Sanky for staining the cen- tral nervous system, in 1876, and again revived by Beran Lewis. Its use will be treated of under Staining of the Central Nervous System. Anilin Black, Collin's Black (CsIIsN).-Luys recom- mends a one-tenth per cent, aqueous solution for stain- ing sections that are to be photographed. The sections are to be stained for from three to four minutes and mounted as usual. Bismarck Brown, Vesuvin.-The chloride of triamido- azobenzol. Weigert makes a concentrated solution in boiling water and filters. Sections stain almost instantly. After stain- ing, the sections are washed in alcohol, which removes the excess of the color, and mounted in glycerine or bal- sam. Nuclei stain brown, connective tissue and proto- plasm light yellow. It is an excellent stain for sections that are to be photographed. Mayer employs a staturated solution in alcohol. List employs it in combination with methyl green as a double stain. It is also used as a contrast stain for bacteria that have been stained violet. Acetic Acid Anilin Solutions.-These solutions resem- ble the acetic acid carmine solutions in confining their action to the nuclei. They are good stains for fresh preparations. Ehrlich employs a saturated solution of dahlia in a mixture of fifty cubic centimetres of absolute alcohol, one hundred cubic centimetres of water, and twelve and one-half cubic centimetres of acetic acid. Sections are stained for twenty-four hours; then washed in alcohol, which removes the color from all the tissues except the nuclei and plasma cells. In some cases, especially for connective tissue, eight cubic centimetres of acetic acid in the above mixture suffice. Strasburger employs a small quantity of methyl green, Bismarck brown, or methyl violet in a one per cent, so- lution of acetic acid. The quantity of dye used should be regulated by the size of the specimen, so that the nuclei will take up the greater part of the dye. If over- staining occurs it may be removed with a one per cent, solution of acetic acid. Double Staining.-Haematoxylin and Eosin.-Sec- tions are first stained in a solution of haematoxylin until they are of a distinct purple color, then washed well in water, and then stained in a dilute alcoholic solution of eosin. They can be mounted either in glycerine or bal- sam. If in glycerine, it is to be slightly tinged with eosin, or the color will be extracted from the specimen. If in balsam, the specimens are placed in alcoholic eosin, in which they become stained and dehydrated at the same time ; then cleared in oil of cloves, which extracts some of the color, and then mounted in balsam. Nuclei stain purple, cell bodies and intercellular substance rose-red. This method is extremely useful for general work. Renaut makes a saturated solution of eosin in glyce- rine containing sodium chloride, and mixes this with a saturated solution of potash alum in glycerine. To this mixture he adds an alcoholic solution of haematoxylin until the green fluorescence of the eosin becomes im- perceptible, filters, and uses the filtrate for staining. The sections are to be mounted in the staining fluid, or, if in Canada balsam, they must be dehydrated in eosin alcohol and cleared in oil of cloves. Osmic and chromic acid preparations give selective stains. Nuclei violet, con- nective tissue pearl-gray, elastic fibres and blood-cells deep red, protoplasm and axis cylinders light red. Haematoxylin and Carmine.-Strelzoff uses a double staining of haematoxylin and carmine for sections of de- veloping bone. The calcified bone stains blue, the new bone red. This stain is not permanent, the haematoxy- lin fading in the course of a year. Sterling uses a combination of haematoxylin and picro- carmine for the skin, developing bone and smooth muscle. Gibbes, after staining in picro-carmine, washes the sec- tions for an hour in water acidulated with acetic or picric acid ; then in the haematoxylin. This is recommended for cell division and the development of epithelium and spermatozoa. Ribsein and Eosin.-This process is the same as for haematoxylin and eosin, or the two stains can be mixed. The alcohol and oil of cloves must contain a little eosin. Eosin and Methyl Green.-Calberla mixes one part of eosin with sixty parts of methyl green, and dissolves this in warm thirty per cent, alcohol. Sections are stained in this fluid for five to ten minutes, then washed quickly in successive alcohols, and mounted in glycerine. Nu- clei stain reddish-violet or blue, cell-bodies rose-red, stri- ated muscle red, nuclei green, smooth muscle green, the 678 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. intercellular substance red. Cells of the ducts of salivary glands stain blue, secreting cells and cells of surrounding connective tissue greenish-blue. In tendon the connec- tive tissue surrounding the bundles stains faint green, nu- clei intense green, Ranvier's cells green, and the stroma of the tendon bundles rose-red. List uses these stains separately. He first stains in an alcoholic solution of eosin (5 c.c. of a one-half per cent, aqueous solution of eosin to 15 c.c. of alcohol) for two to five minutes ; then in a one-half per cent, solution of methyl green. Eosin and Dahlia, etc.-Schiefferdecker stains sections first in Fischer's solution of eosin for one-half to three hours, then in a one per cent, aqueous solution of dahlia, methyl violet, or anilin green for a few minutes, when they become almost black. Washes in water and then places in alcohol, which withdraws the excess of the stains, until the proper color is obtained ; clears in oil of cloves, and mounts in balsam. The anilin green stains green, the others blue. The eosin stains protoplasm, while the others principally the nuclei. These stains are selective in their action. Cartilage stains blue, cell-mem- branes red, elastic fibres bright red, connective tissue dark rose, bone scarlet. Beautiful pictures are obtained with bone and cartilage, glands of the digestive system, prostate, ovary, female generative organs, and lymph- nodes. Not good for muscle, kidney, or sense organs. Bismarck Brown and Methyl Green.-List stains sections for one to fifteen minutes in Weigert's solution of Bis- marck brown ; washes in water, and stains in a one-half per cent, aqueous solution of methyl green until they are a dark green color ; washes in water, and places in abso- lute alcohol until they become of a sap-green color ; clears in oil of bergamot or xylol, and mounts in balsam. Nu- clei stain dark green, cell substance lighter. Intercel- lular substance of mucous membrane and goblet-cells stain brownish-green or dark brown. Carmine and Anilin Blue.-Duval stains sections by the usual method in carmine ; then for ten minutes in an al- coholic solution of anilin blue (ten drops of a saturated solution to ten cubic centimetres of alcohol). Dehydrates, clears in turpentine, and mounts in balsam. Nerve-cells and axis-cylinders stain reddish-violet; blood-vessels blu- ish-violet ; connective-tissue elements blue. This is ap- plicable to all tissues. Picro-carmine and Iodine Green.-Sections are stained for from one-half to one hour in picro-carmine, washed in water acidulated with acetic acid, stained for a moment in a one per cent, solution of iodine green, washed in water, dehydrated rapidly in alcohol, cleared in oil of cloves, and mounted in balsam. Sections of developing bone stained by this method show cartilage green, bone red. In the skin the super- ficial epithelial layers Stain yellow, rete Malpighii green, ducts of sweat-glands green, connective tissue red. Mu- cous glands stain green. Indigo-carmine and Carmine.-Norris and Shakespeare prepare the following solutions: carmine, and then for several hours in Delafield's haema- toxylin, washed in water and mounted in glycerine or balsam. Fibrillae of connective tissue stain rose or red ; muscle, yellowish-red, also all cell-bodies ; cell-nuclei, dark purple violet; horny substance of hair, yellow (pale green in old chromic-acid preparations) ; the inner root- sheath, so far as it is horny, a brilliant light blue. Metallic Impregnations.-Silver Nitrate.-This is used chiefly for staining the cement-substance between cells, especially the endothelium of serous membranes, lymphatics, and blood-vessels. It also stains the base- ment substance of connective tissue and cartilage. It may be used either in the solid state or in solution. The tissues to be acted upon must be fresh. For membranes, silver nitrate is used in solutions of 1-300 to 1-500. The fresh membrane (omentum or mes- entery) is carefully removed and stretched over the rim of a porcelain dish, filled with distilled water, and is al- lowed to sag in the centre so that both sides of the mem- brane will be immersed in the water ; it is washed care- fully by agitating the dish, so as to remove any blood or albuminous substance that may be on the surface. Now pour off the water carefully, and fill the dish with a 1 to 500 aqueous solution of silver nitrate. Agitate the dish frequently, and after twenty to thirty minutes-when the membrane has become semi-opaque-pour off the silver solution and wash carefully with distilled water. Now transfer to a dish containing alcohol and water (1 to 2) and expose to the sunlight until it becomes of a brown color. This requires from twenty minutes to half an hour. Pre- serve in glycerine and protect from the light. The silver is deposited in the cement-substance between the cells as an albuminate, and after being reduced by the action of the light, shows as fine black or brownish lines. • The cornea may be treated with silver in solution or in the solid state. In treating the cornea with the solid salt proceed as follows : Remove the eye and rub the anterior surface of the cornea with a piece of silver nitrate. Excise the cornea and place in distilled water; brush with a camel's-hair pencil to remove the epithelium. Then ex- pose the cornea to the action of the light until it has be- come brown. Preserve in glycerine. Silver in solution is applied as follows: Submit the cornea of a freshly killed animal to the action of a jet of steam, and scrape off the opaque epithelium, gently, with a scalpel. Allow a five per cent, solution of silver nitrate to flow over it, from a pipette, for two or three minutes ; then wash with a one per cent, solution of sodium chlo- ride ; excise and expose to the light in a mixture of al- cohol and water (1 to 2) until it becomes brown. Pre- serve in glycerine. By these processes the basement-substance becomes stained yellowish brown, the cell-spaces appearing as clear, irregular-shaped openings. For injecting the blood-vessels, a one-fourth per cent, aqueous solution is used. The animal is bled to death, and the vascular system washed out with distilled water ;* this is followed by the silver solution, which is allowed to act for ten minutes and is then washed out with distilled water. Bits of thin membrane are removed and exposed to the light until brown, and then mounted in glycerine. In warm-blooded animals the solution should be heated to 30° C.; in cold-blooded animals the injection may be made at the ordinary temperature. Hoyer adds to a solution of silver nitrate, of known strength, concentrated ammonia until the precipitate which forms is seen to be just barely redissolved ; then dilutes this solution with distilled water until it con- tains from 0.75 to 0.5 per cent, of silver nitrate. This solution stains the cement-substance only, leaving the ordinary tissues unstained. Instead of reducing the silver by light I have employed an aqueous solution of hydrochinon (1 to 1,000), to which is added a few drops of a saturated solution of ammonia carbonate to render it alkaline. The tissue, after being treated with the silver, is placed in this solution until it No. 1. Carmine 2 Gm. Sodium biborate 8 Gm. Water 130 c.c. No. 2. Indigo-carmine 8 Gm. Sodium biborate 8 Gm. Water 130 c.c. The solutions are thoroughly mixed in a mortar, and, after standing, the supernatant fluid is poured off and pre- served for use: Sections are stained in a mixture of equal parts of the above fluids for fifteen to twenty minutes, then transferred, without washing, to a saturated aqueous solution of oxalic acid, and allowed to remain in this for ten to fifteen minutes. When sufficiently bleached they are to be washed well in water and mounted in glycerine or balsam. The basement-substance of connective-tissue cartilage and bone stain blue, the cells red. Ganglion cells stain purplish, their nuclei red, and the nucleoli blue. The medullary sheath of nerve-fibres stains blue or green, the axis-cylinders red. Sections of the kidneys, liver, spleen, intestinal tract, and lungs give beautiful pictures. Piero-carmine and Hamatoxylin.-Flemming uses this combination for staining the inner root-sheath of hairs. The sections are stained for twenty-four hours in picro- ♦Reich (Sitzber. d. Wien. Akad., 1873) uses a one-eighth to one- fourth per cent, solution of potassium nitrate in water for washing out the vessels. 679 flistoloaical Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. becomes brown, which requires from five to ten minutes ; then it is washed thoroughly in water and preserved in glycerine. Krauss uses a bright-red solution of potassium perman- ganate for reduction. The tissue is placed in this solu- tion after washing, and the reduction is very rapid, even in the dark. Sometimes failures occur. Oppitz treats tissue impregnated with silver with a quarter to a half per cent, solution of stannic chloride. The reduction is very rapid, and the precipitate fine grained. Auric Chloride.-Gold is reduced in the bodies of cells of cartilage, connective tissue, cornea, and epithelium, leaving the intercellular substance free ; also in the axis cylinders of nerve-fibres. It is very uncertain in its ac- tion, but when successful beautiful pictures are obtained. Tissues submitted to its action must be fresh. Cohnheim's Method : Cohnheim, who introduced this salt, proceeds as follows: Bits of fresh tissue are placed in a one per cent, solution of auric chloride until they be- come yellow, and are then exposed to the light in water acidulated with acetic acid until the gold becomes re- duced-until it becomes of a deep purple color ; this re- quires from one to three days. The specimens are pre- served in glycerine. Lowit's Method : Lowit employs the following method for nerve-terminations in muscle: Bits of tissue are placed in a mixture of 1 part formic acid and 2 parts water, until they become transparent; then for ten or fif- teen minutes in a one per cent, solution of auric chloride until they become yellow; then in the formic-acid mixture for twenty-four hours in a dark place ; then for twenty- four hours in pure formic acid in the dark. After this they are washed in distilled water and preserved in glycerine. Ranvier's Method: Bits of fresh tissue are placed in fresh filtered lemon-juice, until they become transparent. Then wash in water and place in a one per cent, solution of auric chloride for fifteen to twenty minutes ; then wash in water, and place in dilute acetic acid (2 drops to 50 c.c. of aq.), and expose to the light for two to three days, when the reduction will become complete. For muscle he places the tissue from the gold solution in a twenty per cent, solution of formic acid in the dark for twelve hours, when the reduction will be complete. He also employs the following mixture : One per cent, solution of auric chloride, 4 parts ; formic acid, 1 part; boil and allow to cool. Bits of fresh tissue are placed in this mixture for twenty minutes ; then washed in water, and placed in formic acid 1 part, water 4 parts, in the dark for twenty-four hours. Pritchard's Method : After the tissue has been treated with the gold solution, Pritchard reduces the gold with the following mixture: Amyl alcohol, 1 c.c.; formic acid, 1 c.c.; water, 98 c.c. The tissue is removed from the gold solution, washed in water, and placed in the above mixture for twenty-four hours in the dark, when it will probably have become of a violet color ; if not, it is placed in a fresh quantity of the fluid for twenty-four hours longer. Wash in water and harden in alcohol. Chrchtschonovitsch's Method : The fresh tissue is placed in a one-half per cent, solution of auric chloride for thirty to forty-five minutes ; then in distilled water for twenty-four hours ; then in a saturated solution of tar- taric acid, at a temperature of 50° C., until the gold is re- duced. Wash in water and harden in alcohol. Auric and Potassium Chloride.-This is of a more un- varying composition than the simple chloride ; it is per- fectly neutral in its reaction, and its solutions are more stable. It is used in solutions of the same strength as auric chloride. As a reducing agent Hoyer uses the ordi- nary pyrogallic acid developing solution used in photo- graphy. He adds one or two drops of this solution to 50 c.c. of water, and places the specimen in this for sixteen to twenty-four hours. Gerlach hardens the spinal cord in ammonium bichro- mate, then puts it in a one to ten thousand solution of auric chloride, to which a few drops of HC1 are added. Leaves it in this solution for ten or twelve hours ; washes in acidulated water, finally in sixty per cent, alcohol, acidulated with HC1. Boll states that material that has been in the ammo- nium bichromate for eight days does not stain well, and after fourteen days does not stain at all. Alcohol should not be used for cutting sections, as it may cause a pre- cipitate. He also finds that twelve hours' action of the gold gives the best results. Auric and Cadmium Chloride.-This double salt has been employed by G. V. Ciaccio in investigating nerve- terminations in muscle. Place bits of fresh tissue for five minutes in freshly filtered lemon-juice; wash in distilled water ; then in a one per cent, solution of auric and cadmium chloride for one hour, protected from the light. Remove and wash well in -water. Place in a one per cent, solution of formic acid in the dark for twelve hours ; expose to the sunlight for twelve hours ; then in pure formic acid, in the dark, for twenty-four hours ; finally, wash in water and preserve in glycerine. The nerve-fibres stain different colors, some a more or less deep blue, others an intense violet, others a red or reddish brown. Auric and Potassium Chloride, with, Osmic and Arsenic Acid.-Mays places bits of fresh muscle in a one-half per cent, solution of arsenic acid until transparent; then in a fresh mixture of auric and potassium chloride (one per cent.), 4 vols.; osmic acid (one per cent.), 1 vol.; arsenic acid (one-half per cent.), 20 vols. After twenty minutes they are removed, washed in water, and placed in a one per cent, solution of arsenic acid on a water-bath at a temperature of 45° C., and placed in the sun. After three minutes they are removed and placed in a mixture of: Glycerine, 40 vols.; water, 20 vols.; hydrochloric acid (twenty per cent.), 1 vol., and examined in the same. This method he employs for nerve-terminations in muscle. Auric Chloride and Grape Sugar.-Miura, for demon- strating a peculiar network in the liver, employed the following method : Bits of fresh liver or liver that has been in Muller's fluid for a day are placed in a mixture of grape-sugar, 20 parts ; sodium chlorate, 1 part; water, 100 parts, for eight to twelve hours; then in a one-half per cent, solution of auric chloride for twelve to twenty- four hours. They are then kept in the grape-sugar solu- tion at the ordinary temperature for twelve to forty-eight hours, or for two to three hours at a temperature of 40° C. Preserve in glycerine. According to Leber, sections of the nervous system, which have been hardened in Muller's fluid, can be im- pregnated with auric chloride. For this purpose he places sections in a one-half per cent, solution of auric chloride for one hour, and then in distilled water, when they show, after a day or two, a deep violet staining of the parts containing normal medullated nerves. Frisch stains specimens hardened in alcohol as follows : Wash the sections well in distilled water and place in a six-tenths per cent, solution of sodium chloride for twenty- four hours ; then for ten minutes in a ten per cent, solution of formic acid; after washing in water, place in a one per cent, solution of auric chloride, in the dark, for three hours. Wash in water and place in a ten per cent, solu- tion of formic acid for twenty-four hours. Flechsig hardens in one per cent, solution of ammo- nium bichromate ; washes sections in water; stains in five-tenths per cent, solution of auric chloride for one- fourth to one-half hour ; washes in water ; transfers to ten per cent, solution caustic soda, where the reduction takes place instantaneously. Osmic Acid.-The property possessed by osmic acid of staining fat black, makes it a useful stain for the medul- lated nerve-fibres. It also stains some other tissues various shades of black, but its action is uncertain. At present it is used chiefly for staining fat and nervous tissue. It is best used in the form of vapor, as its penetrating power is greater. The specimen to be submitted to the action of the vapor is pinned out on a cork fitted to a wide-mouthed bottle, in the bottom of which a few crys- tals, or a few cubic centimetres of a strong solution of osmic acid are placed and left until the desired coloration is obtained. It may also be used in solution in water or glycerine of 680 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. the strength of one-half to one per cent. Small bits of the tissue are placed in the solution for from one-half to twenty-four hours, and then washed thoroughly in water. Or a mixture of 1 part glycerine, 1 part alcohol, 1 to 3 parts water, and 1 part of a one per cent, solution of the acid may be used. Specimens may remain in this mixt- ure for several days, until they are sufficiently stained. All osmic-acid preparations should be preserved in glycerine. 'Overstained specimens may be bleached by Mayer's method (see Methods of Fixing and Hardening). Owsjannikow recommends an osmiamide as a substi- tute for the acid, in solutions of 1 to 1,000. Molybdate of ammonia is used in five percent, neutral solutions for staining tissues marine blue-nervous sys- tem, lymphatic glands, and ciliated cells. The tissue is placed in the solution for twenty-four hours, exposed to the light. Potassio-ferrous Ferrocyanide - Prussian Blue. -Im- pregnation with this salt is recommended by Leber, especially for the cornea. The fresh tissue is placed in a one-hali to one per cent, solution, in water, of ferrous sulphate for five to ten minutes ; then in a one per cent, solution of potassium ferrocyanide until the specimen is colored deep blue. Wash well in water, and mount in glycerine. In the cornea the basement substance is stained blue, the corneal cells and canals remain colorless. Ferric Chloride.-Polaillon uses a combination of ferric chloride and tannic acid for studying the peripheral nerve ganglion. The tissues are hardened in a solution of fer- ric chloride. Sections are cut and washed well in water, and then placed in dilute solution of tannic acid until they become black. The nerve elements stain black, while the connective-tissue elements remain uncolored. Palladium Chloride.-F. E. Schulze employs for mus- cle tissue and cells rich in protoplasm (epidermis and glands) a solution of this salt in the strength of 1 to 800, or 1 to 1,000. The tissues are placed in the solution for twenty-four hours, and the hardening completed in alco- hol, or they are allowed to remain for three or four days, when they will be hard enough to cut. Fat and connective tissue do not stain. Smooth and striated muscle stain brownish. Medullary matter of nerves stains black. Sections stain quickly in carmine. He also recommends this solution for the retina and lens. Sections are to be well washed in water and mounted in glycerine. Methods of Injecting.-Self-injection of the Living Animal.-This is accomplished by allowing a definite quantity of blood to escape from an opening in a vein of a living animal, and replacing the blood lost by some innoc- uous coloring-matter, so that by the contractions of the heart the vessels are filled with much less injury than by an injection apparatus. Chrzonszczewsky recommends a solution of 7.75 Gm. of carmine in 3.6 c.c. of ammonia, to which is added 30 c.c. of distilled water. This fluid is to be filtered before injecting. Ten cubic centimetres of blood are removed from the jugular vein of a medium-sized rabbit, and ten cubic centimetres of the above fluid injected. If the larger vessels are now rapidly ligated, first the vein and then the artery, a physiological injection of the blood- vessels is obtained. Good results are obtained with the kidney, spleen, etc. The injection may also be accom- plished by placing the above fluid in the stomach, rec- tum, and abdominal cavity ; and in amphibia by placing it in the lymph cavities. After the injection is accom- plished the organs are placed in acidulated alcohol, to cause the fixation of the carmine. This solution, as well as the sulph-indilate of soda, when injected in large quantities, is rapidly excreted by the kidneys, and the latter substance is precipitated in the biliary passages. If immediately after injecting a rabbit the ureter be ligated and the animal killed at the end of an hour, the urinary tube will be found filled with carmine. In injecting the biliary passages it is not neces- sary to ligate. The blood-vessels of the organ are to be washed out and the original coloring-matter that remains in them is to be replaced with another. The organs in- jected with the sulph-indilate of soda, after the blood- vessels have been washed out, are placed in a concen- trated solution of calcium chloride, then in alcohol, when the coloring-matter will become fixed. Heidenhain found that the commercial indigo-carmine was composed of a mixture of substances, generally three in number : 1, indigo blue-sulphate ; 2, indigo blue-hy- posulphate ; 3, phoenizine-sulphate of soda. He found for the purpose of injection that 1 and 3 were the only ones useful. He injects twenty-five to fifty cubic centi- metres of a cold, saturated solution of the above salts into the vein of a medium-sized rabbit, and fifty to seventy-five cubic centimetres into that of a medium-sized dog. After the animals have passed blue urine for some time they are killed by bleeding, and the coloring-matter fixed by injecting the kidney through the renal vessels with abso- lute alcohol. For injecting the biliary passages of the frog, he places a piece of indigo-carmine, the size of a pea, in the lymph- sac of the thigh, and closes the wound in the skin firmly. After twenty-four hours the biliary passages will be found beautifully injected. Arnold21 and Thoma22 found that, when indigo-car- mine was injected in a certain manner into the blood- vessels of a living frog, it was precipitated in the cement substance between the epithelial cells and in the plas- matic channels, especially in cartilage ; Kuttner23 found the same to occur in the cement substance between the epithelium of the lung alveoli. Injection after Death.-For filling the vessels of an ani- mal after death, or the vessels of a removed organ or tu- mor, we employ two kinds of injecting masses, one fluid the other solid at ordinary temperatures-cold and warm flowing masses. Cold-flowing Masses.-If a solution of gelatine in water, to which is added a little ammonia, be boiled for several hours' on a water-bath, the gelatine is converted into metagelatine, and no longer congeals upon cooling. To this fluid, as a vehicle, may be added various coloring substances, when a good cold-flowing mass will be ob- tained. After injecting, the object is placed in alcohol, which coagulates the metagelatine. The addition of glycerine and chloral hydrate, after Hoyer's method, will preserve the mass for some time. Beal's Cold-flowing Fluids : (a) Blue-Dissolve 0.777 Gm. of potassium ferrocyanide in 30 c. c. of glycerine; mix 3.6 c.c. of tinct. ferri mur. with 30 c.c. of glycerine ; add the iron mixture, drop by drop, to the potassium fer- rocyanide solution. Then add to this mixture 5.5. c.c. of methylic alcohol, 30 c.c. of alcohol, and 88 c.c. of water, shaking strongly. (b) Acid Glycerine Fluid : Dissolve 0.194 Gm. of potas- sium ferrocyanide in 30 c.c. of strong glycerine ; to 30 c.c. of strong glycerine add 10 drops of tincture ferri mur. Add the latter, drop by drop, to the former, under constant shaking. Then add 30 c.c. of water, to which 3 drops of HC1 have been added. This fluid flows well and does not exude from the capillaries. Carmine-Mix 1 Gm. of pulverized carmine with a lit- tle water and sufficient ammonia to dissolve the carmine ; add 50 c.c. of glycerine and shake well. Then add gradually, with constant shaking, 100 c.c. of glycerine, acidulated with 25 to 30 drops of HC1 or acetic acid. Test the fluid with litmus-paper, and if not decidedly acid add a few drops of acid. Then add 25 c.c. of alcohol and 75 c.c. of water. Robin's Cold-flowing Fluids : Robin uses as a vehicle, 2 parts of glycerine, 1 part of alcohol, and 1 part of water, combined with a third or a quarter of its volume of the following coloring masses : Carmine-Rub up 3 Gm. of carmine in a mortar with a little water and enough ammonia to dissolve the carmine ; add 50 c.c. of glycerine and filter. Add a ten per cent, solution of acetic acid in glycerine, drop by drop, until a slightly acid reaction is obtained. Prussian Blue-(a) Potassium ferrocyanide (sat. sol.), 90 c.c.; glycerine, 50 c.c. (d) Liquor ferri perchloride, 80°, 3 c.c.; glycerine, 50 c.c. Mix (a) with (6) slowly. 681 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Green-Saturated sol. potassium arsenite, 80 c.c., and glycerine, 50 c.c., are mixed with saturated solution of cupric sulphate, 40 c.c., and glycerine, 50 c.c. Mahogany Red-(1) Potassium ferrocyanide (concent, sol.), 20 c.c.; glycerine, 50 c.c. (2) Cupric sulphate (concent, sol.), 35 c.c.; glycerine, 50 c.c. Mix (1) and (2) slowly with agitation, and add to the vehicle at the moment of injecting. Yellow-(1) Cadmium sulphate (sat. sol.), 40 c.c.; glycerine, 50 c.c. (2) Sodium sulphide (sat. sol.), 30 c.c.; glycerine, 50 c.c. Mix (1) with (2) with constant shak- ing. Briicke's Red Mass : Inject a concentrated solution of potassium ferrocyanide into the artery until it runs clear from the vein, and allow as much as possible to drain away. Then inject a concentrated solution of cupric sul- phate, free from iron. By this method the red cupric ferrocyanide is precipitated in the vessels. Richardson's Neutral Blue Fluid : Dissolve 0.648 Gm. of ferrous sulphate in 15 c.c. of glycerine, and 2.07 Gm. of potassium ferrocyanide in a litre of water, to which 15 c.c. of glycerine have been added. Mix the tw'o solutions gradually ; then add 30 c.c. of alcohol and 120 c.c. of water. The color of this fluid is less apt to fade than the Prussian blue. Bjeloussow's Gum Arabic and Borax Mass : Take 1 part, by weight, of gum arabic and make a syrupy solu- tion in water. Take a half part, by weight, of sodium biborate and make a solution in water. Mix the two solutions, when a mass resembling gelatine will be ob- tained. This mass, which is almost insoluble in water, is rubbed up with water ; forcibly strain through linen ; repeat the operation, when a solution miscible in all pro- portions with water is obtained. For coloring, any pigment except cadmium and cobalt may be used. Carmine will be found the most useful. After injecting, place the object in alcohol, which coagu- lates the mass. Acetic acid dissolves the mass; glyce- rine renders it transparent. Warm-flowing Masses.- Robin's Gelatine Vehicle: One part of gelatine is soaked in seven, eight, nine, or ten parts of water, according to the consistency of the mass wanted, and when soft is melted on a water-bath. This vehicle is then combined with any of the coloring masses just mentioned in the proportion of one part color to three parts vehicle. Filter through flannel before in- jecting. Thiersch's Prussian Blue Mass: (1) A solution of gela- tine, one part to two parts water ; (2) saturated aqueous solution of ferrous sulphate ; (3) saturated solution of potassium ferrocyanide ; (4) saturated solution of oxalic acid. Mix 12 c.c. of (2) with 30 c.c. of (1), at a temperature of 50° C. Mix at the same temperature 24 c.c. of (3) with 60 c.c. of (1), and add 24 c.c. of (4), with constant stirring. Add this solution to the solution of gelatine and iron; stir constantly until all the Prussian blue is pre- cipitated. Heat on a water-bath to 100° C., and filter through flannel. Ranvier's Prussian Blue Mass: Prepare the Prussian blue as follows: Add to a saturated solution of ferrous sulphate, in water, a saturated aqueous solution of potas- sium ferrocyanide. Filter through a double filter of felt and paper. Wash with distilled water, for several days, until the filtrate has a deep blue color. The Prussian blue has now become soluble. The precipitate is then dissolved in distilled water, and the solution kept in bot- tles until wanted. Twenty-five parts of this solution are mixed with one part of gelatine. The gelatine is soaked for half an hour in water, and melted in the water it has absorbed, on a water-bath. Heat the Prussian blue fluid to the same temperature, and mix with the gelatine solution, gradu- ally, under constant stirring. Filter through flannel. Briicke's Berlin Blue Mass: Potassium ferrocyanide, 217 Gm. ; water, 1,000 c.c. Ferrous chloride, 1 part; water, 10 parts. Take equal volumes of these solutions and add to each twice its volume of a cold saturated solu- tion of sodium sulphate. Add the iron solution to the ferrocyanide solution, with constant stirring. Filter, and wash the precipitate with the filtrate until it runs through clear; then wash with water until the filtrate runs off blue. Dry the precipitate. To a concentrated solution of this blue add enough gela- tine to make a firm jelly when cold. Heat to 60° C. and filter through flannel. Thiersch's Carmine Mass: Carmine, 1 part; ammonia, 1 part; water, 3 parts. Dissolve and filter. Make a solu- tion of gelatine in water, 1 to 2. Heat to 30° C. on a water-bath, and add 1 part of carmine fluid for every 3 parts of gelatine solution. Then add acetic acid, drop by drop, stirring, until the free ammonia is used up. Inject at a temperature of 30° to 35° C. Gerlach's Carmine Mass: Dissolve 5 Gm. of carmine in a mixture of 4 c.c. of water and 0.5 c.c. of ammonia. Allow it to stand several days, and mix with 8 parts of a solution of gelatine, 1 to 2. Filter and inject at a temper- ature of 40° C. Ranvier's Carmine Mass : Rub up 2.5 Gm. carmine with a little water, and just enough ammonia to bring the carmine in solution. Soak 5 Gm. of gelatine in wa- ter, and melt on a water-bath in the water it has absorbed. Add the carmine fluid slowly, with constant agitation. Neutralize the free ammonia by adding, drop by drop, a mixture of acetic acid and water, 1 to 2. Filter through flannel. Davies and Dale's Carmine Mass: Digest in a flask for thirty-six hours, at the ordinary temperature, 11.6 Gm. of carmine in a mixture of 15 c.c. of ammonia (0.92 strength) and 118 c.c. of water. Filter, and dilute with water to 472 c.c. Dissolve 38.88 Gm. of potash alum in 295 c.c. of water, and add, under constant boiling, a solu- tion of sodium carbonate until a slight precipitate is pro- duced. Boil and add to carmine fluid, shaking vigor- ously. A drop of the fluid, when placed on white filter- paper, should show no color ring. Allow it to cool and settle for a day or two, and draw off the supernatant fluid with a siphon. Wash, by decantation, until the wash-water ceases to give a precipitate with barium chloride. So much water must be kept with the color that it shall measure 1,180 c.c. For use soak 100 Gm. of gelatine in 750 c.c. of this fluid and melt on a water-bath. According to the authors, this mass has no tendency to extravasate. Thiersch's Yellow Mass: (1) One part of gelatine in two parts of water; (2) one part of neutral potassium chromate in eleven parts of water ; (3) one part of plum- bic nitrate in eleven parts of water. Mix four parts of (1) with two parts of (3). In another vessel mix four parts of (1) with one part of (2). Heat both mixtures to 30° C., and then combine, with constant stirring. Heat on a water-bath to 90° C., and filter through flannel. Thiersch's Transparent Green Mass : Combine the blue injection mass in various proportions with the yellow mass. Frey's White Mass : Precipitate 125 to 185 c.c. of a cold, saturated, aqueous solution of barium chloride by adding sulphuric acid, drop by drop. Allow the precipitate to set- tle for twenty-four hours, and decant the clear fluid. The remaining mucilaginous mass is mixed with an equal vol- ume of strong gelatine solution. Hartig's White Mass: Dissolve 125 Gm. of lead ace- tate in enough water to make the whole weigh 500 Gm. Dissolve 95 Gm. of sodium carbonate in enough water to make the whole weigh 500 Gm. One volume of each of the above solutions is mixed with two volumes of strong gelatine solution. Fol's Dry Masses : Carmine-An indefinite quantity of ammonia is mixed with four times its volume of water, and carmine added ; after standing an hour, with occa- sional shaking, no deposit should remain ; then filter. Soak gelatine, in shreds, for two days in a sufficient quan- tity of the carmine solution. Then melt on a water-bath with a small quantity of the solution. When melted add acetic acid until the color becomes blood-red, taking care not to add an excess of acid. Too little acid is not a disadvantage ; too much will cause a granular precipi- tate. Allow the mass to cool, and tie up in a piece of 682 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. coarse net, and by pressing with the hands, under water, acidulated with 0.1 per cent, acetic acid, force the mass out into vermicelli. These are placed in a sieve, washed well with running water, and dried on waxed paper. Blue Mass-The mass is prepared according to Thiersch's formula. After cooling press out into vermi- celli, as above, and dry on waxed paper. For use, soak the vermicelli in water; when soft, melt with enough saturated solution of oxalic acid to render them fluid. Brown and Black Masses-Soak 50 Gm. of gelatine in 200 c.c. of water in which is dissolved 14 Gm. of sodi- um chloride. Melt on a water-bath, and stir in briskly a solution of 30 Gm. of silver nitrate, dissolved in 100 c.c. of distilled water. This pro- duces a fine-grained, white emulsion, which is allowed to cool. When cold, press out into vermicelli, as above, wash in running water, and by clear daylight mix with the fol- lowing : Cold, saturated aqueous so- lution of potassic oxalate, 300 c.c.; cold, saturated aqueous solution of ferrous sulphate, 100 c.c. When the mass has become black throughout, wash in running water for several hours, and dry the vermicelli on waxed paper. The color of this mass, by transmitted light, is sepia- brown. If a gray-black tint is wanted, substitute 24 Gm. of potas- sium bromide for the sodium chlo- ride in the first solution. Purple Mass - Prepare a silver chloride emulsion, as for the brown mass. This is re- duced with the following mixture : Alcoholic solution of hydrochinon (1 to 20), 82 c.c.; aque- ous solution of ammonia carbonate (1 to 30), 60 c.c.; water, 300 c.c The proceeding is the same as for the black mass. This mass cannot be preserved, as the hydrochinon soon renders the gelatine insoluble. These dry masses, with the excep- tion of the purple, can be preserved indefinitely in tightly stoppered bottles. For use, 1 part of the dry mass is dissolved in from 10 to 20 parts of water, and filtered warm through flannel. Hoyer's Masses: Hoyer uses as a preservative for the gelatine inasseschlo- ral hydrate and glyce- rine. To each vol- ume of the gelatine mass add two per cent., by weight, of chloral hydrate, and from five to ten per cent., by volume, of glycerine. Carmine Mass-Add to a concentrated solution of gel- atine an equal volume of carmine fluid (see Methods of Fig. 1732.-Ludwig's Mercury-pressure Apparatus. Staining, p. 674). Digest on a water-bath until the color begins to pass into a bright red, then add the above pre- servatives ; filter through flannel. Blue Mass-Mix a small quantity of a dilute solution of Berlin blue with an equal quantity of dilute gelatine Fig. 1730.-Injecting Syringe. Fig. 1733.-Water-pressure Injecting Apparatus. solution. Then mix this with a larger quantity of a con- centrated warm solution of gelatine. Yellow Mass-Mix a concentrated solution of gelatine with an equal volume of a four per cent, solution of sil- ver nitrate, warm, and then add slowly a small quantity of an aqueous solution of pyrogallic acid, which reduces the silver. This mass shows yellow in the capillaries, and brown in the larger vessels. Injecting with a Syringe.-The syringe for this purpose should be made of brass or German silver, and should be of the form of that shown in Fig. 1730. Such a syringe, with half a dozen cannulae of various sizes will answer all purposes for which a syringe can be used. It can only be used for injecting small organs. Fig. 1731.-Mercurial Injecting Apparatus. 683 Histological Technique. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. A cannula is tied to the vessel and filled with a three- fourth per cent, salt solution. The syringe is then filled with the injecting mass, and to exclude all air the syringe sing the air. The compressed air acting on the injecting mass, forces it through the rubber tube and cannula. The amount of pressure can be regulated by the distance of the can a above the bottle B. In using warm flowing masses it is necessary that the object to be injected and the masses should be kept warm. Tile injecting tank of Harting, Fig. 1734, will be found very convenient for this purpose. The perforated shelf e is for the injecting flasks, the shelf d for the object to be injected. The tank is filled one-third full with water, which is heated by a Bunsen burner placed underneath. In Fig. 1735 are shown several forms of injecting cannulae. The two upper ones are made of brass, and should be of different sizes. The lower one is made from a piece of glass tubing. Several stopcocks, Fig. 1737, fitted to the brass cannula?, are to be provided. Also a dozen or more serres fines (Fig. 1736), which are used for clamping leaking vessels. Injecting an Entire Animal.-The animal-a rabbit or guinea-pig-is rendered insensible with chloroform. The thorax is opened by making an incision through the skin over the sternum and cutting out a small win- dow over the base of the heart. The pericardium is opened, the heart pulled out and its apex cut off, the ani- mal being allowed to bleed to death. The aorta is exposed, care being taken not to injure the vessels; a cannula is introduced (Fig. 1735) through the left ventricle into the aorta and fastened firmly with a ligature, the ends of the latter being tied around the arms of the cannula, or around the constriction of the glass one, if it be used. If a glass cannula be used, a piece of rubber tubing is attached to the large end and the whole filled with a three-fourths per cent, salt solution. The latter is retained by placing a spring clip upon the end of the rubber tube. The cannula is then introduced as above and tied. The vessels are now washed out with a three- fourths per cent, salt solution. This is accom- plished as follows : The animal is placed upon the shelf, d, of the injecting tank, Fig. 1734, the water in which has been heated by a Bun- sen burner placed underneath. A flask, filled two-thirds with salt solution, is placed on the shelf c, and connected with the pressure- bottle B, Fig. 1733. A piece of rubber tubing attached to a stopcock is connected with the delivery tube of the flask. The pressure is now applied by raising the can a, Fig. 1733, until the manometer registers about 50 mm. Now the stopcock is opened and all the air allowed to escape ; then the stopcock is connected with the cannula introduced into the aorta. The salt solution is allowed to run through the vessels until it escapes perfectly clear from the right side of the heart. The stopcock is now closed, disconnected from the cannula, and a flask containing the injecting mass substituted for the one containing the salt solution. The stopcock is opened, and as soon as the injecting mass flows free from air-bubbles the stopcock is connected with the can- nula as above. The injection is continued until the mass flows from the right side of the heart, and is allowed to run for from twenty minutes to half an hour. A liga- ture is then tied around the vessels conifected with the right side of the heart, and the injection is continued, the pressure being gradually increased to not over 100 mm., until the vascular system is filled, which can be judged from the color of the ears, lips, etc. When the injection is completed the vessels at the base of the heart are ligated, the stopcock disconnected, and the animal put in a cold place until the gelatine has set. The organs Fig. 1736.-Serres Fines. Fig. 1734.-Harting's Injecting Tank. is held vertically, nozzle up, and a few drops of the inject- ing mass expelled. The nozzle of the syringe is to be in- serted in the cannula and the injection made slowly and steadily. On account of the difficulty of keeping up a steady pressure by the hand, the method of injecting with the syringe has been practically discarded. Injecting with Constant Pressure.-The pressure is ob- tained in this case by a column of mercury or water. In Fig. 1731 is shown a simple form of a mercurial ap- paratus. The bottle A is filled two-thirds full with the injecting mass, which flows through the rubber tube i. The bottle A is connected with the bottle B, which is partially filled with mercury. The tube d, with a funnel end e, is fitted air-tight into the cork B (all joints must be air-tight). Upon pouring mercury into the tube d, it flows down into B, compressing the air, which in turn compresses the air in A, and forces the injecting mass out through i. In Fig. 1732 is shown the more satisfactory apparatus of Ludwig. It consists of two Wolff's bottles, a, which contains the mer- cury, and b, into which, owing to the difference in the level of the two bottles, the mercury flows. This compresses the air in b, which, act- ing on the injecting fluid in c, causes the latter to flow out through the tube g. The pressure-bottle a rests on a wooden support, which is raised by the screw d, until sufficient pressure is obtained. The mercurial manome- ter attached to the bottle, c, is for indicating the amount Fig. 1737.-Stopcock. Fig. 1735.-Injecting Cannulse. of pressure. If a gelatine mass is employed, the bottle, c, must be placed in a vessel of warm water. The water-pressure apparatus, Fig. 1733, is arranged as follows: The flask C is for holding the injection- mass, and is connected with the pressure bottle by a rubber tube. The manometer Jf is for measuring the pressure. The pulley P is fixed to the ceiling, and through it a rope passes which is attached to the can a, to the bottom of which is attached a rubber tube con- nected with the bottle B. The can a is filled with •water which, upon raising the can, flows into B, compres- 684 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Histological Technique. and parts wanted are then removed and hardened in alcohol. For injecting a single organ-the kidney-the animal is killed by bleeding, the abdominal cavity opened, and the intestines pushed aside. The renal artery is sepa- rated from its surroundings with forceps ; then the renal vein in the same way. The artery is opened by a valvu- lar opening, a cannula inserted and firmly tied. An open- ing is then made in the vein. The organ is washed out with salt solution, which is followed by the injecting mass. The constant-pressure apparatus is to be used. After the injection is completed a ligature is passed around both vessels close to the organ, which is removed and hardened in alcohol. For injecting pathological new-formations, cold flowing masses are to be preferred. The pressure employed must be moderate on account of the thinness of the walls of the blood-vessels. The serres fines will be in great de- mand for checking the leakage from the numerous lateral branches of the blood-vessels. Double Injections.-Double injections are best made by injecting the artery and vein at the same time, with dif- ferent colored masses-carmine for the artery, blue for the vein. A T-tube is attached to the outlet tube of the pressure- bottle B, Fig. 1733, and from each arm a rubber tube is carried to flasks containing the injecting masses. These are then to be connected with the cannulse fastened in the artery and vein. By this means both sets of vessels are filled at the same time and under the same pressure. The pressure, at first, must be low, so that the arteries and veins shall be completely filled before either mass passes into the capillaries. The pressure is finally increased, and each set of capillaries will be filled with its proper mass. Injection of Lymphatics.-For injecting lymphatics the puncture method is the one chiefly employed. The punct- the cover-glass. This can be accomplished by placing a hair under the cover, or we may make a shallow cell by painting a ring of some cement on the slide (see Fig. 1741). Again, we may have a thick specimen, or we may wish to use an aqueous mounting medium. In these cases thin glass cells are to be cemented to the slide, the specimen placed in them, and the mounting media added until the cell is filled ; the cover-glass is then applied. Mounting in Glycerine.-The specimens are either soaked in a small dish of glycerine until transparent, and then transferred to the slide ; or they may be placed on the slide from water, the excess of the latter absorbed with filter-paper or sucked up with a pipette (Fig. 1738), a drop or two of glycerine placed on the specimen, and the whole covered with a cover-glass. In covering a specimen, care must be taken not to include air-bubbles. If the cover-glass is placed in position in the manner Fig. 1739.-Placing the Cover-glass in Position. shown in Fig, 1739, any that may be present will be forced out with the excess of glycerine. The cover being in position, the superfluous glycerine is to be removed and the cover cemented down. All traces of glycerine must be removed, or the cement will not adhere to the glass. This is accomplished by washing out a camel's- hair brush in alcohol, absorbing the greater part of the alcohol by wiping the brush on fllter-paper until it is only moist, and then going over the slide in a systematic manner with the brush until all the glycerine is removed. A brush only moistened with alcohol will not suck up the traces of glycerine. The brush must be washed in the alcohol and dried very frequently. If the cover is a square one, it is cemented by pass- ing a camel's-hair brush along the edge of the cover, whereby the latter as well as the slide receives a stripe of the'cement. Circular covers are easily cemented by aid of the turn-table (Fig. 1740). Concentric circles engraved on the surface of the table, according to the size of the covers, show where the brush is to be applied. •The brush is to be held perpendicularly, and is filled, with a cement of such a consistency that it will flow-it is not to be painted-on the cover and slide while the table is Fig. 1738.-Pipette. ure can be made from the cavity of a blood-vessel into the surrounding tissue, with the idea that a lymph-vessel may be opened and that thus both sets of vessels may be injected. Or it may be made into the tissue and the injec- tion made from this. The puncture must not be made at random, but in the direction in which small lymphatics are supposed to exist. The injection is made with a syringe fitted to the small cannula used for puncturing, and cold-flowing masses are to be used. If the extrava- sation is small and remains so, the injection is likely to succeed, but if the extravasation grows rapidly, the pro- cedure is a failure and a new attempt is to be made. Methods of Mounting.-Specimens, after being duly prepared, are mounted on glass slides for study and pres- ervation. The usual form of slide is known as the Eng- lish. It is made of plate glass, measuring one by three inches, with the edges ground smooth. For covering the specimen thin pieces of glass, either circular or square in form, and of a size suitable to the specimen, are used. These are known as cover-glasses. The slides and covers, as received from the dealers, are generally covered with an oily material, making it dif- f